Real-Time Magnetic Resonance Imaging–Guided Endovascular Recanalization of Chronic Total Arterial Occlusion in a Swine Model

Raval, Amish N.; Karmarkar, Parag; Guttman, Michael A.; Ozturk, Cengizhan; Sampath, Smita; DeSilva, Ranil; Aviles, Ronnier J.; Xu, Minnan; Wright, Victor J.; Schenke, William H.; Kocatürk, Özgür; Dick, Alexander; Raman, Venkatesh K.; Atalar, Ergin; McVeigh, Elliot R.; Lederman, Robert J.

doi:10.1161/circulationaha.105.586727

Cited by 57 publications

(52 citation statements)

References 45 publications

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“…If this could be combined with technologies that allow precise wire steering and effective wire advancement, the triad of capabilities required to elevate the success of crossing CTOs (coronary and peripheral) to the 95% to 98% success rate now achieved for subtotal stenosis would be in place. In this issue of Circulation, Raval et al 6 from the cardiovascular branch of the National Heart, Lung, and Blood Institute share a provocative preliminary animal study suggesting that magnetic resonance imaging (MRI) fluoroscopy, coupled with catheters and guidewires equipped to serve as active antennas within the MRI system, may be able to fulfill that goal.…”

Section: Article P 1101mentioning

confidence: 99%

“…Despite these considerable challenges, Raval et al 6 have demonstrated feasibility of using MRI guidance to recanalize carotid artery CTO in a swine model. Several technical developments were required: Nonmagnetic materials (MP35N, nitinol) were used to build custom guidewires, loopless and microcoil active antennas were created on the guidewires and catheters to allow real-time detection of these devices, and the microcoils and their associated circuitry were detuned and decoupled to prevent device heating during real-time MRI.…”

Section: Article P 1101mentioning

confidence: 99%

“…It is also important to appreciate how hard it may be to move from the relatively static carotid artery studied by Raval et al 6 to cardiac or coronary intervention. Several groups have demonstrated preclinical success in MRI-guided cardiac interventions, including left and right heart catheterization, 18 targeted injections of intramyocardial contrast 19,20 and stem cells, 21 catheter-based closure of atrial septal defect, 22,23 atrial septal puncture, 24 abdominal aortic aneurysm repair, 25 and even transcatheter aortic valve replacement.…”

Section: Article P 1101mentioning

confidence: 99%

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Is Magnetic Resonance Image Guidance the Key to Opening Chronic Total Occlusions?

Baim

Kwong

2006

Circulation

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T hrough progressive plaque growth or fibrotic organization of occlusive thrombus, atherosclerosis may result in chronic total occlusion (CTO) of a major arterial conduit. If CTO develops slowly, collateral pathways may supply sufficient perfusion to retain tissue viability despite occlusion of the major inflow conduit. However, such collateral-mediated perfusion rarely matches that provided by an open main conduit, particularly during the peak demand of regional muscular activity. Although strategies to limit regional oxygen demand (eg, ␤-blockers for the treatment of angina pectoris) or to enhance collateral function (eg, a walking program for superficial femoral occlusion, experimental angiogenesis) may be of some benefit, these approaches generally offer less complete return of normal physiology and relief of ischemic symptoms than does direct revascularization of the occluded vessel. With surgical bypass, the nature of the occlusion (its length, duration, tortuosity, calcification) is less important than the presence of a suitable distal anastomotic target. On the other hand, with catheter-based techniques, success depends heavily on these lesion characteristics. In fact, crossing such occluded segments with a guidewire remains the dominant barrier to catheter-based treatments of occluded arterial segments. Once the guidewire has been passed successfully into the distal true lumen, the process of dilating and stenting the segment is usually straightforward and durable, at least with the use of drug-eluting stents in coronary CTOs. 1,2 Article p 1101Devices designed to cross CTOs should have 3 key features: an ability to distinguish a true luminal path from one created within (dissection) or through (perforation) the vessel wall of the occluded segment, an ability to change direction (steer) to correct deviations from the desired path through the occlusion, and an ability to penetrate the frequently fibrotic and focally calcific substance of the occlusion through the use of either mechanical stiffness or an alternative energy modality (laser, radiofrequency, ultrasound, blunt microdissection).Despite these seemingly simple requirements, devices that have emphasized only the third feature-penetrating powerhave generally failed to deliver significant enhancements in their ability to cross the occluded segment and reenter the distal true lumen, because they can easily enter a vessel wall dissection plane (the path of least resistance) within the occlusion and then remain next to (rather than within) the distal true lumen. 3 Fluoroscopic or intravascular ultrasoundguided devices can then be used to attempt puncture back into the distal true lumen to augment the success of such devices. Secondary success for crossing lesions that are uncrossable with conventional guidewire, however, is only 50% to 60%. On the other hand, if the energy source leads to frank perforation of the vessel wall, safe conclusion of the procedure may be difficult (except in the superficial femoral, where it may be possible to negotiate alo...

