Impact of proximal cap ambiguity on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS‐CTO Registry

Kostantinis, Spyridon; Şimşek, Bahadir; Karácsonyi, Judit; Rempakos, Athanasios; Alaswad, Khaldoon; Megaly, Michael; Krestyaninov, Oleg; Khelimskii, Dmitrii; Karmpaliotis, Dimitrios; Jaffer, Farouc A.; Khatri, Jaikirshan; Poommipanit, Paul; Patel, Mitul; Mahmud, Ehtisham; Koutouzis, Michael; Tsiafoutis, Ioannis; Görgülü, Şevket; Elbarouni, Basem; Nicholson, William J.; Rinfret, Stéphane; Rafeh, Nidal Abi; Göktekín, Ömer; ElGuindy, Ahmed; Allana, Salman; Rangan, Bavana V.; Sandoval, Yader; Burke, M. Nicholas; Brilakis, Emmanouil S.

doi:10.1002/ccd.30580

Cited by 6 publications

(3 citation statements)

References 25 publications

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“…Proximal cap ambiguity is defined as an inability to determine the precise location of the proximal cap of CTO lesions, which is present in almost one-third of CTOs and was associated with the failed CTO PCI [ 62 – 64 ]. It is a crucial parameter utilized to decide whether the dominant approach is antegrade or retrograde according to current CTO crossing algorithms [ 46 , 65 – 68 ].…”

Section: Resultsmentioning

confidence: 99%

Coronary chronic total occlusion on coronary CT angiography: what radiologists should know?

Xu,

Ma,

Chen

et al. 2024

Insights Imaging

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Coronary chronic total occlusion (CTO) often occurs in patients with obstructive coronary artery disease, which remains one of the greatest challenges for interventional cardiologists. Coronary computed tomography angiography (CCTA) with its emerging post-processing techniques can provide a detailed assessment of CTO lesions before percutaneous coronary intervention (PCI), playing an important role in the clinical management of CTO PCI, from early diagnosis, pre-procedural outcome prediction, the crossing algorithm planning, intraprocedural guidance, and finally post-procedural assessment and follow-up. In addition, the feasibility of CT perfusion (CTP) in patients with CTO has been validated. Combined CCTA and CTP have the great potential to be the one-stop-shop imaging modality for assessing both anatomy and function of CTO lesions. This review aims to make radiologists understand the role of CCTA in the diagnosis and assessment of CTO lesions, thus assisting interventionalists in optimizing CTO PCI crossing strategies with the expertise of radiologists.Critical relevance statement The anatomical features of CTO on CCTA can reveal the complexity of CTO lesions and are associated with CTO PCI outcome, thus helping interventionalists optimize CTO PCI crossing strategies.Key points • CTO is the common lesion in invasive coronary angiography, and CTO PCI is technically difficult and its success rate is relatively low.• Length, collaterals, and attenuation-related signs can help distinguish CTO from subtotal occlusion.• The anatomical features of CTO lesions can help grade the difficulty of CTO PCI and predict procedural outcomes and long-term outcomes of CTO PCI.• The real-time fusion of CCTA with fluoroscopic angiography can be applied in highly complicated CTO lesions.• After CTO PCI, CCTA can help guide a second CTO PCI re-entry or follow up stent patency. Graphical Abstract

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Section: Resultsmentioning

confidence: 99%

Coronary chronic total occlusion on coronary CT angiography: what radiologists should know?

Xu,

Ma,

Chen

et al. 2024

Insights Imaging

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“…BASE is a dissection technique that was first described by Vo et al in 2016 2 to treat lesions with an ambiguous or impenetrable proximal cap. Proximal cap ambiguity is common 14 and the “move the cap” techniques, such as BASE can help overcome the ambiguity by entering the extraplaque space proximal to the proximal cap and advancing a knuckled guidewire around the proximal cap 15 . The Global CTO crossing algorithm recommends the “move the cap” techniques for proximal cap ambiguity without side branches at the proximal or distal cap, so as to avoid side‐branch loss 16 .…”

Section: Discussionmentioning

confidence: 99%

Balloon‐assisted subintimal entry (BASE) in chronic total occlusion percutaneous coronary interventions

Alexandrou,

Rempakos,

Al Ogaili

et al. 2023

Cathet Cardio Intervent

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BackgroundThere is limited data on the use of the balloon‐assisted subintimal entry (BASE) technique in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).MethodsWe analyzed the baseline clinical and angiographic characteristics and outcomes of 155 CTO PCIs that utilized the BASE technique at 31 US and non‐US centers between 2016 and 2023.ResultsThe BASE technique was used in 155 (7.9%) of 1968 antegrade dissection and re‐entry (ADR) cases performed during the study period. The mean age was 66 ± 10 years, 88.9% of the patients were men, and the prevalence of diabetes (44.6%), hypertension (90.5%), and dyslipidemia (88.7%) was high. Compared with 1813 ADR cases that did not use BASE, the target vessel of the BASE cases was more commonly the RCA and less commonly the LAD. Lesions requiring BASE had longer occlusion length (42 ± 23 vs. 37 ± 23 mm, p = 0.011), higher Japanese CTO (J‐CTO) (3.4 ± 1.0 vs. 3.0 ± 1.1, p < 0.001) and PROGRESS‐CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention chronic total occlusion) (1.8 ± 1.0 vs. 1.5 ± 1.0, p = 0.008) scores, and were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate to severe calcification, and proximal tortuosity. Technical (71.6% vs. 75.5%, p = 0.334) and procedural success (71.6% vs. 72.8%, p = 0.821), as well as major adverse cardiac events (MACE) (1.3% vs. 4.1%, p = 0.124), were similar in ADR cases that used BASE and those that did not.ConclusionsThe BASE technique is used in CTOs with longer occlusion length, higher J‐CTO score, and more complex angiographic characteristics, and is associated with moderate success but also low MACE.

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“…In this issue of CCI, 2 Kostantinis et al analyzed data of 9498 patients from the prospective PROGRESS‐CTO registry (mean age 64 years, median left‐ventricular ejection fraction 50%). Proximal cap ambiguity was present in 3376 CTOs (35%).…”

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confidence: 99%

Looking but not seeing the cap: The case for PROGRESS‐CTO

Tarantini

Cardaioli

2023

Cathet Cardio Intervent

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Key Points Chronic total occlusion (CTO) procedures are a well‐established treatment strategy for selected patients with chronic coronary disease. Proximal cap ambiguity is one of the key aspects impacting procedural success and final results. In this issue of CCI, data from a large multicenter prospective registry confirmed that proximal cap ambiguity is related to worse procedural outcomes, more aggressive procedural techniques, and higher rates of procedural complications. Proximal cap ambiguity should be considered for patients' selection and procedural planning. Further analysis will be needed to test different imaging modalities for a clearer cap visualization.

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Impact of proximal cap ambiguity on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS‐CTO Registry

Abstract: Background: Proximal cap ambiguity is a key parameter in the global chronic total occlusion (CTO) percutaneous coronary intervention (PCI) crossing algorithm.

Cited by 6 publications

References 25 publications

Coronary chronic total occlusion on coronary CT angiography: what radiologists should know?

Coronary chronic total occlusion on coronary CT angiography: what radiologists should know?

Balloon‐assisted subintimal entry (BASE) in chronic total occlusion percutaneous coronary interventions

Looking but not seeing the cap: The case for PROGRESS‐CTO

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