|GUIDELINE AND CONSENSUS
|Year : 2018 | Volume
| Issue : 1 | Page : 30-37
Strategic roadmap of percutaneous coronary intervention for chronic total occlusions
Junbo Ge on behalf of Chronic Total Occlusion Club China (CTOCC)
Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
|Date of Web Publication||16-May-2018|
Junbo Ge on behalf of Chronic Total Occlusion Club China (CTOCC)
Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai
Source of Support: None, Conflict of Interest: None
Keywords: Chronic total occlusion, percutaneous coronary intervention, roadmap
|How to cite this article:|
Junbo Ge on behalf of Chronic Total Occlusion Club China (CTOCC). Strategic roadmap of percutaneous coronary intervention for chronic total occlusions. Cardiol Plus 2018;3:30-7
|How to cite this URL:|
Junbo Ge on behalf of Chronic Total Occlusion Club China (CTOCC). Strategic roadmap of percutaneous coronary intervention for chronic total occlusions. Cardiol Plus [serial online] 2018 [cited 2019 Apr 19];3:30-7. Available from: http://www.cardiologyplus.org/text.asp?2018/3/1/30/230530
| Introduction|| |
Chronic total occlusions (CTOs) are lesions to native coronary arteries or bypass grafts that result in a thrombolysis in myocardial infarction (TIMI) antegrade flow score of 0 for at least a 3-month period. An occlusive lesion is still considered a CTO lesion if there are bridging or ipsilateral collateral channels that provide a TIMI score >0 in distal blood flow., Previous studies have shown that up to 20% of all coronary artery disease patients will have one or more CTO lesions. Due to low success and high complication rates in percutaneous coronary intervention (PCI) treatment, CTO-PCI is regarded as the final challenge in contemporary PCI therapy. Clinical evidence has shown that successful recanalization of CTO lesions can effectively improve myocardial perfusion and angina relief,,, improve left ventricular function,, decrease need for coronary artery bypass graft (CABG) procedure,, and improve prognosis.,,,, According to the current clinical research,, when a patient displays symptoms of ischemia or heart failure related to one or more occlusive coronary arteries, recanalization therapy is recommended. If a patient does not experience any related symptoms, noninvasive assessment such as electrocardiogram exercise test, resting and stress echocardiography, and resting and stress myocardial perfusion scintigraphy are recommended. For CTO lesions affecting a small area of the myocardium or with no surviving myocardium in the affected area, optimal medical therapy should be considered.
Early CTO-PCI success rates were limited to roughly 50%–70%,,,, but innovations in interventional devices and techniques ,, have increased the average success rates of CTO PCI to >80%.,, In experienced centers, >90% success rates can be achieved. To improve the standard operating procedure of CTO-PCI, the Chronic Total Occlusion Club, China (CTOCC), has drafted the “Strategic Roadmap of Percutaneous Coronary Intervention for Chronic Total Occlusions” to provide a reference for interventional cardiologists.
| Chronic Total Occlusion-Percutaneous Coronary Intervention Techniques, Strategies, and Roadmap|| |
Comprehensive evaluation of chronic total occlusion lesion
Diligent and comprehensive assessment of coronary angiography is the foundation for a successful CTO-PCI. A preprocedural simultaneous bilateral angiogram is strongly recommended in most CTO cases. Coronary computed tomography angiography is recommended for the assessment of CTO lesions with prior failed attempts or with complex anatomy such as heavy tortuosity, anomalous origin, and ostial CTO lesions.
Key CTO lesion angiographic evaluations should include CTO lesion proximal anatomy (proximal cap anatomy, proximal lesion side branches, etc.), CTO lesion body anatomy (lesion calcification, tortuosity, and length), and CTO lesion distal anatomy (distal cap anatomy, major side branches or bifurcation distal to CTO lesion, and presence of diffused distal lesion). Furthermore, collateral channel assessment is indispensable for retrograde intervention. Collateral circulation evaluation should focus on donor vessel anatomy, collateral lumen size, collateral channel tortuosity, collateral channel angle with donor artery and target artery, and length to emerging point.,, Intervention of the collateral donor artery should be performed prior to retrograde PCI intervention if there are critical lesions present in the donor artery.
