Percutaneous Coronary Intervention for Chronic Total Occlusion: The Hybrid Approach

Description

The second edition of this essential text provides readers with a detailed guide to performing various percutaneous coronary intervention (PCI) techniques for treating coronary chronic total occlusion (CTO). PCI continues to be an effective procedure to help patients with this pathology, with high success and low complications rates. Chapters feature a step-by-step approach to relevant techniques and describe their potential pitfalls, enabling the reader to develop a thorough understanding of how to perform those procedures successfully. Details of the latest methods for angiography analysis and the management of ostial CTOs, plus heavily revised chapters on topics such as contemporary device-based antegrade dissection and the retrograde approach through septal and non-septal collateral channels ensure that this Work remains the most up-to-date reference on the subject. Percutaneous Intervention for Coronary Chronic Total Occlusion: The Hybrid Approach represents a vital reference to assist practicing and trainee interventional cardiologist in learning these techniques. Various examples are provided, with a vast selection of still images and angiographic video loops to enable the reader become confident in applying these methodologies into their day-to day clinical practice. 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 Positioning of Retrograde Microcatheter After Externalization Removal of Retrograde Equipment Troubleshooting Unable to Create Common Space Both Wires in the Same Compartment Wires in Different Compartments Unable to Advance Retrograde Microcatheter Through the CTO Retrograde Guidewire Tracking a Saphenous Vein Graft Remnant References 20: How to Manage Ostial Right Coronary Artery Chronic Total Occlusions and to Perform Externalization Techniques Introduction Access and Guide Catheter Selection Algorithm Part 1: Antegrade-Crossing Attempt Is Possible Algorithm Part 2: Antegrade Crossing Not Possible Algorithm Part 3: Retrograde Guidewire Externalization Conclusions References 21: CTO Stenting: Impact of Intraplaque and Extraplaque Strategies Introduction Lesion Preparation The Role of Intravascular Imaging Intraplaque Versus Extraplaque Stenting Duration of Dual Antiplatelet Therapy After CTO PCI Conclusions References 22: When, Why, and How to Recanalize In-Stent Chronic Total Occlusions Introduction Prevalence What Is Unique to In-Stent Occlusions? Pathophysiology In-Stent Occlusive Re-stenosis In-Stent CTO from Previous Thrombosis Angiographic Appearance of In-Stent CTOs When and Why to Recanalize In-Stent Occlusions? Treatment Algorithm that Applies to this Entity Hybrid Approach for IS CTO Antegrade Wiring CrossBoss for IS CTO Retrograde Approach Long-Term Outcomes Problem-Solving Strategies Conclusions References 23: When, Why, and How to Fix Common Problems Encountered in Chronic Total Occlusion Percutaneous Coronary Intervention: The Expanded Hybrid Approach Wire Impenetrable Cap Despite Standard Wire Escalation Wire Across Cap/Lesion but Gear Will Not Follow Algorithm Working Over the Initial Wire Solutions that Require Sacrificing the Initial Wire Position CTO Cap Ambiguity Algorithms Proximal Cap Ambiguity Distal Cap Ambiguity Difficult Anterograde Dissection Reentry Algorithm Wire Across Retrograde Collateral but Microcatheter Will Not Follow Algorithms Septal Algorithm Bypass Graft Algorithm Epicardial Algorithm Difficult Retrograde Dissection Reentry (R-CART) Algorithm Inability to Externalize Wire During R-CART Algorithms Retrograde Wire Is in Anterograde Guide but the MC Will Not Follow When the Retrograde MC Has Reached the Anterograde Guide, but the Externalization Wire Will Not Progress Wire/Gear Track into a Side Branch at a Cap or Within a Lesion Algorithm Difficulty Crossing Due to Graft Insertion (Suture Line) Algorithm In-Stent CTO Algorithm Conclusion References 24: Why, When, and How to Perform Plaque Modification and Subintimal Tracking and Re-entry with Deferred Stenting for Failed Chronic Total Occlusion Percutaneous Coronary Intervention Cases Introduction Why? When? How? Conclusion References 25: Why IVUS When Approaching a CTO? Introduction Types of IVUS More Commonly Used Indications Antegrade Approach Entry Point Evaluation and Wire Penetration in Ambiguous Proximal Cap IVUS for ADR Retrograde Approach Difficult Re-entry in Retrograde Approach: True Ostial CTOs IVUS for Retrograde Dissection and Re-entry: Confirming Wire Position, Guiding Balloon Sizing, Assisting with Connection of Wires IVUS for Coronary Sizing, Stent Implantation, and Optimization During CTO PCI Limitations Conclusions References 26: How to Manage Calcified Chronic Total Occlusion Lesions Introduction Preprocedural Assessment of Calcified CTO Post Bypass Native Vessel CTOs Management of Calcified CTOs Calcium and CTO Crossing Procedural Setup Proximal Cap Calcium Occlusive Segment Calcium Distal Cap Calcium Reentry Zone Calcium Calcium Modification Conclusion References 27: How to Improve Catheter Support During Chronic Total Occlusion Percutaneous Coronary Intervention? Introduction Access Choice Recommendations Sheaths Recommendations Guide Catheters Size, Length, and Stiffness Shape Recommendations Guide Catheter Extensions Recommendations Anchoring Techniques Recommendations Microcatheters Recommendations