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Table of Contents
Intro
Foreword
Preface of the First edition
Preface of the Second edition
Contents
About the Editor
1: What Is What: Important Definitions in Chronic Total Occlusion Percutaneous Coronary Intervention
Introduction
Anatomical and Procedural Definitions
Efficacy and Safety Endpoints
Conclusion
References
2: The Histopathophysiology of Chronic Total Occlusion and Its Impact on Mode of Treatment
Introduction
Mechanisms of Lesion Progression and Histologic Studies of CTO
Characteristics of the Arterial Wall
The Lesion Characteristics of CTO With or Without Prior CABG
Clinical Translation from a Pathological Point of View
Conclusions
References
3: Who Are Best Candidates for Chronic Total Occlusion Revascularization
Introduction
Prior Evidence
EXPLORE Trial
REVASC Trial
EUROCTO Trial
DECISION-CTO Trial
Conclusions from Trials
Which Patients Are Best Candidates?
Final Remarks
Conclusions
References
4: Why, When and How to Assess Ischemia and Viability in Patients with Chronic Total Occlusions
Introduction
Ischemia, Hibernation, and Viability
Why to Assess Ischemia and Viability?
Ischemia
Ischemia and Collaterals, and After Opening the CTO
Ischemia and Prognosis
Ischemia and Symptoms
Viability
When to Assess Ischemia and Viability?
Guideline Recommendations
STEMI Patients with a CTO
Stable Patients with a CTO
Case Examples
How to Assess Ischemia and Viability?
Ischemia
Nuclear Myocardial Perfusion Imaging
Stress Echocardiography
Stress Cardiac Magnetic Resonance Imaging
Viability
Stress Echocardiography
Cardiac Magnetic Resonance Imaging
Nuclear Imaging
Conclusion
References
5: How to Set Up a Chronic Total Occlusion Angioplasty Program
Introduction
Developing CTO Skills.
Operator Selection
Operator Training
CTO Program Built Around Two Operators
Infrastructure
Cardiac Catheterization Laboratory Volume
Cardiac Catheterization Laboratory
Cardiac Surgery Program/Extracorporeal Membrane Oxygenation (ECMO)
Nonmedical Staff
Administrative Support
Quality Control
Pre-procedure: CTO Clinic
Pre-PCI Explanation of the Plan
Post Procedure: CTO Rounds
Getting Started, the Practicalities
References
6: Equipment Requirement for Chronic Total Occlusion Percutaneous Coronary Intervention
Sheaths
Guide Catheters
Microcatheters
Finecross
Corsair Series
Turnpike Series
Mamba Series
Guidewires
Dissection/Reentry Equipment
Guide Catheter Extensions
Snares
Equipment for "Uncrossable-Undilatable" Lesions
Intravascular Ultrasound (IVUS)
Complication Management Equipment
References
7: The Hybrid Approach and Its Variations for Chronic Total Occlusion Percutaneous Coronary Intervention
Introduction and Historical Perspective
Simplifying the Complex
The Algorithms.... Combined
Who Should Do the Procedure?
Pre-procedure Coronary CT Angiography
Choosing the Initial Strategy
Antegrade Wiring
Secondary and Bailout Strategies with Primary AW Approach
Antegrade Dissection and Reentry (ADR)
The Retrograde Approach
In-Stent Chronic Total Occlusion
Switching Strategies
Ending the Procedure
Conclusions
References
8: When, Why, and How to Perform Good Angiographic Analysis Before CTO PCI
Introduction
When and Why
How
CTO Angiography
CTO Angiographic Analysis
Target Vessel
CTO Characteristics
Donor Vessels
Collateral Circulation
Collateral Pathways
Interventional Collaterals
Conclusion
References
9: Specific Basic Techniques to Master in CTO PCI
Approaching the CTO Segment.
