Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been rapidly evolving during recent years. With improvement in equipment and techniques, high success rates can be ...achieved at experienced centers, although overall success rates remain low. Prospective, randomized-controlled data regarding optimal use and indications for CTO PCI remain limited. CTO PCI should be performed when the anticipated benefit exceeds the potential risk. New high-quality studies of the clinical outcomes and techniques of CTO PCI are needed, as is the expansion of expert centers and operators that can achieve excellent clinical outcomes in this challenging patient and lesion subgroup. In the current review the authors summarize the latest publications in CTO PCI and provide an overview of the current state of the field.
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Vascular bypass surgery takes a significant place in the treatment of vascular disease. According to various assessments, this type of surgery is associated with almost 20 % of all vascular surgery ...episodes (up to 23 % according to the Federal Neurosurgical Center of Novosibirsk). Even though the problem of using of vascular grafts is obvious and natural, many problems associated with them are not still elucidated. From the mechanics’ point of view, a vascular bypass is a converging or diverging tee, and the functioning of such structures still does not have strict mathematical formulations and proofs in the general case, which forces many researchers to solve specific engineering problems associated with shunting. Mathematical modeling, which is the gold standard for virtual simulations of industrial and medical problems, faces great difficulties and limitations in solving problems for vascular bypasses. Complications in the treatment of the vascular disease may follow the difficulties in mathematical modeling, and the price can be a cardiac arrest or a stroke. This work is devoted to the main aspects of the medical application of vascular bypasses and their functioning as a mechanical system, as well the mathematical aspects of their possible setup.
Background: Most complex chronic total occlusions (CTOs) require the utilization of multiple recanalization strategies. However, data on wire manipulation time within CTO percutaneous coronary ...intervention (PCI) are limited. Objectives: We sought to investigate the impact of crossover time between crossing strategies on CTO PCI technical success. Methods: A total of 1026 patients admitted to our center between 2013 and 2019 for CTO PCI were assessed, of whom 143 were included for analysis. In these patients, the primary antegrade approach was changed to retrograde within one procedure. The crossover time between strategies remained at the operator's decision. Results: In most cases the target vessel was the right coronary artery (72%), followed by the left anterior descending (18.2%) and left circumflex (9.1%) arteries. The mean J-CTO score was 2.1 ± 1.1. Logistic regression analysis was used to estimate the odds of technical success associated with various crossover times. The results showed that 33 minutes was the threshold of the initial timing at which to review crossover of antegrade to retrograde recanalization of CTO. The odds of technical success with earlier crossover were 3.4 times higher 95% confidence interval (CI): 1.3 to 8.6. The chances of success reduced by 3% for every 1 minute longer than the threshold time (odds ratio: 0.97; 95% CI: 0.94 to 0.99, p = 0.05). Conclusions: Crossover to the retrograde approach should be considered no later than 33minutes after antegrade wire manipulation in order to maintain the maximum chances of final technical success.
There is a lack of data regarding the long-term clinical efficacy of the kissing balloon inflation (KBI) after provisional stenting of coronary bifurcation lesions. The aim of this study was to ...analyze the impact of KBI on long-term clinical outcomes in patients undergoing provisional stenting for the coronary bifurcation lesions in a large real-world population.
A total of 873 patients who underwent percutaneous coronary interventions (PCI) with provisional stenting and had clinical follow up were analyzed. Patients treated with 2-stent strategy were excluded. To reduce the effect of potential confounding factors in this observational study, propensity score matching was conducted.
KBI was performed in 325 patients (37.2%). The median follow-up duration was 37.3 months. Patients treated with KBI more often had a previous PCI (48.6% vs. 42.5% SMD = 0.123). Patients in non-kissing group had more complex coronary disease with higher prevalence of calcification (14.8% vs. 21.4% SMD = 0.172), thrombosis (2.8% vs. 5.8% SMD = 0.152) and longer side branch lesions (8.3% vs. 11.7% SMD = 0.113). There were no significant differences in the major adverse cardiac events including death, myocardial infarction, target lesion revascularization after KBI versus no KBI (15.4% vs. 15.7%, p = 0.28), in total cohort or in matched patients (17.1% vs. 15.8%, adjusted HR 1.01, 95% CI: 0.65–1.65, p = 0.95). The lack of effect of KBI on clinical outcomes was consistent across various subgroups including left main disease.
