Subintimal dissection/reentry techniques are increasingly being used for crossing coronary chronic total occlusions both antegradely (using a knucle wire or the Bridgepoint system) or retrogradely (using the controlled antegrade and retrograde tracking and dissection, and reverse controlled antegrade and retrograde tracking and dissection technique). Subintimal dissection/reentry techniques can increase procedural success rates, but their subsequent clinical outcomes are poorly studied, and they appear to be associated with high rates of in-stent restenosis and repeat target lesion revascularization. In the present review, we describe in detail the chronic total occlusions subintimal dissection/reentry techniques, clarify the related terminology and summarize the published studies in this area and the current gaps of knowledge.

Subintimal Dissection/Reentry Strategies in Coronary Chronic Total Occlusion Interventions

Background
Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) is challenging and has been associated with low success rates. However, recent advancements in equipment and the flexibility to switch between multiple technical approaches during the same procedure (“hybrid” percutaneous algorithm) have dramatically increased the success of CTO PCI. We sought to compare the contemporary procedural outcomes of “hybrid” CTO with previously published CTO PCI studies.

The efficacy and safety of the "hybrid" approach to coronary chronic total occlusions: Insights from a contemporary multicenter US registry and comparison with prior studies

https://www.internationaljournalofcardiology.com/article/S0167-5273(14)00663-9/pdf

Angiographic success and procedural complications in patients undergoing retrograde percutaneous coronary chronic total occlusion interventions: A weighted meta-analysis of 3482 patients from 26 studies

Background— The performance of the Japan–chronic total occlusion (J-CTO) score in predicting success and efficiency of CTO percutaneous coronary intervention has received limited study.

Methods and Results— We examined the records of 650 consecutive patients who underwent CTO percutaneous coronary intervention between 2011 and 2014 at 6 experienced centers in the United States. Six hundred and fifty-seven lesions were classified as easy (J-CTO=0), intermediate (J-CTO=1), difficult (J-CTO=2), and very difficult (J-CTO≥3). The impact of the J-CTO score on technical success and procedure time was evaluated with univariable logistic and linear regression, respectively. The performance of the logistic regression model was assessed with the Hosmer–Lemeshow statistic and receiver operator characteristic curves. Antegrade wiring techniques were used more frequently in easy lesions (97%) than very difficult lesions (58%), whereas the retrograde approach became more frequent with increased lesion difficulty (41% for very difficult lesions versus 13% for easy lesions). The logistic regression model for technical success demonstrated satisfactory calibration and discrimination ( P for Hosmer–Lemeshow =0.743 and area under curve =0.705). The J-CTO score was associated with a 2-fold increase in the odds of technical failure (odds ratio 2.04, 95% confidence interval 1.52–2.80, P <0.001). Procedure time increased by ≈20 minutes for every 1-point increase of the J-CTO score (regression coefficient 22.33, 95% confidence interval 17.45–27.22, P <0.001).

Conclusions— J-CTO score was strongly associated with final success and efficiency in this study, supporting its expanded use in CTO interventions.

Clinical Trial Registration— URL: . Unique identifier: [NCT02061436][1].

 [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT02061436&atom=%2Fcirccvint%2F8%2F7%2Fe002171.atom

Clinical Utility of the Japan-Chronic Total Occlusion Score in Coronary Chronic Total Occlusion Interventions: Results from a Multicenter Registry.

Objectives The purpose of this study was to evaluate long-term clinical outcomes after drug-eluting stent–supported percutaneous coronary intervention (PCI) for native coronary total occlusion (CTO). Background The benefit of successful recanalization of CTO on prognosis remains uncertain. Methods Between March 2003 and May 2014, 1,173 consecutive patients with CTO of native coronary vessels requiring PCI were enrolled. Drug-eluting stent implantation was performed in all successful procedures (1,004 patients, 85.6%). Results During a median follow-up of 4.6 years, the adjusted risks of all-cause mortality (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 0.53 to 2.04; p = 0.92) and the composite of death or myocardial infarction (HR: 1.05; 95% CI: 0.56 to 1.94; p = 0.89) were found to be comparable between patients with successful and failed CTO-PCI, whereas the adjusted risk of target vessel revascularization (HR: 0.15; 95% CI: 0.10 to 0.25; p  Conclusions Successful CTO-PCI compared with failed PCI was not associated with a lesser risk for mortality. However, successful CTO-PCI was associated with significantly less subsequent coronary artery bypass grafting.

Successful Recanalization of Native Coronary Chronic Total Occlusion Is Not Associated With Improved Long-Term Survival

Objective
Percutaneous treatment of coronary chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The strategies of recanalisation in CTO have changed drastically due the development of new techniques such as the retrograde approach via collaterals. In this single-centre experience we sought to analyse the success rates with the use of different CTO techniques, the complication rates, and we evaluated predictors of failed CTO recanalisation attempts.

/pdf/recanalisation-of-coronary-chronic-total-occlusions-with-new-4ywmn6uja2.pdf

H. Guelker

Papers

Recanalisation of coronary chronic total occlusions with new techniques including the retrograde approach via collaterals