Wire Manipulation Techniques in CTO
Trapping Balloon Technique
References
10: When, Why and How to Perform an Antegrade Approach Using a Wiring Technique
Introduction
Anatomical Subsets That Favor Antegrade Wiring
Lesion Length
Proximal Cap Anatomy
In-CTO Tortuosity (>
45°)
Presence of Intra-CTO Calcium
Previous Procedural Failure
Other Factors
Degree of Disease in the "Distal Landing Zone"
Presence of "Interventional Collaterals"
Basic Principles of CTO PCI
Planning
Visibility
Backup Support
Use of "Over-the-Wire" Equipment
Wire Selection
Tapered Polymer-Coated Wires
Medium Weight Wires
High Gram Weight Wires
The Proximal Cap and How to Assess It
Wire Selection: Principles and Rationale
Polymer-Coated Wires
Penetration Force
Tactile Feel
Torque Transmission
Wire Selection
Wire Shaping
Confirming Progress and Ensuring Safety
Confirming True Lumen Entry
Angiographically
Wire Feel
Intravascular Ultrasound (IVUS)
Advancing Equipment
Anchor Balloon
Guide Extension
Higher Support Microcatheter
Laser Atherectomy
Rotational Atherectomy
Indications and Use of Adjunctive Imaging Strategies
CTA
IVUS
When to Switch Strategy
References
11: When, Why, and How to Perform Wire-Based Antegrade Dissection and Reentry Technique
References
12: When and How to Perform Contemporary Device-Based Antegrade Dissection and Re-entry Technique
Introduction
Evolution of Strategies for ADR
Primary ADR: A Step-by-Step Approach
Troubleshooting ADR Procedures and Bailout Manoeuvres
Outcomes with ADR in Contemporary Practice
Conclusions
References
13: How to Deal with Difficult Antegrade Issues
Difficult Antegrade Issues That Apply to Both AW and ADR
Ambiguous Proximal Cap
Impenetrable Cap.
Uncrossable Lesion
Difficult Antegrade Issues That Are Unique to Antegrade Dissection Reentry
Crossboss Challenges
Reentry Challenges
References
14: Intra-occlusion Microinjection of Contrast: When, Why, and How
References
15: When, Why, and How to Perform the Antegrade Fenestration and Reentry Technique
Introduction
Pathophysiological Bases and Development of Antegrade Fenestration and Reentry (AFR)
Procedural Description of Antegrade Fenestration and Reentry (AFR)
Real-Life Experience with Antegrade Fenestration and Reentry (AFR)
Role of Antegrade Fenestration and Reentry (AFR) in the Hybrid Algorithm
Further Developments in Antegrade Fenestration and Reentry (AFR)
Conclusions
References
16: When, Why, and How to Perform the Retrograde Approach Through Septal Collateral Channels
When to Select the Retrograde Approach: How to Analyze the Coronary Angiography
How to Set Up the Procedure
Pathways to the Distal Cap (Table 16.1)
Collateral Channels
Step-by-Step Approach
Selecting the Microcatheter, Crossing the Collateral Channel with a Wire, and the Microcatheter
Selecting the Microcatheter
Crossing a Septal CC with the Wire
Surfing from PDA to LAD: A More Difficult Task
Advancing the Microcatheter to the Distal Cap Through the Septal CC
Special Situations and Considerations
Using an Internal Mammary Artery as a Donor Artery to Septal CCs
LAD or LCX CTOs in a Dominant Left System
References
17: When, Why, and How to Perform the Retrograde Approach Through Epicardial and Non-septal Collateral Channels
When to Perform Retrograde CTO PCI Via Non-septal Connections? Anatomic Evaluation
Algorithms for Performing Retrograde Approach
Collateral Channel Scores
Why Performing Retrograde CTO PCI Via Non-septal CCs? Clinical Evaluation.
Indication and Timing of Using Non-septal Collateral CCs
Risk-Benefit Assessment of Selecting Non-septal CCs
How to Perform Retrograde CTO PCI Via Non-septal Connections: Practical Considerations
Arterial Access
Non-septal Collateral Channel Crossing
Crossing the CTO
Externalization
Complications Related to Retrograde CTO PCI Via Non-septal Connections
Perforation of the CC When the CTO Is Crossed
Perforation of the CC When the CTO Remains Uncrossed
References
18: When, Why, and How to Perform the Retrograde Approach Through Patent or Occluded SVGs
Introduction
CTO PCI in Post-CABG Patients
Retrograde Approach Through an SVG
Retrograde Via Diseased But Patent SVGs
Retrograde Via Occluded SVGs
Guide Extensions in SVGs
Specific Situations
Stumpless SVG Use
Retrograde Access Via Acutely or Recently Thrombosed SVG in ACS Patients
How to Deal with Acute Angle of Distal Anastomosis
Distal Anastomosis Ambiguity
Stenting Coronary Across Distal SVG Anastomosis After CTO PCI
Dealing with Anastomotic Stents in SVGs
Protecting the Graft
What To Do with the SVG Once the Native Artery CTO is Open?
Potential Complications When Using SVGs as Retrograde Conduits
Distal Embolization
SVG Perforation
Aortic Dissection
Mediastinal Bleeding/Haematoma
References
19: How to Cross the Occlusion Using a Retrograde Approach, How to Externalize, and How to Snare Long Wires
Introduction
Retrograde Wiring
Wire Choice
Confirming Wire Position
Note on Safety in RW
Retrograde Dissection and Re-entry
Creating an Antegrade Dissection
Use of Guide Catheter Extension
Creating a Retrograde Dissection
Joining the Spaces
Externalization
Use of Snare for Externalization
Principles of Snaring
How to Snare.
