Coronary chronic total occlusion (CTO) is a frequent finding in patients with coronary artery disease. It remains one of the most challenging subsets, accounting for 10-20% of all percutaneous coronary interventions (PCI). Although remarkable progress in PCI has been made, it is reasonable to state that successful recanalization of CTO represents the “last frontier” of PCI. PCI of CTOs has been limited historically by technical success rates of 50-70%. The introduction of enhanced guidewires, microcatheter, channel dilatator with increasing operator experience, and innovative techniques such as the retrograde approach have raised hopes for better outcomes. This article goes into depth into various strategies of retrograde approach in CTO.
Chronic total occlusion (CTO) is a frequent finding in patients with coronary artery disease and when clinically indicated, remains one of the most challenging subsets for intervention. Although successful recanalization rates of CTO have remained suboptimal in percutaneous coronary intervention, evolving techniques including retrograde approach, have raised hopes for improving the overall success. Reverse controlled antegrade and retrograde subintimal tracking is the most commonly used out of various retrograde approaches. In this review, the author has thrown light on a step-by-step approach of this technique, its standardization, various modifications along with complications.
The introduction of drug-eluting stents (DESs) and superior anticoagulation has successfully improved the safety and patency rates of complex percutaneous coronary interventions (PCIs). The evolving techniques of contemporary PCI have been unable to completely eliminate coronary injury and mechanical complications. Primary causes for abrupt closure include dissection, thrombus formation and acute stent thrombosis. Initial treatment for abrupt closure includes balloon redilatation, optimisation of activated clotting time (ACT) and deployment of stent to stabilise a dissection. Coronary perforation is one of the most challenging and feared complications of PCI. It is most frequently due to distal wire or balloon/stent oversizing and should be fixed with balloon occlusion. Covered stent may be needed for large perforation in major proximal vessels. Perforations in small or distal vessels not resolving with balloon occlusion may be managed by coil or Gelfoam embolisation. Referral to emergency coronary artery bypass surgery (CABG) should be an option in case perforations do not seal.
For several decades, coronary artery bypass grafting (CABG) has been considered as the gold standard treatment of unprotected left main coronary artery (LMCA) disease. The marked improvement in technique and technology makes percutaneous coronary interventions (PCIs) feasible for patients with unprotected LMCA stenosis. The recent introduction of drug-eluting stents (DESs), together with advances in periprocedural and postprocedural adjunctive pharmacotherapies, has improved outcomes of PCIs of these lesions. Recent studies comparing efficacy and safety of PCIs using drug-eluting stents and CABG revealed comparable results in terms of safety and a lower need for repeat revascularisation for CABG. Patient selection for both the techniques directly impacts clinical outcome. Despite improvement in stent technology and operator experience, management can be challenging especially in LMCA bifurcation lesions and, therefore, an integrated approach combining advanced devices, tailored techniques, adjunctive support of physiological evaluation, and adjunctive pharmacological agents should be reinforced to improve clinical outcome.
espite technical improvements in percutaneous coronary interventions (PCI), treatment of bifurcation lesions remains difficult and is associated with an unfavourable outcome. 1 Drug-eluting stents (DES) have dramatically reduced the restenosis rate in the main vessel, but with conventional T-stenting, a restenosis rate greater than 10% is still observed, mainly because of poor ostial coverage. 2 Different techniques, such as V-stenting, culottestenting or crush stenting, allow full ostial coverage and may therefore achieve uniform drug distribution throughout the lesion. With the crush stenting techniques using DES, few data are available. In one study, if final kissing balloon dilatation was performed, restenosis caused mainly by a focal ostial lesion in the side branch vessel occurred in 11.1% of cases, compared with 37.9% if final kissing balloon dilatation was not done. 3 The crush technique results in a strong mechanical constraint on the side branch stent, as demonstrated in this case presentation. Case ReportDiagnostic invasive angiography was done in a 73-yearold man complaining of typical chest pain, and revealed a significant left main artery (LM) bifurcation lesion (Fig 1a). Elective percutaneous treatment of the lesion was performed, using the crush stenting technique. A stent was firstly implanted in the LM and left circumflex (LCX) arteries (Cypher 3.5×23 mm; 16 atmosphere), followed by a LM and left anterior descending stent (Cypher 3.5×23 mm; 20 atm), thus, "crushing" the LM -LCX stent. A wire was then inserted into the LCX through the LM -LCX stent with subsequent strut dilatation. A final kissing balloon (Crossail 3.5 and Cypher balloon 3.5; 22 atm) dilatation was also performed, with a good end-result (Fig 1b). The patient was discharged with standard medication (aspirin: 100 mg, daily, lifelong; ticlopidine: 100 mg, bd, lifelong).The patient remained symptom free. Routine follow-up coronary angiography was performed and showed a severe ostial in-stent restenosis of the LCX (Fig 1c). On the fluoroscopy images, hypermobility of the LM -LCX stent was observed. In fact, the stent was implanted from the LM to the LCX, limiting therefore the freedom of mobility of the circumflex artery, as this was the case at the index procedure. However, as shown in Fig 2, the angulation between the LM and LCX varied widely at follow-up coronary angiography, indicating strut fracture, which was visualized best on the end-systolic frame in the epicranial view (Fig 3). At baseline, the intravascular ultrasound reading showed moderate to severe calcification, and contiguous stent coverage could be seen (Fig 4). However, discontinuity of the stent strut over an arc of about 150 degrees at the ostium of the LCX could be observed at follow-up (Fig 5). Because of this moderate stent fracture and the need for mechanical scaffolding, the lesion was treated by stent in-stent implantation (Cypher 3.5×18 mm) with a final kissing balloon dilatation. DiscussionComplex lesions are increasingly treated by PCI, thanks to the impr...
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