A b s t r a c tBackground and aim: Percutaneous coronary interventions (PCI) within chronically occluded coronary arteries remain challenging procedures with a lower success rate compared to classic PCI. However, over the last years we have witnessed many technological advances in the treatment of chronic total occlusion (CTO) including new wires, retrograde approach, subintimal tracking and re-entry technique, all underlying which the current success rate of up to 95% in dedicated centres. Subintimal space wire penetration is no longer a problem that would require terminating the procedure. It is now a desired part of hybrid CTO approach involving both antegrade and retrograde crossing and re-entry. The new device which facilitates controlled dissection and true lumen re-entry is the Boston Scientific Coronary CTO Crossing System consisting of a CrossBoss microcatheter and Stingray balloon and dedicated wire. Methods: On October 29th and 30 th , 2014, percutaneous coronary recanalisation using the CrossBoss/Stingray system was performed in 3 men aged 63-75, with symptoms of stable CCS class II/III angina, without prior myocardial infarction in the area of CTO artery supply and with preserved myocardial contractility. Each patient underwent at least one previous unsuccesful antegrade/retrograde CTO recanalisation procedure. The J-CTO score was 3-4. Results:The procedure was successful in all 3 patients: 2 right coronary arteries and 1 left anterior descending artery were opened. In all 3 cases, both the CrossBoss catheter and the Stingray re-entry system were used. Two to three drug eluting stents were implanted in each patient, with the total length of 62-106 mm and final TIMI 3 flow. The mean procedure time was 141 min (130-150 min), mean fluoroscopy time was 53 min (48-56 min), absorbed dose was 4772 mGy (4098-5633 mGy), dose area product was 565,208 cGy × cm 2 (535,109-590,266 cGy × cm 2 ), and the mean contrast volume was 343 mL (320-350 mL). No procedure-related complications were note except for an asymptomatic increase in high-sensitivity troponin T level up to 157 ng/mL (reference range 0-14 ng/mL) in 1 patient. Conclusions:The Boston Scientific Coronary CTO Crossing System is a useful device for percutaneous recanalisation of chronically occluded coronary arteries. It helps to achieve procedural success in more complex cases within relatively short crossing times and with a limited amount of the contrast agent and X-ray dose.
Introduction Treatment of chronic total occlusions (CTO) despite improvement in techniques and results over the last years still seems to be limited to a small number of centres and operators. Application of the hybrid strategy may support further spread of CTO percutaneous coronary intervention (PCI) and increase procedural success rates. Aim Our single-centre prospective ongoing registry aims to provide details and results of recanalizations of coronary CTO performed according to the hybrid algorithm in a series of consecutive patients. Material and methods Between January 2015 and September 2019 the clinical and procedural data of CTO PCI procedures on consecutive patients were collected. Lesion complexity was assessed according to the Multicenter CTO Registry of Japan (J-CTO) score: 0 – easy, 1 – intermediate, 2 – difficult, ≥ 3 – very difficult and PROGRESS score. Strategies applied were classified as: antegrade wire escalation (AWE), antegrade dissection and re-entry (ADR), retrograde wire escalation (RWE) and retrograde dissection and re-entry (RDR). Angiographic success was defined as < 30% residual stenosis with TIMI 3 flow. Angiographic and clinical complications were reported. Results Two hundred sixty-six patients were included and 285 procedures were performed in total. Success rate was 87.7% (calculated per procedure) and 92.5% (calculated per patient). Four patients underwent successful staged double CTO recanalization. Fifteen patients out of 31 primary failures underwent a second attempt with a 73% success rate (11/15). Fifty-two patients (18.2%) were referred for a second attempt from other institutions. Mean J-CTO score was 2.6 (13 cases with J-CTO of 0, 41 cases with J-CTO of 1, 80 cases with J-CTO of 2, and 151 cases with J-CTO ≥ 3) and the success rate was respectively 92.3%, 95.1%, 91.3% and 83.4%. Higher complexity of occlusion required a higher number of applied strategies including retrograde access in over a quarter of cases. Complete revascularization was achieved in 215 (75.4%) cases. In-hospital MACCE rate was 3.5% – 1 patient died due to acute kidney injury complications, 9 (3.2%) patients sustained myocardial infarction (1 STEMI due to side branch occlusion). All 7 (2.5%) coronary perforations (Ellis 1 and Ellis 2) were treated conservatively and we recognised 10 (3.5%) cases of acute kidney injury (one dialysis). Conclusions The hybrid algorithm in CTO PCI can be successfully applied with good early results and low complication rates. Higher complexity CTOs require more procedural strategies with a significantly lower success rate in very difficult cases.
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