Foreword
Preface of the First edition
Preface of the Second edition
Contents
About the Editor
1: What Is What: Important Definitions in Chronic Total Occlusion Percutaneous Coronary Intervention
Introduction
Anatomical and Procedural Definitions
Efficacy and Safety Endpoints
Conclusion
References
2: The Histopathophysiology of Chronic Total Occlusion and Its Impact on Mode of Treatment
Introduction
Mechanisms of Lesion Progression and Histologic Studies of CTO
Characteristics of the Arterial Wall
The Lesion Characteristics of CTO With or Without Prior CABG
Clinical Translation from a Pathological Point of View
Conclusions
References
3: Who Are Best Candidates for Chronic Total Occlusion Revascularization
Introduction
Prior Evidence
EXPLORE Trial
REVASC Trial
EUROCTO Trial
DECISION-CTO Trial
Conclusions from Trials
Which Patients Are Best Candidates?
Final Remarks
Conclusions
References
4: Why, When and How to Assess Ischemia and Viability in Patients with Chronic Total Occlusions
Introduction
Ischemia, Hibernation, and Viability
Why to Assess Ischemia and Viability?
Ischemia
Ischemia and Collaterals, and After Opening the CTO
Ischemia and Prognosis
Ischemia and Symptoms
Viability
When to Assess Ischemia and Viability?
Guideline Recommendations
STEMI Patients with a CTO
Stable Patients with a CTO
Case Examples
How to Assess Ischemia and Viability?
Ischemia
Nuclear Myocardial Perfusion Imaging
Stress Echocardiography
Stress Cardiac Magnetic Resonance Imaging
Viability
Stress Echocardiography
Cardiac Magnetic Resonance Imaging
Nuclear Imaging
Conclusion
References
5: How to Set Up a Chronic Total Occlusion Angioplasty Program
Introduction
Developing CTO Skills.
Operator Selection
Operator Training
CTO Program Built Around Two Operators
Infrastructure
Cardiac Catheterization Laboratory Volume
Cardiac Catheterization Laboratory
Cardiac Surgery Program/Extracorporeal Membrane Oxygenation (ECMO)
Nonmedical Staff
Administrative Support
Quality Control
Pre-procedure: CTO Clinic
Pre-PCI Explanation of the Plan
Post Procedure: CTO Rounds
Getting Started, the Practicalities
References
6: Equipment Requirement for Chronic Total Occlusion Percutaneous Coronary Intervention
Sheaths
Guide Catheters
Microcatheters
Finecross
Corsair Series
Turnpike Series
Mamba Series
Guidewires
Dissection/Reentry Equipment
Guide Catheter Extensions
Snares
Equipment for "Uncrossable-Undilatable" Lesions
Intravascular Ultrasound (IVUS)
Complication Management Equipment
References
7: The Hybrid Approach and Its Variations for Chronic Total Occlusion Percutaneous Coronary Intervention
Introduction and Historical Perspective
Simplifying the Complex
The Algorithms.... Combined
Who Should Do the Procedure?
Pre-procedure Coronary CT Angiography
Choosing the Initial Strategy
Antegrade Wiring
Secondary and Bailout Strategies with Primary AW Approach
Antegrade Dissection and Reentry (ADR)
The Retrograde Approach
In-Stent Chronic Total Occlusion
Switching Strategies
Ending the Procedure
Conclusions
References
8: When, Why, and How to Perform Good Angiographic Analysis Before CTO PCI
Introduction
When and Why
How
CTO Angiography
CTO Angiographic Analysis
Target Vessel
CTO Characteristics
Donor Vessels
Collateral Circulation
Collateral Pathways
Interventional Collaterals
Conclusion
References
9: Specific Basic Techniques to Master in CTO PCI
Approaching the CTO Segment.
