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Chronic total occlusion pci


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Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.

Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.

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Chronic total occlusion pci

  1. 1. Chronic total occlusion of coronary artery Durga Pavan Nizam’s Institute of Medical Sciences, India
  2. 2. For a layman
  3. 3. DEFINE • >99% stenosed • Duration >3 months • TIMI 0-1
  4. 4. Histopathology • Organized thrombus. • Fibrotic plaque • Calcified lesions. • Proximal/ distal fibrous cap • Micro channel in the occlusion segment
  5. 5. Micro channel inside the occlusion • Often extend to small side branch & to adventitia • Extravascular micro channels in early phase of occlusion • More mature CTO –intravascular channels increase • Matured CTO - both fewer • Longitudinal continuity – 85% of entire length of CTO
  6. 6. Benefits of CTO-PCI ▫ Symptom relief, ▫ Improvement in left ventricular function, ▫ Improve tolerance of a future acute coronary syndrome ▫ Reduce the need for coronary artery bypass graft surgery ▫ Better long-term survival.
  7. 7. Symptom relief • TOAST-GISE (Total Occlusion An-gioplasty Study–Società Italiana di Cardiologia Invasiva) trial, CTO-PCI success - 86%, CTO-PCI failure - 70% , angina-free survival (p=0.008) • Cheng et al. Demonstrated that 76% of patients with CTO who were treated with PCI experienced an improved angina classification, whereas 17% of patients who were not treated with PCI improved (p<0.05).
  8. 8. • A 3.8% to 8.4% absolute reduction in mortality was associated with successful versus failed CTO-PCI. Survival advantage
  9. 9. • Symptoms ▫ A CTO with well developed collaterals is hemodynamically similar to 90% coronary stenosis without collaterals – significant recovery of ventricular function is expected • Viable myocardium ▫ Recovery of LV function depends on the presence of hibernating viable myocardium • Success ▫ If the likelihood of success is moderate to high (>60%) and the likelihood of complications less, PCI is encouraging. Patient selection
  10. 10. Barriers • Complications • Failure rates • Economic burden • CIN
  11. 11. Complications • Impairment of collateral flow ▫ spasm, shearing off side-branches and collateral by dissection, distal embolization • Dissection with branch occlusion & Perforation ▫ intra-wall balloon expansion, side-branch dilatation, damage of neochannels connecting vasa vasorum • Guidewire entrapment • Subacute vessel reocclusion ▫ 8% of total occlusion within 24hr Vs. 1.8% of non total occlusion • CIN • Radiation
  12. 12. Reasons • Not able to cross guidewire – 63% • Long intimal dissection – 24% • Dye extravasation – 11% • Balloon did not cross or dilate – 2% • Thrombus – 1.2% Kinoshita I, et al. JACC 1995;26:409-411
  13. 13. Predictors • Clinical- ▫ Duration - >3-6 monthS ▫ CRF • Angiographic ▫ Calcification(at entry point/at distalcap) ▫ Blunt stump ▫ >45 angulation of target vessel ▫ Length of occlusion >15-20mm ▫ Vessel <3mm ▫ Multiple lesions in target art ▫ Lack of distal vessel filling ▫ Bridging collaterals and side branch
  14. 14. Predictors of success or failure in PCI of CTO Predictors of success Duration < 3 months Antegrade flow + Tapered morphology + Bridging collaterals – Side branch – lesion length < 15 mm Single vessel disease Predictors of failure Duration > 3 months Antegrade flow – Tapered morphology – Bridging collaterals + Side branch +, ostial lesion lesion length > 15 mm Multi vessel disease Vessel & lesion tortuosity & calcification Bridging collaterals are more common in lesions > 3 months old. Extensive bridging collaterals that form caput medusae around the occluded vessel are generally not suitable for PCI
  15. 15. Predictors of Procedural SuccessTOAST - GISE
  17. 17. Economic burden • 2 procedure • Fluoroscopy • Hardware more
  18. 18. 4 angiographic parameters • Location of the proximal cap using • Length • Side branches • Target vessel at the distal cap • Collaterals for retrograde techniques.
