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Chronic Total Occlusions

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PanVascular Medicine

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Abstract

Chronic total occlusions (CTOs) represent the “last frontier” of percutaneous coronary interventions (PCI). CTOs are frequently (~30 %) detected on diagnostic coronary angiograms, but CTO PCI is currently performed infrequently mainly because of higher technical difficulty and perceived risk of complications. Nonetheless, successful CTO PCI can significantly improve the patient’s quality of life, improve left ventricular function, reduce the need for subsequent coronary artery bypass graft surgery, and possibly improve long-term survival. The introduction of novel catheters, guidewires, adjunctive imaging, PCI techniques, and higher operator volumes has led to an increased success rate of CTO PCI. Moreover, the introduction of drug-eluting stents has led to higher rates of sustained patency following CTO recanalization. This chapter aims to provide an overview of the anatomy and histopathology of CTOs, a concise review of techniques and devices for CTO PCI, and a comprehensive summary of the evidence regarding the clinical relevance and rationale of CTO PCI.

Disclosures

Dr. Mehran and Dr. Dangas have received institutional research grant support from The Medicines Co., Bristol-Myers Squibb/Sanofi-Aventis, Lilly/Daiichi Sankyo, Regado Biosciences, and STENTYS and honoraria/consulting fees from Abbott Vascular, AstraZeneca, Boston Scientific, Covidien, CSL Behring, Janssen (JNJ), Maya Medical, and Merck; serve on the advisory boards of Covidien, Janssen Pharmaceuticals, and Sanofi-Aventis; and have equity/shares in Endothelix, Inc. Dr. Brilakis has received consulting fees/speaker honoraria from St Jude Medical, Boston Scientific, Asahi, Janssen, Sanofi, and Terumo; research support from Guerbet; and his spouse is an employee of Medtronic. The other authors have nothing to disclose.

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Abbreviations

Antegrade approach to chronic total occlusions:

When attempting an antegrade approach, crossing of a chronic total occlusion is attempted by advancing equipment proximal to the lesion and penetrating the proximal cap.

Chronic total occlusion:

A complete interruption of coronary blood flow with an estimated duration of at least 3 months.

Microchannels:

Small channels frequently found in chronic total occlusion lesions with an average diameter of 200 μm that can be engaged by tapered-tip polymer-jacketed guidewires.

Retrograde approach to chronic total occlusions:

When attempting a retrograde approach, crossing of a chronic total occlusion is attempted by advancing equipment in the distal true lumen by interrogating collateral vasculature.

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Further Reading

  • Dangas GD (ed) (2007) Handbook of chronic total occlusions. Informa Healthcare, London, UK

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Authors and Affiliations

  1. Department of Cardiology, The Academic Medical Center – University of Amsterdam, Meibergdreef 9 Room B2-223, 1105 AZ, Amsterdam, The Netherlands

    Dr. Bimmer E. Claessen M.D., Ph.D. & Dr. José P. S. Henriques M.D., Ph.D.

  2. VA North Texas Healthcare System and University of Texas Southwestern Medical School at Dallas, 4500 South Lancaster Road, Dallas, TX, 75216, USA

    Dr. Emmanouil S. Brilakis M.D., Ph.D.

  3. Mount Sinai Medical Center, 1450 Madison Ave.;KCC Building, 6th Flr, Room 6-682, New York, NY, 10029, USA

    Prof. Usman Baber M.D. & Dr. George D. Dangas M.D., Ph.D.

  4. Guggenheim Pavilion, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, Mount Sinai Medical Center, 1190 Fifth Avenue – 1 South, New York, NY, 10029, USA

    Roxana Mehran M.D.

Authors
  1. Dr. Bimmer E. Claessen M.D., Ph.D.
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  2. Dr. Emmanouil S. Brilakis M.D., Ph.D.
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  3. Prof. Usman Baber M.D.
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  4. Dr. José P. S. Henriques M.D., Ph.D.
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  5. Roxana Mehran M.D.
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  6. Dr. George D. Dangas M.D., Ph.D.
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Corresponding author

Correspondence to Bimmer E. Claessen M.D., Ph.D. .

Editor information

Editors and Affiliations

  1. Akademisches Lehrkrankenhaus MLU, Bitterfeld-Wolfen, Germany

    Peter Lanzer

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Claessen, B.E., Brilakis, E.S., Baber, U., Henriques, J.P.S., Mehran, R., Dangas, G.D. (2014). Chronic Total Occlusions. In: Lanzer, P. (eds) PanVascular Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-37393-0_75-1

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  • DOI: https://doi.org/10.1007/978-3-642-37393-0_75-1

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