The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention

Objective: With the evolution of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) technique and equipment, the success rate of CTO PCI has improved over the years.We examined the failed cases in this expert registry and looked at the mode of failure.Methods: In 2016, consecutive CTO PCI performed by eight high volume CTO with an agreed CTO algorithm were examined in a registry.Results: There was a total of 485 patients with 497 CTOs were treated with technical and procedural success rates of 93.8% and 89.9%, respectively. The mean J-CTO score was 2.9 ± 1.2. The main mode of failure in cases with only antegrade attempt was inability to wire to true lumen despite advanced antegrade wiring technique for example, parallel wiring or IVUS guided wiring (10 out of 11 cases). The mode of failure in retrograde attempt was: 30% was due to inability to wire the collateral channel; 30% was due to failed reverse controlled antegrade and retrograde subintimal tracking (CART); 30% was due to inability to cross CTO by retrograde microcatheter. Four cases were terminated prematurely due to procedure complications.Conclusion: Similar to previous reported studies, primary failure mode of only antegrade attempt was inability to wire to true lumen. However, contrary to other registries where failure to cross the retrograde channel with wire was the predominant failure mode, the retrograde failure mode was equally divided between failure to cross the channel with wire, failure to do reverse CART, and failure to cross the CTO with the microcatheter. K E Y W O R D Schronic total occlusion, percutaneous coronary intervention, percutaneous coronary intervention registry, technical failure

Section: Discussionsupporting

confidence: 79%

Section: Discussionsupporting

confidence: 79%

Procedure failure of chronic total occlusion percutaneous coronary intervention in an algorithm driven contemporary Asia‐Pacific Chronic Total Occlusion Club (APCTO Club) multicenter registry

Chan

Yan

et al. 2019

“…It was clearly the operator. Several series from experienced operators and centers have demonstrated similarly high success rates of 85–90%, in contrast to approximately 60% success rates reported by general PCI registries . CTO PCI is a highly specialized procedure that requires dedicated expertise and should be performed by operators and centers that have invested and continue to invest the time and energy required to develop the necessary skills.…”

mentioning

confidence: 98%

Chronic total occlusion percutaneous coronary intervention failure: Learning from failure

Karatasakis

Brilakis

2019

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Experienced operators can achieve high success rates in chronic total occlusion percutaneous coronary intervention.• Complications remain an important cause of chronic total occlusion intervention failure. Every effort should be made to prevent them and treat them appropriately should they occur.• The most common failure mechanism for antegrade cases is failure to cross the occlusion with a guidewire. For retrograde cases the causes of failure are inability to cross the collateral (one third), inability to perform reverse CART (one third), and inability to cross with a microcatheter after guidewire crossing (one third).Failure is part of every human endeavor, including chronic total occlusions (CTO) percutaneous coronary intervention (PCI). Failure can be frustrating and demoralizing and lead to withdrawal or "blaming others". Failure can also be a source of learning and growth. The Asia Pacific CTO Club (APCTO Club) took the latter approach and provides us with insightful lessons from failed CTO PCI cases performed in 2016 by eight expert operators. 1 First, failure rates were low: 6.2% technical failure and 11.1% procedural failure. In other words, 9 out of

“…Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can be challenging to perform, especially in more complex lesions and in patients with prior coronary artery bypass graft surgery (CABG). The hybrid algorithm for CTO PCI advocates dual coronary angiography that is carefully reviewed to determine the initial crossing strategy, followed by change of crossing strategies (antegrade wiring, antegrade dissection and re‐entry, and the retrograde approach) until crossing is achieved . Use of the hybrid algorithm has been associated with success rates of 85–90% in various contemporary registries .…”

mentioning

confidence: 99%

“…However, some cases (10–15%) still fail. Moreover, in some cases, use of advanced techniques (such as retrograde crossing through tortuous and small epicardial collaterals) carries increased risk for complications, especially in prior CABG patients . In other cases, the procedure needs to stop due to high radiation dose or administration of large contrast volume.…”

mentioning

confidence: 99%

Hybrid 2.0: Subintimal plaque modification for facilitation of future success in chronic total occlusion percutaneous coronary intervention

Hall

Brilakis

2019

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