  19. 19. Two injection same time • Collaterals to the distal target vessel. • Lesion length and the size and location of the distal target vessel, evaluating whether there is a significant bifurcation at the distal cap, and for deciding on the optimal CTO PCI strategy
  20. 20. Collaterals Assessment • CAG ▫ Visible collaterals of 0.3-0.5mm ▫ <100 micro m are not visualized ▫ Selective using micro catheters
  21. 21. Collaterals grade[Rentrop] 0 1 2 3 Visible filling of any collateral channel Filling of the side branches of the occluded artery, with no dye reaching the epicardial segment Partial filling of the epicardial vessel Complete filling of the epicardial vessel by collaterals
  22. 22. Collaterals -Levine etal ▫ Septal ▫ Intra arterial (bridging) ▫ Epicardial  Proximal take off  Distal takeoff
  23. 23. Collaterals
  24. 24. Werner et al • 3 grades ▫ CC0-no continues connection ▫ CC1 - continuous , threadlike ▫ CC2 – continuous , small side branch like
  25. 25. CT angiogram • Procedural success • Distal vessel • Collateral • Best angle for PCI approach
  26. 26. IVUS • Entrance • Subintimal vs true lumen
  27. 27. Guide catheter • First key to success • For effective guide wire manipulation : ▫ coaxial orientation of guide catheter important ▫ stability& back up force • RCA - AL1/0.75 with side holes • Shepard crook RCA - AL1or2 • Prox RCA lesion - JR ( avoid ostial damage) • LCA - Extra back up(XBU,EBU,) • LCX (short left main) - AL1 or2 (better support & co-axial)
  28. 28. Guide catheter • 7F or 8F guide catheter ▫ Superior backup support (needed in CTO) ▫ Inter twining is less common while using parallel wires ▫ Switching over to devices like rotablator is easy ▫ Permit better contrast injection. So, radial approach is not preferred for CTO. • Side hole guide catheter is useful for RCA ▫ Maintains perfusion to the sinus node artery & conus branch
  29. 29. CTO wires
  30. 30. Fielder XT wire (Asahi Intec, Nagoya, Japan) and Run- through taper wire (Terumo Corporation, Tokyo,Japan) ▫ A hydrophilic and/or polymer-jacket ▫ 0.014-inch guide wire, ▫ Low gram-force ▫ Tapered 0.009-inch tip • Antegrade micro channel or soft tissue probing and also for knuckle techniques.
  31. 31. Fielder FC wire (Asahi Intecc) and Pilot 50 wire (Abbott Vascular,Santa Clara, California) ▫ Polymer-jacket hydrophilic ▫ Non tapered ▫ Low stiffness ▫ 0.014-inch guide wire.
  32. 32. Pilot 200 guidewire (Abbott Vascular). ▫ Polymer-jacket ▫ Moderately high– gram-force (4 to 6 g),, ▫ Non tapered ▫ 0.014-inch guide wire. • For complex lesion crossing, long lesions, knuckle technique, and dissection/re-entry. • Performs well in very tortuous segments with an ambiguous course
  33. 33. Confianza Pro 12 wire (Asahi Intecc). ▫ High– gram-force ▫ Non jacketed tipped ▫ 0.014inch guidewire,tapered 0.009-inch guide wire. • Penetration techniques, cap puncture, complex lesion crossing, and lumen reentry techniques. • Best used when the vessel pathway and location target coronary segment are well understood.
  34. 34. Hydrophilic wires • Slippery upon contact with blood • Useful in lesions with visible channels. • Excellent for markedly tortuous lesions • Can easily find way in to a false lumen with less tactile feed back  intimal dissection & proceedural failure or even perforation & tamponade • They are less steerable  Asahi Fielder (Abott Vascular)  Asahi Prowater (Abott Vascular)  Whisper – Guidant  Pilot – Guidant  Shinobi – Cordis  Choice PT (Boston scientific)
  35. 35. Stiff guide wires • Non hydrophilic coil tip designed to facilitate the penetration of distal or proximal cap. • Stiff guide wires are particularly useful when proximal fibrous cap is hard. (esp. the tapered tip wires) • Gradual step up approach using wires with increasing stiffness is useful. • Cross-IT • Conquest • Miracle
  36. 36. Tapered tip
  37. 37. Tapered guide wire • Technical success: 76% • Success rate in visible micro channel ▫ Incomplete micro-channel: 81% ▫ Micro-channels with distal filling: 100% Buettner HJ, et al. JACC 2002;39:30A
  38. 38. Micro catheters • Wire exchange[floppy to dedicated stiffer] • Torque to tip & improve feedback • Tip stiffness of guide wire
  39. 39. Corsair micro catheter (Asahi Intecc) • 2.7-F catheter with OTW hybrid catheter • Both micro catheter and support • Bidirectional wire braiding for torque transmission, and an inner polymer lumen with soft tip for optimal wire control • Cross collateral channels and provides the primary basis for conventional retrograde procedures. • Super selective injection for collaterals • Antegrade direction for wire support.
