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Percutaneous Coronary Intervention of Chronic Total Occlusion (CTO)

  • Anitha VargheseEmail author
  • Peter F. Ludman
Chapter

Abstract

For patients with limiting angina in spite of medical therapy coronary revascularisation either by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is extremely efficacious for symptom relief. Whether to treat using the surgical option or by PCI is decided by several factors which impact on the relative efficacy of each technique. These include a patient’s presenting coronary syndrome, their co-morbidities and their coronary anatomy. Coronary artery stenoses usually pose little challenge to current percutaneous techniques. During PCI, the aim is to cross the diseased segment of vessel with a fine guidewire (0.014″ in diameter), dilate the narrowed lumen and implant a stent to scaffold the vessel walls open. The wire is steered by rotating and advancing its curved tip through the vessel lumen until it sits in a distal position and can provide a rail to introduce subsequent equipment such as angioplasty balloons and stents. Difficulties are encountered when treating heavily calcified vessels and where atheroma sits at bifurcations or trifurcations, but arguably the most challenging subset of lesion to treat by PCI are those which are chronically occluded.

Keywords

Percutaneous Coronary Intervention Cardiovascular Magnetic Resonance Left Anterior Descend Right Coronary Artery Chronic Total Occlusion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

Video 3.1a

Baseline biplane angiographic views of RCA CTO – via RCA injection. Prior to attempted PCI, radiographic contrast was injected via the RCA and shows the level of obstruction. A Right anterior oblique (RAO) view (AVI 3086 kb)

Video 3.1b

Baseline biplane angiographic views of RCA CTO – via RCA injection. Prior to attempted PCI, radiographic contrast was injected via the RCA and shows the level of obstruction. B Left anterior oblique (LAO) view (AVI 2816 kb)

Video 3.2a

Baseline biplane angiographic views of RCA CTO – Left and right coronary artery injections. On this occasion, radiographic contrast has been injected via both the RCA and left coronary artery to reveal retrograde filling of RCA beyond the occlusion. A RAO view (AVI 3305 kb)

Video 3.2b

Baseline biplane angiographic views of RCA CTO – Left and right coronary artery injections. On this occasion, radiographic contrast has been injected via both the RCA and left coronary artery to reveal retrograde filling of RCA beyond the occlusion. B LAO view (AVI 3198 kb)

Video 3.3

The ‘Knuckle’ wire. After penetrating into the vessel wall at the site of the occlusion, a Corsair microcatheter TM (Asahi Intecc Co. Ltd., Nagoya, Aichi, Japan) has been used to deliver a ‘knuckle’ wire. This is a soft wire shaped to advance safely in the subintimal plane of the vessel, thereby bypassing the luminal occlusion. (AVI 3387 kb)

Video 3.4

The CrossBoss device TM . Having achieved a position in the vessel wall beyond the occlusion, the Corsair microcatheter TM is switched for a CrossBoss TM device. This can be seen in position, and the wire on which it was delivered can be seen being withdrawn. (AVI 2041 kb)

Video 3.5

Advancing the CrossBoss device TM . The CrossBoss TM has been advanced to a more distal position in the vessel wall (using a rapid spinning motion) to get close to where it is intended to re-enter the vessel lumen. (AVI 1771 kb)

Video 3.6

The Stingray balloon TM . The CrossBoss TM is swapped for a Stingray balloon TM which is positioned at the site of intended re-entry. (AVI 2759 kb)

Video 3.7

The Stingray wire TM . This sharp wire has been used to exit the Stingray balloon TM , and cross from the vessel wall back into the lumen. The wire can be seen within the lumen beyond the occlusion. (AVI 3107 kb)

Video 3.8a

Biplane views of final angiographic result. Having successfully crossed back into the lumen, the track is dilated with balloons and stents have been implanted. The final angiogram is shown here (A RAO, B LAO) and demonstrates the newly re-opened RCA. (AVI 2777 kb)

Video 3.8b

Biplane views of final angiographic result. Having successfully crossed back into the lumen, the track is dilated with balloons and stents have been implanted. The final angiogram is shown here (B LAO) and demonstrates the newly re-opened RCA. (AVI 2667 kb)

