The retrograde approach to coronary artery chronic total occlusions

Brilakis, Emmanouil S.; Grantham, J. Aaron; Thompson, Craig A.; DeMartini, Tony; Prasad, Abhiram; Sandhu, Gurpreet S.; Banerjee, Subhash; Lombardi, William

doi:10.1002/ccd.23004

Cited by 132 publications

(74 citation statements)

References 62 publications

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“…They represent the results of operators who are highly experienced in CTOs, performing more than 100 CTO procedures/year. Often they report on high success rates in both easy and difficult lesions, using different guidewires, devices and complex techniques, including retrograde and hybrid approaches [12,13] Intecc Co.) and the Progress ® -family (Abbott Vascular)), allowing operators to get familiar with a limited set of wires. With the use of this set of dedicated CTO-wires and the routine use of a microcatheter, this algorithm should simplify procedures.…”

Section: Discussionmentioning

confidence: 99%

Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI

Godino¹,

Bassanelli²,

Economou

et al. 2013

International Journal of Cardiology

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To improve the success rates of chronic total occlusion (CTO) intervention, a large range of CTO-dedicated guidewires (GWs), devices and techniques have been developed. However, such an abundant choice of materials confuses inexperienced operators. Therefore, the usefulness of a simple antegrade treatment algorithm with a limited set of GWs, for easy to intermediate lesions, was investigated. Between November 2011 and March 2013, 105 patients were included, who underwent CTO PCI following the algorithm. Lesions were classified according to the Multicenter CTO Registry of Japan score. Overall technical success was achieved in 77%. Study endpoint was successful GW crossing within 30 min and was reached in 57%. High success rates were achieved in easy (81%) and intermediate (64%) lesion types. In both types, a soft wire could successfully cross in 57% and 51% respectively, with the Fielder XT ® (Asahi Intecc Co.) capable of crossing most commonly (90%). The proposed treatment algorithm simplifies the percutaneous treatment of easy to intermediate CTO lesions. However, it merits further evaluation, especially for operators/centers who perform a low to intermediate amount of CTO PCI.

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Section: Discussionmentioning

confidence: 99%

Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI

Godino¹,

Bassanelli²,

Economou

et al. 2013

International Journal of Cardiology

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“…However, the retrograde approach is also a source of intimidation, because it requires skillsets and equipment not routinely used in routine PCI and also carries unique risks, such as donor vessel injury [2,3]. Development of the "Guideliner reverse CART" and other novel techniques is rapidly improving our ability to treat CTOs faster, easier, and safer.…”

Section: Va North Texas Healthcare System and University Of Texas Soumentioning

confidence: 99%

“…The retrograde approach involves two main steps: (a) delivering a guidewire and microcatheter distal to the occlusion via a collateral vessel and (b) crossing the CTO segment [2,3]. CTO crossing can be achieved using three techniques (Fig.…”

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confidence: 99%

Faster, easier, safer: “guideliner reverse CART” for retrograde chronic total occlusion interventions

Brilakis

2014

Cathet Cardio Intervent

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The retrograde approach has revolutionized percutaneous coronary intervention (PCI) to coronary chronic total occlusions (CTO) by significantly improving success rates [1,2]. The retrograde approach involves two main steps: (a) delivering a guidewire and microcatheter distal to the occlusion via a collateral vessel and (b) crossing the CTO segment [2,3]. CTO crossing can be achieved using three techniques (Fig. 1a): (a) using the distal true lumen guidewire as a marker for antegrade guidewire crossing ("just marker" and "kissing wire" techniques); (b) achieving "true to true" lumen crossing with the retrograde guidewire; or (c) using dissection/re-entry techniques, in which the guidewire is redirected from the subintimal space into the true lumen. There are two main dissection/re-entry techniques: in controlled antegrade and retrograde subintimal tracking (CART), a balloon is inflated over the retrograde guidewire allowing the antegrade guidewire to enter the distal true lumen. In reverse CART a balloon is inflated over the antegrade guidewire followed by retrograde guidewire crossing into the proximal true lumen using the space created by the antegrade balloon inflation.With the advent of the channel dilator (Corsair, Asahi Intecc, Nagoya, Japan), reverse CART is currently the most commonly utilized retrograde CTO crossing technique, since it is very common for the antegrade and retrograde guidewires to enter the subintimal space during CTO segment crossing attempts, especially in long occluded segments. Reverse CART also allows for wire externalization, which provides the strongest support for balloon/stent delivery. However, reverse CART may be difficult to perform, necessitating the development of several facilitating techniques. One such technique is the use of large balloons over the antegrade guidewire. Another technique is the use of intravascular ultrasonography, which allows better understanding of the spatial relationship between the antegrade and retrograde guidewires, plaque morphology, vessel size, and allows selection of suitable size balloon for subintimal space dilation [4]. Still, recoil of the subintimal space may occur, even when adequately sized balloons are used. To solve this problem, several additional techniques were developed. The "stent reverse CART" technique involves deploying a stent over the antegrade wire in the subintimal space to create a target for the retrograde wire. Deploying a snare in the antegrade subintimal space can prevent recoil and facilitate retrograde wire crossing into the antegrade true lumen. However, "stent reverse CART" cannot be reversed, i.e. a deployed stent cannot be retrieved and the use of a snare can be cumbersome and expensive.In this issue of the Journal, Mozid et al. describe a novel and elegant modification of reverse CART, the "Guideliner reverse CART" [5] (Fig. 1b). A guide catheter extension is advanced over the antegrade guidewire, creating a new "target" for the retrograde guidewire to enter. This technique can achieve re-entry faster and safer ...