In this multicenter real-world registry, KBI did not improve long-term clinical outcomes in patients with coronary bifurcation lesions treated with provisional stenting technique.
•While POT considered as a mandatory step of the provisional stenting, efficacy of KBI is still questioned due to controversial data.•In this multicenter real-world registry KBI didn't improve clinical outcomes in patients treated with 1-stent technique.•The lack of effect of KBI on clinical outcomes was consistent across various subgroups including left main bifurcation.
A 68-year-old woman was initially admitted with 2 subannular pseudoaneurysms of the aortic root after aortic valve replacement. The aneurysm expanded after 10 days and was treated using endovascular ...closure devices. (Level of Difficulty: Advanced.)
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A 68-year-old woman was initially admitted with 2 subannular pseudoaneurysms of the aortic root after aortic valve replacement. The aneurysm expanded…
BACKGROUNDInability to cross the lesion with a balloon is the second-most common cause of technical failure, with the most common cause being the inability to cross with the wire. We propose a new, ...effective method for treating balloon-uncrossable lesions, called the "deep-wire crossing" (DWC) technique. OBJECTIVESThe aim of this study was to evaluate the procedural outcomes of the DWC technique for treating balloon-uncrossable lesions. METHODSFrom 2017 to 2018, a total of 95 patients with balloon-uncrossable lesions were treated using the DWC technique at our center. Procedural and in-hospital outcomes were assessed. RESULTSIn most cases, the target vessel was the left circumflex (46.3%), followed by the right coronary artery (31.6%) and left anterior descending (22.1%). According to the American College of Cardiology/American Heart Association classification, 41% of lesions were classified as type C, 40% as type B2, and 18.9% as type B1. Chronic total occlusion occurred in 24 patients (25.3%). Overall technical success was achieved in 84 patients (88.4%). Successful DWC technique was achieved in 74 patients (77.9%). In-hospital major adverse cardiac event rate was 3.2%. Coronary perforation required pericardiocentesis in only 1 patient. Periprocedural myocardial infarction occurred in 1 patient and was managed conservatively; urgent revascularization was required for 1 patient. CONCLUSIONOur experience with the DWC technique demonstrated that it can be a viable option for treating balloon- uncrossable lesions, and operators should become familiar with it.
The aim of this study was to determine the techniques and outcomes of hybrid chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a diverse group of patients and operators on 2 ...continents.
CTO PCI has been evolving with constant improvement of equipment and techniques.
Contemporary outcomes of CTO PCI were examined by analyzing the clinical, angiographic, and procedural characteristics of 3,122 CTO interventions performed in 3,055 patients at 20 centers in the United States, Europe, and Russia.
The mean age was 65 ± 10 years, and 85% of the patients were men, with high prevalence of diabetes (43%), prior myocardial infarction (46%), prior coronary artery bypass graft surgery (33%), and prior PCI (65%). The CTO target vessels were the right coronary artery (55%), left anterior descending coronary artery (24%), and left circumflex coronary artery (20%). The mean J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores were 2.4 ± 1.3 and 1.3 ± 1.0, respectively. The overall technical and procedural success rate was 87% and 85%, respectively, and the rate of in-hospital major complications was 3.0%. The final successful crossing strategy was antegrade wire escalation in 52.0%, retrograde in 27.1%, and antegrade dissection re-entry in 20.9%; >1 crossing strategy was required in 40.9%. Median contrast volume, air kerma radiation dose, and procedure and fluoroscopy time were 270 ml (interquartile range: 200 to 360 ml), 2.9 Gy (interquartile range: 1.7 to 4.7 Gy), 123 min (interquartile range: 81 to 188 min) and 47 min (interquartile range: 29 to 77 min), respectively.
CTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the United States, Europe, and Russia. (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention PROGRESS CTO; NCT02061436).
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