  40. 40. The Corsair catheter is advanced by rotation in either direction. The Corsair should not be over-rotated (10 consecutive turns without release) as over-rotation could cause catheter kinking
  41. 41. Tornus micro catheter (Asahi Intecc) • Braided-wire mesh OTW microcatheter with left- handed thread allowing for channel preparation and lesion crossing in resistant occlusions. • Advanced using counterclockwise rotation and removed using clockwise rotation. • Guidewire should remain within the Tornus inner lumen during manipulations, and over-rotation should be avoided to minimize the risk of kinking. • Contrast injections should not be performed through the Tornus, as the contrast escapes through the wire braid.
  42. 42. Lesion crossing and lumen re-entry technologies • CrossBoss catheter (BridgePoint Medical, Plymouth, Minnesota) • Stingray balloon and Stingray guidewire systems (BridgePoint Medical).
  43. 43. Precautions ▫ Covered stents ▫ Embolization coils ▫ Pericardiocentesis trays ▫ Thrombectomy devices
  44. 44. STRATEGIES Antegrade approach Retrograde approach ▫ SINGLE WIRE ▫ DOUBLE WIRE  Parallel wiring  Seesaw wiring  Subintimal tracking and reentry  IVUS guided approach  Retrograde wire crossing  Kissing wire technique  Knuckle wire technique  CART  Reverse CART
  45. 45. Next wire • 1. Floppy wire as the 1st wire • 2. Intermediate or MIRACLE 3 • 3. MIRACLE 6 • 4. MIRACLE 12 or Conquest Family
  46. 46. Stepwise • 1.Atraumatic, tapered, hydrophilic FIELDER XT • 2.Stiffer, tapered wire like CONFIANZA9/ MIRACLE6 • 3.Step down to softer wire
  47. 47. • Wire shaping 1ºbend of 30-45º 1-2mm from tip Find softest part 2ºbend-10-15º @3-6mm Work as a navigator to orient tip
  48. 48. Tip curve should be just larger than lumen diameter CTO, the lumen diameter = 0 mm For CTO lesion – Guide wire-tip curve should be very small Larger curve may hurt the vessel wall during direction control
  49. 49. Guide wire negotiation • Different methods • Sliding AT proximal cap • Drilling inside CTO • Penetration Distal cap • Micro channel tracking
  50. 50. •Simultaneous rotation & probing of lesion •High chance of entering to subintimal space ( tactile response - nil ) SLIDING •Recent occlusion •Predominance of micro channels •Extremely low friction wires for picking micro channels used • Recent total, subtotal occlusion ,ISR attempted with this strategy •Long duration – Micro channels replaced by fibrotic tissue
  51. 51. BEWARE bridging collaterals masquerading as microchannel Polymer sleeved wires NOT forced against resistance, small tip bend, probing with mild rotation Soft wires with polymer sleeve – Fielder series/ Whisper/ PT II
  52. 52. Drilling Strategy • If discrete entry point present •Technique short curve(2mm) @45-60º to distal tip sometimes a secondary curve given proximally wire advanced with rapid rotational tip and gentle probing start with MOD stiffness – progressive increase in stiffness Entry to false lumen judged by tactile feel on pulling stiff wire •Reserved for the most skilled and experienced operator •Ineffective with Blunt entry ,heavily calcific & resistant lesions
  53. 53. Penetration •Technique Pushing stiff wire slowly& gradually – minimum rotation to target direction Tapered tip wires Softer tip intially progressively stiffer wires Route determined – various angio or CT findings not by tactile feel •Useful for blunt ,heavily calcific or resistant lesions •Not for CTO with tortuous angulated or bridging collaterals because of higher chance of perforation Drilling & penetration – guide support & tipload important Tip load - success - chance of perforation
  54. 54. Penetration power = tipload/tiparea
  55. 55. • Tactile sensations ▫ Feeling of the dimple at the entry point, especially in the abrupt type of CTO entry ▫ Feeling of strong resistance when pulling back the wire inside the CTO body, such as when the guide catheter is drawn into it—in this situation, the wire tip has most likely migrated into the subintima ▫ Feeling of no resistance the wire tip moves freely—this most likely means that the wire tip is either in the true lumen or in the extravascular space
  56. 56. Anchoring wire technique ▫ Guiding catheter is unstable ▫ One wire is positioned in a prox side branch ▫ Other wire for crossing of the occlusion
  57. 57. Anchoring wire • Side branch protection ▫ Occlusion is long/ distal to side branch • Correction of tortuousities ▫ Proximal tortuousities • Buddy wire technique ▫ Facilitate passage of stent in complex leisions ▫ Serves as rail