Chronic total occlusion-percutaneous coronary intervention strategy planning
Chronic total occlusion-percutaneous coronary intervention initial strategy planning
- For CTO lesions with a tapered proximal cap, an antegrade approach is recommended as the initial strategy. For CTO lesions without a tapper proximal cap or with ambiguous lesion anatomy, an intravascular ultrasound (IVUS)-guided antegrade approach may be considered.
- Primary Antegrade Dissection Re-entry (ADR),,,, technique is recommended in patients with prior failed antegrade attempts, poor collateral circulation, or prior failed retrograde attempts, in combination with suitable CTO lesion vessel characteristics, such as no severe diffused distal lesion, no major side branches near landing zone, and CTO lesion length >20 mm.
- In CTO lesions unsuitable for antegrade approach, a retrograde approach may be considered as an initial intervention strategy if there are suitable collateral channels.
Chronic total occlusion-percutaneous coronary intervention strategy shifting
- The essence of successful CTO-PCI procedures are timely and flexible strategy shifts.
- In case of failed antegrade wiring, ADR or parallel wire technique may be considered. To further increase the success rate of the parallel wire technique, dual-lumen microcatheters, such as KDLC (Kaneka Corporation, Osaka, Japan) or SASUKE (Asahi Intecc Co., Ltd, Nagoya, Japan) parallel wire technique, may be considered.
- If there is a diffused distal lesion in the target vessel, the success rate of either parallel wire technique or ADR will diminish drastically, and an early shift to retrograde strategy is recommended whenever suitable collateral channels are present.
- Combined antegrade-retrograde technique (bilateral preparation): Using only an antegrade or retrograde approach may prove difficult for a successful intervention of a complex CTO lesion. Thus, a combined antegrade-retrograde technique encourages early shifts or a direct retrograde approach after a previous failed antegrade attempt.
Chronic total occlusion-percutaneous coronary intervention guiding catheter selection
Vascular access site should be chosen according to operator preference, target lesion characteristics, and anticipated device usage. Without compromising for coaxialibity, selection of guiding catheters with strong active supports is recommended. Strong active support guiding catheters such as the EBU (Medtronic CardioVascular, Santa Rosa, CA), XB (Cordis Corporation, Miami, FL), Amplatz guiding catheters, and others are recommended for left coronary intervention and the Amplatz, XB RCA (Cordis) guiding catheters, and others are recommended for right coronary intervention. A minimal lumen size of 7F is recommended to accommodate the real-time use of IVUS catheter. A minimal lumen size of 8F is recommended to accommodate the combined use of KDLC dual-lumen microcatheter and IVUS catheter-directed intervention. In the absence of 8F guiding catheter and a need for IVUS-guided dual-lumen catheter intervention, SASUKE dual-lumen catheter or Ping-Pong guide catheter technique may be considered while using a 6F or 7F guiding catheter. 7F or 8F guiding catheters are recommended to accommodate the deployment of ADR devices. Some operators may prefer using guiding catheters with side holes to reduce coronary ischemia and contrast injection-related vessel damage.
Heparin anticoagulation is recommended during CTO-PCI to prevent thrombus formation of guiding catheter. Activated clotting time assessment is recommended every 30–45 min during CTO-PCI procedure, and a safety range of 250~350s is advised.
Chronic total occlusion-percutaneous coronary intervention techniques
Antegrade chronic total occlusion-percutaneous coronary intervention techniques
- Antegrade guidewire selection and escalation [Table 1]: For CTO lesions with tapered proximal cap, tapered and polymer-coated guidewires of low-to-intermediate penetrability are recommended. If the initial guidewire cannot cross the CTO lesion, wire escalation to intermediate-penetrability guidewires is recommended. If the intermediate-penetrability guidewire is still ineffective, further wire escalation to high-penetrability guidewires may be considered.
For a CTO lesion without a stump, an IVUS-guided proximal cap puncture is recommended with suitable side branch. An intermediate-penetrability guidewire is recommended for the initial attempt and a high-penetrability guidewire may be considered for wire escalation. After high-penetrability guidewire puncture of the proximal fibrous cap, a wire step-down to intermediate-penetrability guidewire may be considered for navigating long CTO lesions or lesions with an ambiguous anatomy. In select cases, a wire step-up to high-penetrability guidewire with good manipulability may be considered for distal fibrous cap punctures. Operators should be cautious when using the GAIA series (Asahi Intecc Co., Ltd) guidewires for navigating heavily calcified, tortuous, or long CTO lesions.