Video 3.9a

Cardiovascular magnetic resonance (CMR) results. This scan was reported as demonstrating only minor myocardial ischaemia in the peri-infarct zone adjacent to the inferior MI resulting from RCA occlusion. A STRESS Basal level. Late gadolinium enhancement (LGE) and thinning of the inferior LV segments was thought consistent with scar and non-viable myocardium. (AVI 8764 kb)

Video 3.9b

B STRESS Mid-cavity level (AVI 8265 kb)

Video 3.9c

C STRESS Apical segments (AVI 7727 kb)

Video 3.9d

D REST Basal Level (AVI 7984 kb)

Video 3.9e

E REST Mid-cavity level (AVI 7648 kb)

Video 3.9f

F REST Apical segments (AVI 7749 kb)

Video 3.10a

Transthoracic echocardiogram results. TTE showing only mild hypokinesia of the basal-mid septum and basal-mid inferior walls, with all other segments having reasonable contractility. LV systolic function was noted to be at the lower limits of normal. (AVI 2213 kb)

Video 3.10b

Transthoracic echocardiogram results. TTE showing only mild hypokinesia of the basal-mid septum and basal-mid inferior walls, with all other segments having reasonable contractility. LV systolic function was noted to be at the lower limits of normal. (AVI 1194 kb)

Video 3.11a

Baseline biplane angiogram of RCA CTO prior attempted PCI. Radiographic contrast has been injected via both RCA and left coronary artery to reveal retrograde filling of RCA beyond occlusion. A RAO view (AVI 3897 kb)

Video 3.11b

Baseline biplane angiogram of RCA CTO prior attempted PCI. Radiographic contrast has been injected via both RCA and left coronary artery to reveal retrograde filling of RCA beyond occlusion. B LAO view. (AVI 3855 kb)

Video 3.12a

The Corsair microcatheter TM . A wire has been passed into the left coronary system, crossing the LAD and a septal collateral channel to reach the distal RCA in a retrograde fashion. A Corsair microcatheter TM is seen with its tip at the start of the septal collateral. A RAO view (AVI 1959 kb)

Video 3.12b

The Corsair microcatheter TM . A wire has been passed into the left coronary system, crossing the LAD and a septal collateral channel to reach the distal RCA in a retrograde fashion. A Corsair microcatheter TM is seen with its tip at the start of the septal collateral. B LAO view (AVI 1975 kb)

Video 3.13

Advancing the retrograde wire. Subsequently, the retrograde wire is advanced towards the distal part of the RCA occlusion. (AVI 1658 kb)

Video 3.14

Wire and balloon interplay. The retrograde wire is now directed into the space created by the balloon inflation and tracks back up into the proximal true lumen. (AVI 8425 kb)

Video 3.15

Circuit formation. The retrograde guidewire is now steered back into the RCA guiding catheter. A circuit can now be created, and balloons and stents deployed anterogradely into the RCA. (AVI 3246 kb)

Video 3.16a

Biplane angiogram of final results. The final angiogram (A RAO) demonstrates the newly re-opened RCA. The distal vessel is still attenuated due to spasm and will enlarge over the next few hours. A small septal collateral rupture is seen. This usually resolves spontaneously (which is why septal collaterals are preferred) and was managed conservatively. (AVI 2773 kb)

Video 3.16b

Biplane angiogram of final results. The final angiogram (B LAO) demonstrates the newly re-opened RCA. The distal vessel is still attenuated due to spasm and will enlarge over the next few hours. A small septal collateral rupture is seen. This usually resolves spontaneously (which is why septal collaterals are preferred) and was managed conservatively. (AVI 2501 kb)

Recommended Reading

  1. 1.
    Brilakis ES, Grantham JA, Rinfret S et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5:367–79.CrossRefPubMedGoogle Scholar
  2. 2.
    Brilakis ES, Karmpaliotis D, Werner GS et al. Developments in coronary chronic total occlusion percutaneous coronary interventions: 2014 state-of-the-art update. J Invasive Cardiol. 2014;26:261–6.PubMedGoogle Scholar
  3. 3.
    George S, Cockburn J, Clayton TC et al. Long-term follow-up of elective chronic total coronary occlusion angioplasty: analysis from the u.k. Central cardiac audit database. J Am Coll Cardiol. 2014;64:235–43.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2017

Authors and Affiliations

  1. 1.LondonUK
  2. 2.Queen Elizabeth HospitalBirminghamUK

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