A Novel Modification of the Retrograde Approach for the Recanalization of Chronic Total Occlusion of the Coronary Arteries

Rathore, Sudhir; Katoh, Osamu; Tuschikane, Etsuo; Oida, Akitsugu; Suzuki, Takahiko; Takase, Shimichi

doi:10.1016/j.jcin.2009.10.030

Cited by 160 publications

(104 citation statements)

References 23 publications

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“…While the success rate of PCI to coronary CTO was not sufficient (51-74%) until 2009, 37,38) the introduction of new devices such as guidewires or microcatheters and bidirectional approaches (antegrade and retrograde) has significantly increased the initial success rate of CTO. [39][40][41] Furthermore, the long-term patency of revascularized CTO was low in patients treated using bare-metal stents, 42) however, the long-term patency of revascularized CTO is comparable to non-CTO lesions in patients treated by drug-elution stents. 43) Therefore, PCI to CTO is not a special procedure, and patency following drugeluting stent deployment is to be expected.…”

Section: Discussionmentioning

confidence: 99%

Determinants of Left Ventricular Systolic Function Improvement Following Coronary Artery Revascularization in Heart Failure Patients With Reduced Ejection Fraction (HFrEF)

et al. 2016

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SummaryRevascularization therapy such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) should be considered for heart failure with reduced ejection fraction (HFrEF). However, revascularization therapy does not always improve left ventricular ejection fraction (LVEF). The purpose of this study was to investigate the determinants of LVEF improvement following revascularization in HFrEF patients. From 2,229 consecutive decompensated heart failure patients, a total of 47 HFrEF patients who underwent revascularization were included in the analysis. Improvement of LVEF was defined as [(LVEF during chronic phase) -(LVEF during acute phase)] ≥ 10%. Univariate and multivariate logistic regression analyses were applied to investigate the determinants of LVEF improvement. The prevalence of revascularization by PCIs including chronic total occlusion (CTO) was significantly greater in the improved EF group (45.0%) as compared to the non-improved EF group (11.1%) (P = 0.02). Multivariate logistic regression analysis revealed that revascularization by PCIs including CTO was the significant determinant of the LVEF improvement after adjusting for confounding factors (OR 5.43, 95% CI 1.06-27.74, P = 0.04). Optimal medical therapy (angiotensin-converting enzyme (ACE) inhibitor and/or angiotensin II receptor blocker (ARB) and beta-blockers) was less frequently prescribed in patients with CABG (50.0% for ACE inhibitor and/or ARB and 41.7% for beta-blocker) than in patients without CABG (94.3% for both) (P < 0.01 and P < 0.001, respectively). In conclusion, revascularization by PCIs including CTO was the significant determinant of LVEF improvement in HFrEF patients. Our results underscore the importance of optimal medical therapy even if patients receive complete revascularization such as CABG. (Int Heart J 2016; 57: 565-572) Key words: Percutaneous coronary intervention, Coronary artery bypass grafting, Chronic total occlusion H eart failure is a common disease with a prevalence of 1-2% in the adult population, 1) and still has high mortality in developed countries. One-year mortality rates in population-based studies have been reported to be 25% to 45%.2-5) The mortality rate was higher in heart failure with reduced ejection fraction (HFrEF) than heart failure with preserved ejection fraction (HFpEF). 6) Mortality rates of HFrEF (ejection fraction < 50%) patients were reported to be 32% at one year and 68% at 5 years.6) The most common cause of HFrEF is coronary artery disease, which accounts for approximately two-thirds of HFrEF. 7)Revascularization therapy such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) should be considered in heart failure with coronary artery disease, and sometimes improves clinical outcomes including left ventricular function. [8][9][10][11][12] However, revascularization therapy is not always effective in heart failure with coronary artery disease.13) It is unknown which types of patients receive the benefits such as improvement o...

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Section: Discussionmentioning

confidence: 99%

Determinants of Left Ventricular Systolic Function Improvement Following Coronary Artery Revascularization in Heart Failure Patients With Reduced Ejection Fraction (HFrEF)

et al. 2016

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“…We reported that the prevalence of tapered pattern was significantly more frequent in distal lumen compared to proximal lumen (11). The utilization of retrograde approach is one of the main advances in revascularization techniques during CTO procedures and is responsible for the incremental success rates (6,20).…”

Section: Proximal and Distal Lumen Patternmentioning

confidence: 99%

“…The British Cardiovascular Intervention Society reported that successful CTO Percutaneous Coronary Intervention (PCI) of at least 1 CTO was significantly associated with improved survival (hazard ratio: 0.72; 95% confidence interval: 0.62 to 0.83; P < 0.001) compared to unsuccessful CTO (1). Furthermore, although the success rates of percutaneous revascularization of CTOs were not satisfactory, as they ranged from 51 to 74% up to 2009 (3), recent technological advances and interventional strategies have improved the success rate to 85% (4)(5)(6). On the other hand, human autopsy studies of CTO have contributed significantly to the refinement of PCI techniques and device developments.…”

