Chronic Total Occlusion, An issue of Interventional Cardiology Clinics Book

Preface: The Final Frontier of Percutaneous Coronary Intervention-Coronary Chronic Total Occlusions William L. Lombardi ix

Rationale for Percutaneous Intervention of CTO Kethes C. Waram Nicholas P. Willis Sudhakar Girotra Rimon L. Shaker Ashish Pershad 265

Chronic total occlusion accounts for 15% of cases during diagnostic angiography with higher referral rate to surgical revascularization. With contemporary strategies and techniques, the success rate with experienced operators can exceed 90%. Currently available observational studies in carefully selected patient populations show evidence of a trend toward symptom relief; improvement in quality of life, left ventricular function, and mortality; and improved tolerance toward future ischemic events. Lack of randomized controlled trials comparing current optimal medical management with percutaneous coronary intervention for chronic total occlusion is a major barrier to widespread adaptation of this advanced complex interventional technique.

Toolbox and Inventory Requirements for Chronic Total Occlusion Percutaneous Coronary Interventions Khaldoon Alaswad 281

More interventional cardiologists are adopting chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in their practice. This article follows the steps of the PCI procedure to describe the toolbox and inventory requirements for successful program development. Recent innovations have allowed adoption of controlled dissection and reentry techniques as a primary revascularization strategy for CTO. Other devices have special rules in CTO PCI. Equipment and techniques to enhance guide catheter support are frequently needed during CTO PCI. Tools for complication management are important components. The necessary tools are listed at the end of the article.

CTO PCI Procedural Planning Nicholas J Lembo Dimitri Karmpaliotis David E. Kandzari 299

Chronic total occlusion percutaneous coronary intervention (CTO PCI) procedural planning involves much thought and deliberation before one actually attempts to cross the CTO lesion in the cardiac catheterization laboratory. Careful preprocedural angiographic assessment is a key to successful CTO PCI. CTO PCI represents the most complex PCI one can perform, and thus operator and staff training as well as the concept of CTO days are all essential for a successful CTO PCI program.

Wire Strategy as a First Option: Properties of the Tools M. Nicholas Burke 309

This article discusses interventional guidewires in general and how they are best used in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in particular. The components that make a guidewire and the various design options are described. The specific characteristics of these options and how they relate to various aspects of PCI are discussed. Guidewire design as it applies specifically to the tasks particular to CTO PCI is discussed.

Antegrade Dissection and Reentry: Tools and Techniques R. Michael Wyman 315

The hybrid approach to chronic total occlusion percutaneous coronary intervention requires facility with antegrade and retrograde strategies to achieve high success rates in a time-efficient and safe manner. Antegrade dissection and reentry is an integral component of this approach but historically has been limited by low success rates and an inability to control the site of reentry. The advent of the BridgePoint device, and multiple iterations of technique in conjunction with its use, have markedly improved success rates and procedure efficiency.

Retrograde Procedural Planning, Skills Development, and How to Set Up a Base of Operations James C. Spratt Julian W. Strange 325

This article addresses the practical steps required when adopting retrograde access as part of the treatment of chronic total occlusions (CTOs). The article focuses on procedure rationale, equipment required, the practical steps, and considerations involved in collateral-channel crossing and setting up a "base of operations" at the proximal cap of the CTO. It also describes simple methods of wire escalation.

Retrograde Dissection Reentry for Coronary Chronic Total Occlusions Tony J. DeMartini 339

The retrograde technique is an important aspect to overall success in percutaneous coronary intervention of chronic total occlusions. The reverse controlled antegrade and retrograde subintimal tracking technique is the most commonly used retrograde approach for recanalization as either a primary approach or after unsuccessful antegrade dissection reentry. A stepwise approach to this technique is the key to success.

The Final Steps of the Retrograde Technique: Wire Externalization, Stenting, and Wire Removal J. Aaron Grantham 345

A guidewire can be externalized after retrograde lesion crossing. Wire externalization provides excellent support for ballooning and stenting and for the treatment of chronic total occlusion lesions that are long calcified, tortuous, and difficult to treat. This review discusses the final steps of the retrograde technique via wire externalization, stenting, and wire removal.

The Hybrid Approach for Percutaneous Revascularization of Coronary Chronic Total Occlusions Craig A. Thompson 349

Percutaneous recanalization of coronary chronic total occlusions (CTOs) has been limited by inability to consistently achieve wire position in the distal true lumen across the CTO segment, preventing many patients from having percutaneous coronary intervention (PCI). Furthermore, low success rates, prolonged case times, and wide variability in approaches has resulted in lower adoption of CTO PCI as a routine procedure and has limited educational initiatives. The hybrid approach for CTO PCI is predicated on an algorithm that allows trained operators to react to angiograms and craft strategies in a similar manner, enabling technical success and efficiency.

Transradial Approach for Chronic Total Occlusion Percutaneous Coronary Intervention Rodrigo Bagur Stéphane Rinfret 355

Over the last two decades, the transradial approach has gained an important role in interventional cardiology. A large body of evidence exists supporting the safety and feasibility of the transradial approach in a broad spectrum of patients and settings. In addition, the transradial approach has been applied with good results for chronic total occlusion (CTO) recanalization. This article provides an overview of basic principles and techniques required to perform successful transradial CTO percutaneous coronary intervention.

Informed Consent of the Chronic Total Occlusion Patient Evan Lau Patrick Whitlow 365

This article focuses on the general principles of informed consent, then highlights the particular risks associated with chronic total occlusion interventions. The goal is to provide a basic framework for the interventional cardiologist to use when having consent discussions with his or her patients.

Complications of Chronic Total Occlusion Angioplasty Emmanouil S. Brilakis Dimitri Karmpaliotis Vishal Patel Subhash Banerjee 373

Every percutaneous coronary intervention carries risk for acute and long-term complications. This is also true of chronic total occlusion (CTO) interventions, which can also have complications specific to specialized techniques, such as retrograde crossing and dissection/reentry techniques. Acute CTO intervention complications can be coronary artery-related, cardiac noncoronary, or noncardiac. In the long term, CTO interventions can be complicated by in-stent restenosis, stent thrombosis, or coronary aneurysm formation. Understanding of the pathogenesis of possible CTO intervention complications can facilitate prevention, early recognition, and prompt treatment.

Percutaneous Chronic Total Occlusion Revascularization: Program Development, Resource Utilization, and Economic Outcomes Dimitri Karmpaliotis Nicholas J. Lembo Emmanouil S. Brilakis David E. Kandzari 391

Against the background of current data supporting indications for chronic total occlusion (CTO) revascularization and strategies that promote incrementally higher procedural success rates, this article introduces a multidisciplinary approach to CTO program development, establishes guidelines for the performance of safe and efficient CTO percutaneous coronary intervention, and reviews considerations related to resource utilization and economic outcomes with complex percutaneous coronary revascularization.

Index 397