Wire Manipulation Techniques in CTO
Trapping Balloon Technique
References
10: When, Why and How to Perform an Antegrade Approach Using a Wiring Technique
Introduction
Anatomical Subsets That Favor Antegrade Wiring
Lesion Length
Proximal Cap Anatomy
In-CTO Tortuosity (>
45°)
Presence of Intra-CTO Calcium
Previous Procedural Failure
Other Factors
Degree of Disease in the "Distal Landing Zone"
Presence of "Interventional Collaterals"
Basic Principles of CTO PCI
Planning
Visibility
Backup Support
Use of "Over-the-Wire" Equipment
Wire Selection
Tapered Polymer-Coated Wires
Medium Weight Wires
High Gram Weight Wires
The Proximal Cap and How to Assess It
Wire Selection: Principles and Rationale
Polymer-Coated Wires
Penetration Force
Tactile Feel
Torque Transmission
Wire Selection
Wire Shaping
Confirming Progress and Ensuring Safety
Confirming True Lumen Entry
Angiographically
Wire Feel
Intravascular Ultrasound (IVUS)
Advancing Equipment
Anchor Balloon
Guide Extension
Higher Support Microcatheter
Laser Atherectomy
Rotational Atherectomy
Indications and Use of Adjunctive Imaging Strategies
CTA
IVUS
When to Switch Strategy
References
11: When, Why, and How to Perform Wire-Based Antegrade Dissection and Reentry Technique
References
12: When and How to Perform Contemporary Device-Based Antegrade Dissection and Re-entry Technique
Introduction
Evolution of Strategies for ADR
Primary ADR: A Step-by-Step Approach
Troubleshooting ADR Procedures and Bailout Manoeuvres
Outcomes with ADR in Contemporary Practice
Conclusions
References
13: How to Deal with Difficult Antegrade Issues
Difficult Antegrade Issues That Apply to Both AW and ADR
Ambiguous Proximal Cap
Impenetrable Cap.
Uncrossable Lesion
Difficult Antegrade Issues That Are Unique to Antegrade Dissection Reentry
Crossboss Challenges
Reentry Challenges
References
14: Intra-occlusion Microinjection of Contrast: When, Why, and How
References
15: When, Why, and How to Perform the Antegrade Fenestration and Reentry Technique
Introduction
Pathophysiological Bases and Development of Antegrade Fenestration and Reentry (AFR)
Procedural Description of Antegrade Fenestration and Reentry (AFR)
Real-Life Experience with Antegrade Fenestration and Reentry (AFR)
Role of Antegrade Fenestration and Reentry (AFR) in the Hybrid Algorithm
Further Developments in Antegrade Fenestration and Reentry (AFR)
Conclusions
References
16: When, Why, and How to Perform the Retrograde Approach Through Septal Collateral Channels
When to Select the Retrograde Approach: How to Analyze the Coronary Angiography
How to Set Up the Procedure
Pathways to the Distal Cap (Table 16.1)
Collateral Channels
Step-by-Step Approach
Selecting the Microcatheter, Crossing the Collateral Channel with a Wire, and the Microcatheter
Selecting the Microcatheter
Crossing a Septal CC with the Wire
Surfing from PDA to LAD: A More Difficult Task
Advancing the Microcatheter to the Distal Cap Through the Septal CC
Special Situations and Considerations
Using an Internal Mammary Artery as a Donor Artery to Septal CCs
LAD or LCX CTOs in a Dominant Left System
References
17: When, Why, and How to Perform the Retrograde Approach Through Epicardial and Non-septal Collateral Channels
When to Perform Retrograde CTO PCI Via Non-septal Connections? Anatomic Evaluation
Algorithms for Performing Retrograde Approach
Collateral Channel Scores
Why Performing Retrograde CTO PCI Via Non-septal CCs? Clinical Evaluation.
Indication and Timing of Using Non-septal Collateral CCs
Risk-Benefit Assessment of Selecting Non-septal CCs
How to Perform Retrograde CTO PCI Via Non-septal Connections: Practical Considerations
Arterial Access
Non-septal Collateral Channel Crossing
Crossing the CTO
Externalization
Complications Related to Retrograde CTO PCI Via Non-septal Connections
Perforation of the CC When the CTO Is Crossed
Perforation of the CC When the CTO Remains Uncrossed
References
18: When, Why, and How to Perform the Retrograde Approach Through Patent or Occluded SVGs
Introduction
CTO PCI in Post-CABG Patients
Retrograde Approach Through an SVG
Retrograde Via Diseased But Patent SVGs
Retrograde Via Occluded SVGs
Guide Extensions in SVGs
Specific Situations
Stumpless SVG Use
Retrograde Access Via Acutely or Recently Thrombosed SVG in ACS Patients
How to Deal with Acute Angle of Distal Anastomosis
Distal Anastomosis Ambiguity
Stenting Coronary Across Distal SVG Anastomosis After CTO PCI
Dealing with Anastomotic Stents in SVGs
Protecting the Graft
What To Do with the SVG Once the Native Artery CTO is Open?
Potential Complications When Using SVGs as Retrograde Conduits
Distal Embolization
SVG Perforation
Aortic Dissection
Mediastinal Bleeding/Haematoma
References
19: How to Cross the Occlusion Using a Retrograde Approach, How to Externalize, and How to Snare Long Wires
Introduction
Retrograde Wiring
Wire Choice
Confirming Wire Position
Note on Safety in RW
Retrograde Dissection and Re-entry
Creating an Antegrade Dissection
Use of Guide Catheter Extension
Creating a Retrograde Dissection
Joining the Spaces
Externalization
Use of Snare for Externalization
Principles of Snaring
How to Snare.