- Antegrade wiring techniques: For short CTO lesions, wire escalation is recommended. In long CTO lesions or failed wired escalation, ADR technique, based on the CrossBoss ™ (Boston Scientific, Marlborough, MA) and Stingray ™ (Boston Scientific) systems,, or subintimal guidewire true-lumen-seeking technique ,, may be considered in lesion vessel without severe diffused distal lesion and without major side branches near the distal landing zone. In select cases, IVUS-guided subintimal guidewire re-entry to true lumen is recommended. If ADR technique is not applicable, a parallel wire technique or retrograde wiring technique may be considered. An early shift to retrograde approach with suitable collateral channels is advised in failed antegrade wire escalation.
- Uncrossable or undilatable equipment recommendation: In case of an uncrossable device, after confirming the guidewire in distal true lumen, several techniques may be adopted, such as deep intubation of guiding catheter, balloon anchoring technique (when suitable proximal side branch is present), buddy wire technique, mother–child-guiding catheter technique, combined use of guide extension, utilization of Tornus (Asahi Intecc Co., Ltd.) catheter, small balloon dilatation, excimer laser coronary atherectomy (ELCA), and rotablation atherectomy. In case of undilatable device, utilization of Tornus (Asahi Intecc Co., Ltd.) catheter, ELCA, and rotablation atherectomy may be considered before deploying the device.
|Table 1: Chronic total occlusion-percutaneous coronary intervention-suitable guidewires commonly available in China|
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Retrograde chronic total occlusion-percutaneous coronary intervention techniques
Collateral channel selection and guidewire tracking
- Collateral channel selection: Septal collateral channels are usually recommended for retrograde intervention, but mature epicardial collaterals may also be cautiously considered. Saphenous venous grafts may be considered for previous CABG patients.
- Guidewire selection for collateral tracking [Table 2]: The use of soft-tip guidewires with good feedback and torqueability is recommended for collateral tracking, notably the SION (Asahi Intecc Co., Ltd.) guidewire. In collateral channels with heavy tortuosity and failed SION guidewire tracking, Fielder XT-R (Asahi Intecc Co., Ltd.) is recommended for tiny collaterals. However, operators should be cautious of the Fielder XT-R guidewires entering invisible, small side branches. For tracking of large tortuous collateral channels, SION BLACK (Asahi Intecc Co., Ltd.) may be considered. For extremely tortuous collateral channels, or the so-called instant noodle collaterals, SUOH-03 (Asahi Intecc Co., Ltd.) guidewire is recommended. To improve collateral steerability, tip shaping should be kept short, often at 1 mm or less and at an angle between 70° and 90°. Careful wire advancement through back-and-forth spinning is emphasized during collateral tracking. A direct push advancement may cause channel injury and hence it is not recommended. Surfing technique  may be considered while tracking select septal collateral channels, but it is contraindicated for epicardial collateral channels. To avoid collateral channel damage, tip injection-guided wire manipulation is advised. To prevent collateral channel damage, the operator should perform microcatheter aspiration before each tip injection. Without back blood flow, tip injection should not be performed.
- Collateral channel injury management: Most septal collateral channel damage is benign, and thus can be managed simply by close observation of the patient's vital signs. In septal collateral damage leading to intraseptal hematoma or channel perforation, hemodynamic disturbances require immediate embolization and symptomatic treatment. In epicardial collateral damage, operators should be very cautious of cardiac tamponade, which requires immediate embolization and symptomatic treatment. If the CTO lesion vessel has been recannalized, the operator must perform an embolization treatment from both the CTO vessel and collateral donor vessel. In certain patients, collateral channel injury may be managed by prolonged microcatheter vacuum aspiration to various degrees.
- Guidewire selection after successful collateral tracking: Tip injection assessment of the CTO distal fibrous cap can serve as a basis for lesion-crossing guidewire selection. If the CTO distal cap shows a tapered end, a low-to-intermediate-penetrability guidewire is recommended. In case of an ambiguous or stumpless CTO distal cap, or failed wire crossing, wire escalation to moderate-to-high-penetrability guidewires is recommended.
