Impact of crossing technique on the incidence of periprocedural myocardial infarction during chronic total occlusion percutaneous coronary intervention

Abstract

Objectives: We sought to evaluate the impact of crossing strategy on the incidence of periprocedural myocardial infarction (PMI) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: The optimal technique for crossing coronary CTOs remains controversial. Methods: We retrospectively examined the incidence of PMI among 184 consecutive patients who underwent CTO PCI at our institution between 2012 and 2015. Creatine kinase-myocardial band fraction (CK-MB) and troponin were measured before and after PCI in all patients. PMI was defined as CK-MB increase !33 upper limit of normal (ULN). Results: Mean age was 65 6 8 years, 98% of patients were men, 57% had diabetes mellitus, 36% were current smokers, 38% had prior heart failure, 31% had prior coronary artery bypass graft surgery (CABG), and 55% had prior PCI. The retrograde approach was used in 38% of cases. As compared with antegrade wire escalation and antegrade dissection/re-entry, use of the retrograde approach was associated with higher J-CTO (Multicenter CTO Registry of Japan) scores (P < 0.0001), higher frequency of moderate or severe calcification (P 5 0.0061), longer CTO length (P < 0.0001), more frequent proximal cap ambiguity (P < 0.0001), and lower technical (P 5 0.0007) and procedural (P 5 0.0014) success. The frequency of PMI for the antegrade-only and retrograde cases was 10% and 33%, respectively (P 5 0.0001). On multivariate analysis, use of the retrograde approach and moderate/severe calcification were independently associated with higher incidence of PMI. Conclusions: As compared with antegrade-only crossing techniques, the retrograde approach is used in patients with more complex anatomy but may carry higher risk for PMI. V C 2016 Wiley Periodicals, Inc.

Wire escalation in emergent revascularization procedures of internal carotid artery occlusions: the use of high tip stiffness microguidewires

“…In their series, no carotid perforation could be attributed to guidewire use. Our findings are also consistent with recent reports on stiff guidewire utilization patterns during antegrade wire escalation in chronic total occlusion percutaneous coronary interventions 12. These studies suggest that in specific cases, initiating antegrade crossing with a stiff guidewire might be advantageous over the current practice of using a soft tapered tip guidewire, potentially increasing the success and efficiency of the procedure without increasing the risk of perforation.…”

“…Furthermore, recent experience supports the practice of unprotected cervical carotid artery stenting in patients with tandem extracranial ICA and intracranial occlusions 1 12 14. It seems that despite the proven role of protective devices in the management of carotid stenting, they are used less often in tandem occlusion patients to reduce technical complexity and shorten procedure times, and thus achieve more rapid reperfusion.…”

Development and Validation of a Scoring System for Predicting Periprocedural Complications During Percutaneous Coronary Interventions of Chronic Total Occlusions: The Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) Complications Score

“…Use of the retrograde approach was an independent predictor of complications in our cohort . Although judicious use of retrograde techniques is important for high technical success and is integral to the hybrid algorithm, this specialized and potentially complex technique does carry increased risk for complications, such as donor vessel or collateral injury and donor vessel territory ischemia with increased risk for myocardial infarction . Device entrapment in collateral vessels may also occur .…”

Chronic total occlusions—Is true lumen wire passage preferred to subintimal dissection re‐entry?

“…Procedures with greatest risk are those crossing lesions longer than 23 mm. For these lesions, retrograde approaches increase risk of complications fourfold compared to antegrade approaches . These complications are driven by a higher risk of subintimal crossing complicated by myocardial infarction, in part due to loss of side branches, and perforation requiring pericardiocentesis.…”

“…These complications are driven by a higher risk of subintimal crossing complicated by myocardial infarction, in part due to loss of side branches, and perforation requiring pericardiocentesis. The use of antegrade dissection re‐entry approaches and moderate to severe calcification are also risk factors for complications. Further, use of the antegrade wire escalation approach to stay true lumen has lowered the incidence of MACE compared to use of dissection re‐entry or retrograde approaches .…”