Chronic total occlusions — Current techniques and future directions

Abstract

Chronic total occlusions (CTOs) of coronary arteries represent a common and significant challenge to interventional cardiology. Medical therapy is often regarded as an adequate long term strategy in the management of these lesions with surgical intervention for refractory symptoms. Extensive collateralisation is used as a marker of distal coronary perfusion, further reinforcing non-invasive strategies. This together with relatively low percutaneous success rates outside of specialised centres has meant that rates of percutaneous intervention have remained low. Increasing evidence suggests that CTOs are not a benign entity. Further, symptom control and quality of life improve significantly with successful percutaneous revascularisation. Both factors have reignited interest in percutaneous modalities. The Japanese have been pioneers in the field of CTO intervention although their success rates have been difficult to replicate. New techniques and equipment developed in North America offer an alternative to the Japanese approach. These techniques focus on time, radiation and contrast minimisation. This review will assess the histopathology of CTO and shifting paradigms in CTO treatment strategies.

Transcatheter pulmonary valve perforation using chronic total occlusion wire in pulmonary atresia with intact ventricular septum

“…Two types of CTO wires are currently available - polymer coated hydrophilic and hydrophobic coil wires. [910] Hydrophilic coating attracts very little resistance when they come in contact with tissue in the lumen. It moves easily through soft tissue and therefore has a potential risk of perforation.…”

Parallel Guidewire for Catheter Stabilization in Interventional Radiology: The Anchoring Wire Technique

“…Other techniques of stabilization, using different kind of devices have been described. One of the most widespread technique is the use of an angioplasty balloon, especially in interventional cardiology for chronic total occlusion treatment [6,7]. The use of the wire anchoring technique more than the balloon anchoring technique seems to be easier, faster, cheaper, and safer (regarding complication such as vessel rupture risk).…”

Revascularization of coronary chronic total occlusions with subintimal tracking and reentry followed by deferred stenting: Experience from a high‐volume referral center

“…The subintimal tracking and reentry (STAR) technique for CTO recanalization has been described in several variants, including traditional STAR, contrast‐guided STAR, and mini‐STAR . From an antegrade approach, the subintimal space is accessed proximal to or at the occlusion by established CTO PCI techniques . Next a 0.014″ soft polymeric jacketed wire, such as the Fielder XT (Asahi Intecc, Nagoya, Japan) or Pilot 200 (Abbott Vascular, Santa Clara, CA) with an angled or J‐shaped curve is supported through a microcatheter.…”