  58. 58. Double wire • Parallel wire technique
  59. 59. 1st wire in false channel left in situ 2nd stiffer wire advanced parallel to first wire in same path redirected to enter distal true lumen main pitfall is wire twisting each other Support catheter use, appropriate wire selection& handling –essential to avoid wire twisting Main purpose : - redirecting a wire inside body of a cto & puncturing distal fibrous cap Important prerequisite – distal vessel visualization
  60. 60. See-Saw Wiring
  61. 61. See-Saw Wiring • Modification of parallel wire technique • Uses 2 microcatheters or OTW baloons • When first wire fails , 2nd wire with microcatheter or OTW baloon is inserted • Risk – false lumen may enlarge – procedure failure
  62. 62. Side branch technique
  63. 63. Success • (1) Angle between direction in which the wire lies and the bifurcating side branch is less than 90°; • (2) Side branch less than 1mm; • (3) No diffuse plaque build-up about the true lumen in the distal portion of the CTO • (4)True lumen to the ostium of the side branch, the wire must be just to the side of the true lumen in the distal part of the CTO
  64. 64. Open sesame technique • Hard plaque • Failed even with conquest pro 8-20 • Side branch just in front of proximal cap • Pass stiff guide wire and/ or a balloon into side branch. • Distortion of geometry • Enables guide wire to advance into true lumen.
  65. 65. Dissection reentry techniques • STAR -Uncontrolled • LAST - Somewhat controlled • Dedicated systems -Controlled
  66. 66. • Subintimal tracking and rentry technique Used when attempts to recanalize true lumen failed 0.014 hydrophillic wire with J configration used(whisper,pilot) Hydrophillic wire pushed through subintimal dissection plane When pushed distal to occlusion J tip directed to truelumen In an attempt to reenter •Successful in those with previous attempt failed •High chance of perforation STAR Technique
  67. 67. Knuckle wire technique •Polymer jacket wire (fielder XT or pilot- 200)manipulated • To create wire loop – advanced subintimally across CTO •OTW system advanced to this area- rentry to true lumen with a stiffer wire or pilot 200
  68. 68. Cross Boss catheter • Metal OTW micro catheter with rounded tip to prevent vessel exit • Device rotated rapidly in either direction using fast spin • Can advance through the CTO without a wire in the lead • Subintimal position- true lumen reentry performed • Smaller subadventitial space – less likely to accumulate blood
  69. 69. Sting ray balloon & guide wire system 1mm flat balloon with 3 exit ports connected to the same lumen Distal exit port – for balloon positioning Uses guide wire with extreme tapered tip (0.0025) for reentry Distal true lumen entry confirmed by contralateral injection
  70. 70. RETROGRADE APPROACH • Initially used after a failed antegrade approach • Now used as initial strategy in challenging cases ▫ Ostial occlusion ▫ Large side branch at proximal cap ▫ Long occlusion (>30mm) ▫ Severe tortuosity or calcification ▫ Without stump ▫ Visible continuous collaterals
  71. 71. Collateral selection Preference - Bypass graft > septal > epicardial Selective injection of collateral Surfing technique for crossing invisible septal collateral Wiring collateral – achieved with OTW system or dedicated septal dialator(corsair) Entering septal collaterals large bend or 2 small bend in a work horse wire Contrast injection to assess best connection
  72. 72. Hydrophillic polymer jacket wire with <1mm 30-45º tip used to cross recipient artey Fielder FC,Pilot-50,Whisper, Choicept,Runthrough Wire should move freely - difficulty to advance – perforation? whipping of wire - RV or LV entry (rarely pericardium) Of no consequence if recognized before advancing OTW system Collateral dilatation using 1.5 mm balloon @ 1-2 atm or Corsair Epicardial collaterals size most important factor in wiring success should never be dialated
  73. 73. Antegrade crossing • Simplest form of retrograde technique • Retrograde wire advanced to distal cap • Acts as a marker of distal true lumen • Serves as a target for antegrade wire
  74. 74. Kissing wire Manipulation of both antegrade and retrograde wires in CTO until they meet Antegrade wire follow channel made by retrograde wire in true lumen of distal vessel
