Retrograde Techniques and the Impact of Operator Volume on Percutaneous Intervention for Coronary Chronic Total Occlusions

Thompson, Craig A.; Jayne, John E.; Robb, John F.; Friedman, Bruce J.; Kaplan, Aaron V.; Hettleman, Bruce; Niles, Nathaniel W.; Lombardi, William

doi:10.1016/j.jcin.2009.05.022

Cited by 218 publications

(155 citation statements)

References 17 publications

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“…Operator volumes in CTO PCI significantly affect success rates. In a recent analysis by Thompson et al, 17 high-volume CTO operators had a significantly higher PCI success rate than low-volume CTO operators (75.2% versus 58.9%; PϽ0.001) when using retrograde access techniques. In addition to skilled operators, it is imperative that such centers have the catheterization laboratory resources to perform these complex cases.…”

Section: The Importance Of Operator and Center Experiencementioning

confidence: 95%

Management of Coronary Chronic Total Occlusion

Shah

2011

Circulation

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A 67-year-old man with chronic stable angina presented with worsening angina to class III despite maximal medical therapy. He was referred for myocardial perfusion imaging, which showed a large area of inferior ischemia. Subsequent coronary angiography revealed a chronic total occlusion (CTO) of the right coronary artery with brisk collateral flow from the left anterior descending artery (Figure 1). There was minimal obstructive disease in the remainder of the coronary tree. An attempt at percutaneous coronary intervention (PCI) was unsuccessful. He was treated with continuation of his medical therapy, although he remained with lifestyle-limiting class II to III angina. Chronic Total Occlusion: Definition, Incidence, and PresentationCoronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. 1 Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment-elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment-elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO. Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. 2,3 Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself. 4 -6

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Section: The Importance Of Operator and Center Experiencementioning

confidence: 95%

Management of Coronary Chronic Total Occlusion

Shah

2011

Circulation

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“…To treat patients safely and effectively, there needs to be a cadre of interventional cardiologists who possess the skill sets necessary to perform complete revascularization safely and effectively in the most complex and higher-risk patients. In the current era of PCI with advances in functionally based revascularization, adjunctive pharmacology, and PCI techniques and devices, the success rates for treating the most complex lesion subsets have improved among operators trained in specialized techniques 45,46 but have remained significantly lower among everyday interventionalists. 47 Armed with the knowledge of how and when to use these techniques, dedicated interventionalists with expertise in treating these patients could be more apt to choose the optimal treatment strategies and, most important, improve overall outcomes in these patients.…”

Section: Multidisciplinary Team-based Approach To Higher-risk Cad Patmentioning

confidence: 99%

Treatment of Higher-Risk Patients With an Indication for Revascularization

et al. 2016

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Patients with severe coronary artery disease with a clinical indication for revascularization but who are at high procedural risk because of patient comorbidities, complexity of coronary anatomy, and/or poor hemodynamics represent an understudied and potentially underserved patient population. Through advances in percutaneous interventional techniques and technologies and improvements in patient selection, current percutaneous coronary intervention may allow appropriate patients to benefit safely from revascularization procedures that might not have been offered in the past. The burgeoning interest in these procedures in some respects reflects an evolutionary step within the field of percutaneous coronary intervention. However, because of the clinical complexity of many of these patients and procedures, it is critical to develop dedicated specialists within interventional cardiology who are trained with the cognitive and technical skills to select these patients appropriately and to perform these procedures safely. Preprocedural issues such as multidisciplinary risk and treatment assessments are highly relevant to the successful treatment of these patients, and knowledge gaps and future directions to improve outcomes in this emerging area are discussed. Ultimately, an evolution of contemporary interventional cardiology is necessary to treat the increasingly higher-risk patients with whom we are confronted.

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“…In the ERCTO registry, the overall registry had 11.8% cases attempted by retrograde approach; however, the retrograde approach was used in 24% of the reattempt cases (Dr A. Galassi, personal communication). Although the retrograde approach has been shown in 1 study to improve CTO success rates significantly in complex cases 22 (58.9% versus 75.2%), this particular technique is currently limited to a small number of highly trained, experienced operators because it more complex than the anterograde approach and uses increased radiation dose and contrast use. The case selection between these 2 registries and our study cannot be reliably compared.…”

Section: Discussionmentioning

confidence: 99%

Collagenase Total Occlusion-1 (CTO-1) Trial

Strauss

Osherov²,

Radhakrishnan³

et al. 2012

Circulation

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Background— Percutaneous interventions for chronic total occlusions have low success rates, primarily because of failure of guide wire crossing. Collagen-rich matrix constitutes the main barrier to chronic total occlusion crossing. In preclinical studies, local delivery of a bacterial collagenase formulation improved guide wire crossing. The Collagenase Total Occlusion-1 (CTO-1) Trial is a phase I, dose-escalation trial to assess the safety and efficacy of collagenase therapy to facilitate guide wire crossing in coronary artery chronic occlusions. Methods and Results— Twenty subjects with ≥1 previous failure of chronic total occlusion guide wire crossing were enrolled at 2 sites. Subjects were treated in 4 distinct cohorts of 5 patients, with escalation of collagenase dose in each cohort from 300 to 1200 μg. Collagenase was locally delivered into the occlusions with either an over-the-wire balloon system (n=8) or a fine-cross microcatheter (n=12) for a period of 30 minutes. Subjects were brought back to the catheterization laboratory for guide wire crossing and angioplasty the next day. Guide wire crossing was successfully achieved in 15 subjects (75%). A soft-tip guide wire (Whisper, Pilot-50, Fielder XT) was either the sole or predominant guide wire used in 75% of successful crossings. Non–ST-segment–elevation myocardial infarctions occurred in 3 patients as a result of side-branch ischemia during stenting. Computed tomographic angiography at 3 months showed no late complications and patent stents in successfully treated chronic total occlusion. Anginal improvement occurred with a reduction in Canadian Cardiovascular Society class from baseline to 3 months (2.5±0.6 versus 0.9±0.9; P <0.001). Conclusion— Local delivery of collagenase into coronary chronic total occlusion is feasible and safe with encouraging guide wire crossing results in previously failed cases. Larger clinical trials are required to determine efficacy. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01271335.

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Retrograde Techniques and the Impact of Operator Volume on Percutaneous Intervention for Coronary Chronic Total Occlusions

Abstract: Complex antegrade and retrograde "Japanese style" PCI approaches can be applied in the U.S. practice environment with high technical success and low adverse event rates. Higher CTO-specific operator case volume is associated with improved technical success rates.

Cited by 218 publications

References 17 publications

Management of Coronary Chronic Total Occlusion

Management of Coronary Chronic Total Occlusion

Treatment of Higher-Risk Patients With an Indication for Revascularization

Collagenase Total Occlusion-1 (CTO-1) Trial

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