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“…Subintimal contrast injection may result in compression of the distal true lumen and decrease the likelihood of successful re-entry. That is why many experienced US CTO operators strongly advise against contrast injection through a microcatheter to confirm distal wire position after CTO crossing and rely on contralateral injection or intravascular ultrasonography instead [7]. Finally, the high restenosis rates could potentially be lowered by optimizing the acute procedural result, for example by liberal use of intravascular imaging and by using second generation drug-eluting stents.…”

mentioning

confidence: 95%

Dancing with the “star”: The role of subintimal dissection/re‐entry strategies in coronary chronic total occlusion interventions

Brilakis

Banerjee

2012

Cathet Cardio Intervent

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There is currently a fierce debate among coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) experts who advocate that dissection/re-entry CTO crossing should be avoided at any cost, and those who believe that dissection/re-entry is acceptable or even preferred, both as a primary approach to CTOs (to maximize efficiency) and when other techniques fail [1]. Given that both sides provide rational arguments, the debate is likely to continue, until outcome data becomes available.In this issue of the Journal Godino et al., a group whose tremendous contributions have pioneered the field of subintimal CTO interventions, present muchneeded mid-term outcome data of the contrast-guided subintimal tracking and re-entry (STAR) technique [2]. In their CTO practice, the contrast-guided STAR technique was used in approximately 20% of cases of successful CTO PCI after conventional attempts failed. Although conclusions are limited since only successful procedures were included in the present analysis, the contrast-guided STAR technique appeared to be safe, with low risk for periprocedural myocardial infarction. This is quite important given that side branches are likely to occlude after subintimal crossing followed by stenting. During 2 years of follow-up, the risk of stent thrombosis was low and similar to conventional CTO crossing techniques. However, the contrast-guided STAR technique was associated with significantly higher angiographic restenosis rates (54% vs. 30%) and need for target vessel revascularization (48% vs. 21%). Moreover, approximately 40% of restenosis in both groups was occlusive.Godino et al. convincingly demonstrate that the risk of restenosis after CTO PCI using the contrast-guided STAR technique is much higher than the conventional antegrade CTO crossing techniques. This is similar to the outcomes of the original STAR technique [3] and suggests that the contrast-guided STAR technique should not be used as a primary, but only as bailout strategy. Moreover, given the high-restenosis rates, routine angiographic follow-up at 3-6 months may be of value in such patients to identify early restenosis and prevent it from becoming occlusive.Several questions remain: First, is it preferable to use subintimal dissection/reentry to successfully recanalize a CTO or to abort the procedure if subintimal entry occurs? Although most CTO operators would choose the former over the latter accepting the higher restenosis rate (especially for patients who are not candidates for surgical revascularization), the question remains open.Second, are dissection/re-entry techniques safe? Although no major complications, such as stent thrombosis or aneurysm formation were not observed with guided STAR in this study, additional studies are needed to confirm that adverse long-term sequelae are indeed rare [4].Third, can the high-restenosis rates observed with contrast-guided STAR be extrapolated to other dissection re-entry techniques? There are many reasons why the answer may be no. Contrast-guided STAR creates...

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The retrograde approach to coronary artery chronic total occlusions

Cited by 132 publications

References 62 publications

Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI

Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI

Faster, easier, safer: “guideliner reverse CART” for retrograde chronic total occlusion interventions

Dancing with the “star”: The role of subintimal dissection/re‐entry strategies in coronary chronic total occlusion interventions

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