Fundamental Wire Technique and Current Standard Strategy of Percutaneous Intervention for Chronic Total Occlusion With Histopathological Insights

Currently, successful treatment of chronic total occlusion (CTO) seems markedly improved, due to several new techniques and dedicated device developments. However, this improved success rate is often limited to procedures performed by skilled, highly experienced operators. To improve the overall success rate of percutaneous coronary intervention of CTO from a worldwide perspective, a deeper understanding of CTO histopathology might offer insights into the development of new techniques and procedural strategies. In this review, CTO histopathology and wire techniques are discussed on the basis of the fundamental concepts of antegrade and retrograde approaches. Although details pertaining to wire manipulation are very difficult to explain objectively, we tried to describe this as best as possible in this article. Finally, a systematic review of the current standard CTO strategy is provided. Hopefully, this article will enhance the understanding of this complex procedure and, consequently, promote safe and effective CTO-percutaneous coronary intervention for patients who present with this challenging lesion subset

Different Patterns of Vascular Response Between Patients With or Without Diabetes Mellitus After Drug-Eluting Stent Implantation Optical Coherence Tomographic Analysis

ObjectivesWe performed this study to investigate with optical coherence tomography (OCT) the vascular response after sirolimus-eluting stent (SES) implantation between patients with and those without diabetes mellitus (DM).BackgroundThe difference in vascular response after SES implantation between patients with and those without DM has not been fully evaluated with OCT.MethodsOptical coherence tomography was performed to examine 74 nonrestenotic SES implanted in 63 patients (32 with DM and 31 without DM) at 9 months after SES implantation. For struts showing neointimal coverage, the neointimal thickness on the luminal side of each strut section was measured, and neointimal characteristics were classified into high, low, and layered signal pattern.ResultsBaseline patient characteristics and lesion and procedural characteristics data were similar between the 2 groups. In total, 11,422 struts were analyzed. High signal neointima was observed in 90.2 ± 13.9%, low signal neointima in 7.3 ± 10.0%, and layered neointima in 2.7 ± 5.8%/stents. There was higher incidence of low signal neointima (10.5 ± 10.3% vs. 4.5 ± 5.6%, p = 0.003), neointimal thickness was larger (median: 106.8 μm, interquartile range: 79.3 to 130.4 μm vs. median: 83.5 μm, interquartile range: 62.3 to 89.3 μm; p < 0.0001), and neointimal coverage of stent struts was higher (92.1 ± 6.2% vs. 87.2 ± 11.9%; p = 0.03) in DM patients.ConclusionsHigh signal neointimal pattern was predominantly observed, and low or layered signal pattern was observed in some cases. In DM patients, low signal neointima was observed with high frequency. Neointimal coverage and neointimal thickness was also higher in DM patients as compared with non-DM patients

The Efficacy of a Bilateral Approach for Treating Lesions With Chronic Total Occlusions The CART (Controlled Antegrade and Retrograde subintimal Tracking) Registry

ObjectivesThe aim of this study was to evaluate the safety and feasibility of a new concept for chronic total occlusion (CTO) recanalization—using a bilateral approach that utilizes a Controlled Antegrade and Retrograde subintimal Tracking (CART) technique.BackgroundSuccessful percutaneous recanalization of coronary CTOs results in improved long-term outcomes. The recanalization of CTOs in native coronary arteries no doubt represents one of the most technically challenging of interventional procedures.MethodsA total of 224 consecutive patients (mean age 61 ± 9 years; 86.2% men) were enrolled in this prospective multicenter registry. This technique combines the simultaneous use of antegrade and retrograde approaches. A subintimal dissection is created in both antegrade and retrograde fashion, thereby limiting the extension of the subintimal dissection within the CTO portion.ResultsOf 224 CTO lesions (>3 months in duration) undergoing attempted recanalization using the CART technique, 145 cases (64.7%) had undergone previous CTO recanalization attempts. The success rates of crossing in a retrograde fashion with a wire and a balloon were 87.9% and 79.9%, respectively. The overall technical and procedural success rates achieved in this registry were 92.4% and 90.6%, respectively.ConclusionsA bilateral approach for CTO lesions using the CART technique is feasible, safe, and has a higher success rate than previous approaches. These results indicate that a bilateral technique can solve a major dilemma that commonly affects CTO procedures

Clinical effective use of Conquest Pro 12 Sharpened Tip for chronic total occlusion intervention: A series of three case reports

Abstract A new chronic total occlusion (CTO) guidewire, Conquest Pro 12 Sharpened Tip (CP12ST), has a stronger penetration force than the original CP12 and a deflection effect that it does not have. The CP12ST enables us to advance into hard plaque that has not ever penetrated, which might change CTO treatment as shown in three cases

The First Clinical Experience With a Novel Catheter for Collateral Channel Tracking in Retrograde Approach for Chronic Coronary Total Occlusions

ObjectivesThe aim of this study was to report the initial experience with a novel catheter in the retrograde approach for chronic total occlusion (CTO).BackgroundAlthough the use of the retrograde approach in percutaneous coronary intervention for CTO has been established, some procedural difficulties remain.MethodsA novel over-the-wire catheter (channel dilator) specifically designed for the retrograde approach has been developed for the treatment of CTO. The channel dilator was used in 93 CTO lesions after successful wiring of collateral channels using the retrograde approach.ResultsSuccessful channel crossing of the catheter was achieved in 90 of the lesions (96.8%), and the channel dilator successfully advanced into the occlusion reversely during retrograde wiring in 85 lesions (94.4%). Of the 75 lesions with successful advancement of the retrograde wire into the proximal true lumen, the entire occlusion was crossed retrograde with the channel dilator in 63 lesions (84.0%). To evaluate the feasibility of the catheter, 93 CTO lesions in the preceding period were compared. Procedure and fluoroscopy time tended to be lower in the study group than in the control group. The success of the retrograde procedure was significantly higher in the study group than in the control group (98.9% vs. 92.5%, p = 0.030).ConclusionsThe channel dilator may facilitate the conventional retrograde approach with a high level of success