Retrograde Approach Recommendations Conclusions References 28: When, Why, and How to Perform a Transradial Approach for Chronic Total Occlusion Percutaneous Coronary Intervention Rationale for Radial Artery Access in CTO PCI When to Choose the Radial Artery Access Patient Positioning and Obtaining Access Introducer Sheath Selection Guide Catheter Selection and Enhancing Support from the Radial Artery Advancing and Manipulating the Guide Catheter Sheathless Guide Catheters Commercially Available Sheathless Guide Catheters The Hybrid Algorithm and Radial Artery Access Conclusion References 29: How to Manage Radiation and Contrast During Chronic Total Occlusion Percutaneous Coronary Intervention Contrast-Induced Acute Kidney Injury in CTO Percutaneous Coronary Interventions Definitions of Contrast-Induced Acute Kidney Injury Incidence of Contrast-Induced Acute Kidney in CTO Procedures Risk Factors for Contrast-Induced Acute Kidney in CTO Procedures Prognostic Impact of Contrast-Induced Acute Kidney Prevention of Contrast-Induced Acute Kidney in CTO Procedures Pre-procedural Strategies Intra-procedural Strategies General Measures Procedural Techniques Forced Diuresis (RenalGuard System) Coronary Sinus Contrast Media Extraction (CINCOR System) Follow Up Radiation Exposure Complications in CTO Interventions Radiation Doses in CTO Procedures Deterministic Effects Stochastic Effects Radiation Exposure Effects to Operators Methods for Reducing Radiation During CTO Interventions Pre-procedural Strategies Intra-procedural Strategies General Measures CTO-Specific Techniques Post-procedural Strategies and Follow-Up Conclusions References 30: Why, When, and How to Use Left-Ventricular Assist Devices During Chronic Total Occlusion Percutaneous Coronary Intervention References 31: Specific Considerations When Performing CTO PCI in Post-CABG Patients Introduction Post-CABG Patients and CTO Lesions The Distal CTO Cap Is Submitted to SVG Flow (Systemic Pressure) Multiple Sources of Collateral Flow, Often Epicardial Retrograde via Occluded or Diseased Bypass Grafts Retrograde via Radial Graft Retrograde Through Internal Mammary Artery (IMA) Grafts Opening One CTO in Order to Open Another CTO Remnants of SVG Grafts Anastomosed to Distal Vessels Biplane Angiography Access in Post-CABG CTO Cases Radial vs. Femoral Approach Bilateral Radial Approach in Post-CABG Sheathless Transradial Femoral Approach Third Arterial Access Dual Retrograde vs. Triple Access Triple Injections Setup Retrograde Guide Length Tenting of the Vessel by Old Grafts Consideration of Mechanical Circulatory Support with Impella CP STEMI in Post-CABG Complications in Post-CABG Are Different Loculated Pericardial Effusion True Tamponade in a Post-CABG Patient Distal Wire Perforation Post-CABG CTO Cases as a Learning Opportunity References 32: An Overview of Chronic Total Occlusion Percutaneous Coronary Intervention Complications Antegrade Complications Retrograde Complications The Patient with Prior Coronary Artery Bypass Graft Surgery How to Prevent Complications How to React Once a Complication Has Occurred References 33: Management and Prevention of Perforations During Chronic Total Occlusion Percutaneous Coronary Intervention Outcomes and Predictors of Coronary Perforations During CTO PCI Classifications and Risk Stratification of Coronary Perforations Management of Perforation Prevention Conclusions References 34: How to Prevent and Manage Ischemic Complications During CTO PCI General Overview Ischemic Complications from Target CTO Vessel Injury Ischemic Complications from Donor Vessel Injury Ischemic Complications from Collateral Channel Injury References 35: Managing Entrapped Gear During Chronic Total Occlusion Interventions Introduction Risk Factors Management of Equipment Entrapment and Loss Wires Bailout Technique for Trapped Wires Microcatheters, Balloons, and Stents Bailout Techniques for Trapped Stents, Microcatheters, and Balloons Rotablator Burr Bailout Techniques for Trapped Rotablator Burr Retrograde Scenarios Bailout Techniques for Retrograde Entrapment Managing Complications Management of Major Complications Conclusions References 36: When, Why, and How to Perform Robotic-Assisted CTO PCI Introduction Why Perform Robotic-Assisted PCI? Data for Robotic-Assisted PCI How to Perform Robotic-Assisted PCI, Step-by-Step Future Directions Conclusions References 37: How to Proctor New Operators to Learn CTO PCI Introduction Training New Operators in CTO PCI as Part of a Dedicated Fellowship Training Established Operators to Perform CTO PCI Questions to Ask yourself Question to Ask the Sponsor Prior to the Proctoring Day On the Day of Proctoring End of the Day Conclusion 38: How to Start and Build Your CTO Practice and Maintain Referrals in a Competitive Environment Introduction The New CTO Operator Should Know the Data The New CTO Operator Should Know Himself or Herself The New CTO Operator Should Educate Him or Herself The New CTO Operator Should Get a Mentor The New CTO Operator Should Start a Dedicated Program The New CTO Operator Should Understand that CTOs Should Not Be Attempted Ad Hoc The New CTO Operator Should Learn to ‘Walk Before Running’ When Starting Alone An Ounce of Prevention… The New CTO Operator Should Get Ready to Fail The New CTO Operator Should Track Outcomes The New CTO Operator Should Grow His or Her Program The New CTO Operator Should Keep Learning Conclusion Index