  75. 75. Retrograde true lumen puncture Most pure form of retrograde technique(only in 40% retro tech) Hydrophillic wire advanced to the lesion Advancment of microcatheter or OTW baloon – additional support CTO crossed retrogradely using hydrophillic wire or stiffer wire Manuevers to enhace chance of crossing Inflating retrograde baloon - coaxial anchor Stiffer tapered tip or hydrophillic wires IVUS facilitation of retrograde wire to proximal true lumen
  76. 76. • Basic concept –create subintimal dissection with limited extension only at the site of a CTO. • Antegrade wire advanced into CTO then to subintimal space. • Retrograde wire through collateral with microcatheter to distal end of CTO - into the CTO- then to subintimal space. • Baloon inflation inside CTO using small balloon over the retrograde wire to subintima • Balloon inflated inside CTO • To keep inflated space open deflated baloon left in subintimal space C A R T Controlled antegrade & retrograde subintimal tracking
  77. 77. Two subintimal dissection provide reentry space for antegrade wiring Antegrade wire advanced along deflated retrograde balloon into the distal true lumen Limited subintimal tracking (dissection) only in CTO segment Avoids difficulty of reentering distal true lumen Dilatation and stent implantation after successful recanalization
  78. 78. Use closest sized baloon inside CTO to create sufficient wire reentry space Access to distal CTO mainly via septal collatrels, by polymer jacket wire over microcatheter or otw baloon Septal channel dilatation at 1.25mm baloon at low pressure Major limitations Limited access of collatrel channels to target CTO Empiric estimation of retrograde baloon size Overall unpredictable procedure time
  79. 79. Reverse CART technique • Engage a guidewire retrogradely in the distal cap of the CTO • Another wire anterogradely in the proximal cap of the CTO • Retrograde wire advanced in subintimal space into CTO lesion • Subintimal channel is enlarged by anterograde balloon • Plaque dissection and modification of the lesion • Retrograde wire advanced to cross the dissection • Link up with the anterograde wire in proximal true lumen • Wire externalized (Exchange length) • Anterograde PCI done
  80. 80. KNUCKLE WIRE TECHNIQUE Best suited for long segment of occlusion Retrograde wire usually a polymer jacket wire manipulated to form a loop at wire tip advanced in subintimal space across CTO Eg: Fielder XT or Pilot-200 Rounded wire loop advanced in subintimal space across CTO without causing perforation OTW system advanced to this area followed by attempt to reenter true lumen using a stiffwire with short bend or hydrophillic wire Eg: Confianza Pro 12 or Pilot 200
  81. 81. Antegrade vs retrograde
  82. 82. Treating lesion after crossing CTO crossed by antegrade wiring (kissing wire, just marker,CART Antegrade CTO PCI can be done Retrograde balloon can trap antegrade wire to facilitate procedure Retrograde wire crosses to true lumen Options : Antegrade wiring Retrograde wire externalization Retrograde stent delivery DES is preferred in CTO PCI
  83. 83. APPROACH
  84. 84. IVUS Navigated Wiring IVUS – Depict cross sectional view of coronary tree IVUS focus on plaque distribution, calcification, reference vessel size & side branch anatomy Applicability of IVUS in CTO PCI 1)Side branch method to navigate CTO wire into true lumen from proximal cap 2)Subintimal rentry from the proximal true lumen IVUS guided subintimal rentry – Last resort for getting a subintimal wire into distal true lumen Applicable even after losing site of distal vascular bed on angio
  85. 85. •1.5-2mm baloon dilatation in presumed subintimal space •IVUS is advanced into the space monitored to orient 2nd wire to true lumen Key points a) Ability to translate cross sectional image into 3D needed b) 2nd stiff tapered wire over micro catheter - 8f guide mandatory c) Reentry point should be closer to proximal cap d) Contrast injection should be withheld esp after small ballon dilatation
  86. 86. Farword looking IVUS
  87. 87. Farword looking IVUS
  88. 88. Farword looking IVUS
  89. 89. Optical coherence reflectometry
  90. 90. n
  91. 91. Debulking of calcific lesion • Rotational atherectomy • Directional atherectomy • Silverman plaque excision system
  92. 92. Collagenase plaque digestion
  93. 93. Magnetic navigation • Magnetic navigation wire • Stereo taxis Magnetic Radio Frequency Guide wire • Magnetic navigation micro robot
  94. 94. Complications
  95. 95. CTO=CIN
  96. 96. Into pocket diary CTO-PCI IS SAFE
  97. 97. This Diwali -2014 NO CRACKER