Section: Introductionmentioning

confidence: 99%

Pathology of Coronary Chronic Total Occlusion

Sakakura

Yahagi

Virmani

2016

Int Cardiovasc Res J

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There is an increasing need for percutaneous revascularization procedures of coronary Chronic Total Occlusion (CTO), because many patients with severe coronary artery disease have limited options for revascularization. Although the success rate of percutaneous revascularization of CTOs was unsatisfactory from the 1990s to the 2000s, recent technological advances in interventional strategies have improved the success rate to 85%. Detailed histological assessment of human autopsy studies of CTO has contributed significantly to the refinement in Percutaneous Coronary Intervention (PCI) techniques and device development. We have recently reported the pathological findings and characteristics of CTOs that occur in different clinical scenarios. In this review, we discuss the pathology of CTOs to facilitate greater understanding of revascularization strategies for CTOs.

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“…Excellent results can be achieved with high success rates (8-10) and low complication rates (11) in experienced centers and operators using all available techniques both antegrade approaches including antegrade wire escalation using dedicated guidewires, parallel wire technique and intravascular ultrasound (IVUS)-guided wiring technique, as well as retrograde approaches including reverse controlled antegrade and retrograde subintimal tracking (CART) technique (12) and IVUS guided reverse CART (13).…”

Section: Editorialmentioning

confidence: 99%

Does successful chronic total occlusion recanalization fail to improve long-term survival?

Takao¹

2017

Cardiovasc. Diagn. Ther.

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There has been a significant increase in the number of patients undergoing successful CTO PCI in recent years, even though there might remains considerable controversy regarding the clinical benefit of this procedure. Although no randomized controlled clinical trials comparing CTO-PCI with medical therapy have been published to date, there is a growing body of evidence suggesting clinical benefits (1). These benefits include improvement of anginal symptoms, decreased anti-anginal medication intake, improved exercise capacity, improved left ventricular systolic function, decreased risk of arrhythmia, decreased the number of coronary artery bypass graft (CABG) procedures, and improved tolerance of future coronary occlusion events such as acute coronary syndrome among patients with successful versus failed CTO-PCI. Moreover, CTO is the most common reason for failing to achieve complete revascularization, and incomplete revascularization is associated with poorer clinical outcome compared with complete revascularization.Application of drug-eluting stents (DES) has resulted in significant reduction of target vessel revascularization in non-CTO PCI, and has also led to a surge of interest in CTO-PCI. As a consequence, second-generation DES implantation is the current therapy of choice for percutaneous revascularization of CTO, because it is clear due to supporting clinical evidence in many meta-analyses that implantation of the second-generation DES improves long-term angiographic and clinical outcomes compared with first-generation DES, bare metal stents, and balloon angioplasty without using stents (2).In regards to long-term clinical outcomes, the survival benefit of CTO recanalization is less clearly established, although it has been previously suggested in prior studies (3)(4)(5).A recent study published in this issue of JACC Cardiovasc Interv describes the long-term survival of CTO-PCI. Lee and colleagues evaluated (6) 1,173 consecutive patients with CTO of native coronary vessels requiring PCI of Asan Medical Center in Seoul between March 2003 and May 2014. The procedure was performed successfully, in 1,004 (85.6%) using DES implantation. However, successful recanalization of CTO PCI using DES was not associated with a reduction in long-term mortality over a median follow-up 4.6 years [hazard ratio (HR), 1.04; 95% confidence interval (CI), 0.53-2.04; P=0.94].This report also described that successful CTO PCI was associated with significant fewer subsequent CABG procedures. In contrast, in the group with failed CTO PCI a substantially higher rates of subsequent TVR (HR, 0.15; 95% CI, 0.10-0.25; P<0.001) and CABG procedure (HR, 0.02; 95% CI, 0.006-0.06; P<0.001) was observed.In an evaluation of details of these results, complete revascularization was achieved in 77.2% and 75.9% of patients with failed CTO PCI excluding the CTO lesion and patients with successful CTO PCI within 6 months, respectively (P=0.77). Nevertheless, patients with failed CTO PCI had significantly higher rates of TVR (4.4% vs. Editorial

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A Novel Modification of the Retrograde Approach for the Recanalization of Chronic Total Occlusion of the Coronary Arteries

Abstract: This first series describes a high success rate of CTO recanalization with IVUS-guided reverse CART in selected patients performed by an experienced operator.

Cited by 160 publications

References 23 publications

Determinants of Left Ventricular Systolic Function Improvement Following Coronary Artery Revascularization in Heart Failure Patients With Reduced Ejection Fraction (HFrEF)

Determinants of Left Ventricular Systolic Function Improvement Following Coronary Artery Revascularization in Heart Failure Patients With Reduced Ejection Fraction (HFrEF)

Pathology of Coronary Chronic Total Occlusion

Does successful chronic total occlusion recanalization fail to improve long-term survival?

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