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Section: Article P 1101mentioning

confidence: 99%

Section: Article P 1101mentioning

confidence: 99%

Section: Article P 1101mentioning

confidence: 99%

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Is Magnetic Resonance Image Guidance the Key to Opening Chronic Total Occlusions?

Baim

Kwong

2006

Circulation

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“…Modern scanners designed for the interventional environment can provide real-time images of acceptable quality in excess of 10 frames per second. As a result, real-time MRI (rtMRI) is becoming an attractive method for many minimally invasive cardiac interventions (Kuehne et al, 2003, Raval et al, 2006, Henk et al, 2005, McVeigh et al, 2006, Horvath et al, 2007. However the confined physical space of MRI scanner challenges medical intervention, even the magnets with open architecture provide only a limited working space, at the expense of image quality.…”

Section: Introductionmentioning

confidence: 99%

MRI Compatible Robot Systems for Medical Intervention

Li¹,

Mazilu²,

Kapoor³

et al. 2010

Advances in Robot Manipulators

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“…More promising future technologies might include forward-looking intravascular ultrasound [7,8] or perhaps better, conducting the entire recanalization procedure under real-time MRI guidance [9] to assure wholly intraluminal guidewire traversal.…”

mentioning

confidence: 99%

Recanalization of chronic peripheral artery occlusions: Moving forward by looking sideways

Lederman

2008

Cathet Cardio Intervent

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Chronic peripheral artery occlusions can be challenging to recanalize. Two general strategies are prevalent, and neither is necessarily under the direct control of the operator. In the classic (and in my opinion favored) "centriluminal" technique, the operator attempts to direct guidewires in tandem with controlling catheters to traverse the occlusive atheroma while remaining within the confines of the arterial media. The second technique, inaptly called the "subintimal" approach [1,2], in some ways resembles a controlled perforation in both ease and (in my opinion) attractiveness. The guidewire traverses the occlusion by entering a shallow subadventitial plane using a large guidewire "knuckle" and afterwards can reenter the patent distal arterial lumen. In both techniques, conventional imaging usually provides few robust cues about the true course of the guidewire within the occlusion.In this issue, Kawasaki and colleagues [10] report their experience assuring an intraluminal guidewire trajectory using adjunctive intravascular ultrasound (IVUS) imaging. They take advantage of a new low-profile hydrophilic 0.018*Prime; guidewire (not available in the United States) and generous tolerances apparently afforded by a 0.014*Prime;-rated commercial phased-array IVUS catheter. They use the IVUS catheter as their support device. In the Kawasaki centriluminal approach, the side-looking IVUS device is advanced over the guide-wire step-by-step to assure an appropriate intraluminal position. When the position appears subadventitial, both the IVUS and the guidewire are retracted and redirected before advancing again. Unfortunately, this technique identifies an unsuitable position only in retrospect, since the IVUS device is oriented not forwards but sideways, and the ultrasound transducer is positioned at least 10-15 mm proximal to the guidewire tip.Such retrospective image guidance is analogous to driving through a tunnel watching only the side windows, hoping the front of the car passes or crumples safely. Fortunately in the Kawasaki experience, peripheral artery occlusions were fairly forgiving, in that short distances of unfavorable subadventitial axial advancement of the devices appeared well-tolerated. The authors report a significantly improved success rate and reduced iodinated radiocontrast exposure, although not procedure time or radiation exposure.Other adjuncts are available to enhance conventional radiographic guidance of iliofemoral CTO recanalization, including optical interferometry More promising future technologies might include forward-looking intravascular ultrasound [7,8] or perhaps better, conducting the entire recanalization procedure under real-time MRI guidance [9] to assure wholly intraluminal guidewire traversal.

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Real-Time Magnetic Resonance Imaging–Guided Endovascular Recanalization of Chronic Total Arterial Occlusion in a Swine Model

Cited by 57 publications

References 45 publications

Is Magnetic Resonance Image Guidance the Key to Opening Chronic Total Occlusions?

Is Magnetic Resonance Image Guidance the Key to Opening Chronic Total Occlusions?

MRI Compatible Robot Systems for Medical Intervention

Recanalization of chronic peripheral artery occlusions: Moving forward by looking sideways

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