A 150 cm microcatheters, such as Corsair (Asahi Intecc Co., Ltd.) or Finecross (Terumo Corporation, Tokyo, Japan) are recommended, utilization of a 90-cm guiding catheter is recommended in some cases. In cases of microcatheter collateral tracking resistance, recommendations include switching between 150-cm Corsair and Finecross microcatheters; switching to a 150-cm Caravel (Asahi Intecc Co., Ltd.) or Corsair Pro (Asahi Intecc Co., Ltd.) microcatheter; utilization of the balloon anchoring technique; and combined utilization of guide extension. Deployment of serial small-compliant balloon dilation at low pressures (1.0–1.25 mm, 2–4 atm) is a possibility in septal collaterals, but prohibited in epicardial collaterals. In select cases, switching to a 135-cm Corsair microcatheter before switching back to a 150-cm Corsair microcatheter may be helpful. If all the above recommendations have failed, an early switch of collateral channel or switch to antegrade approach with a retrograde guidewire marker is advised.
Retrograde chronic total occlusion-percutaneous coronary intervention wiring techniques
Retrograde wiring techniques include retrograde wire crossing technique, antegrade and retrograde kissing wire technique, controlled antegrade and retrograde subintimal tracking (CART) technique, and reverse CART technique. Retrograde wire crossing technique and kissing wire technique are mainly suitable for short CTO lesions, and an early adaption of reverse CART technique is recommended if the two techniques have failed. For long, tortuous, or CTO lesions with ambiguous anatomy, success rates for retrograde wire crossing technique and kissing wire technique are low, thus an early adaptation of reverse CART technique is advised to improve operational efficiency and success rate. Extensive retrograde wire manipulation is not advised in tortuous or calcified lesions as it may lead to vessel perforation. Knuckle wire technique, either antegrade or retrograde, may be considered when applicable, especially in CTO lesions with long length, ambiguous anatomy, or stumpless fibrous cap. In case of failed reverse CART deployment, the IVUS-guided reverse CART technique should be considered.
Guidewire selection for externalization
Presently, the 330-cm RG3 (Asahi Intecc Co., Ltd.) guidewire is recommended for wire externalization. In the event of difficult retrograde guidewire entry into the antegrade guiding catheter, the active greeting technique (AGT), with the use of guide extension or mother–child-guiding catheters to steer the retrograde guidewire into antegrade guiding catheter, is recommended. In select cases, such as a right coronary ostial CTO lesion or left main coronary artery CTO lesion, snares and homemade snares may be considered to trap the retrograde guidewire and complete wire externalization. During wire externalization and retraction of the RG3 guidewire, maximum coverage with microcatheter is recommended to prevent wire cutting of the collateral channels and careful manipulation of the retrograde guiding catheter is recommended to prevent coronary artery ostial injury. If the 330-cm RG3 guidewire is not available, other 300–330-cm guidewires may be considered. The use of the rotablation guidewire and extension guidewires for wire externalization is not recommended. The Rendezvous technique, also known as kissing microcatheter technique, and modified techniques based on Rendezvous techniques may also be considered for wire externalization.,
Chronic Total Occlusion Club China chronic total occlusion-percutaneous coronary intervention roadmap [Figure 1]
|Figure 1: CTOCC CTO-PCI roadmap. CCTA: Coronary computed tomography angiography, ADR: Antegrade dissection re-entry, IVUS: Intravascular ultrasound, Reverse CART: Reverse controlled antegrade dissection re-entry technique, CTO-PCI: Chronic total occlusion-percutaneous coronary intervention, CTOCC: Chronic Total Occlusion Club China|
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- Route 1: For CTO lesions with a tapered proximal cap, an antegrade approach is recommended as the initial strategy.
- Route 2: In Route 1, ADR is recommended for CTO lesion with length >20 mm, lesion vessel without severe diffused distal lesion, and lesion vessel without major side branches near landing zone. Wire escalation is recommended for short CTO lesions <20 mm of similar characteristics. In case of failed wired escalation, ADR technique may be considered for crossing the CTO lesion if available.
- Route 3: In Route 1, the parallel wire technique is recommended for CTO lesion with length >20 mm, lesion vessel with diffused distal lesion, and/or lesion vessel with large side branches near distal landing zone. Wire escalation is recommended for short CTO lesions <20 mm of similar characteristics. In failed wire escalation, the parallel wire technique may be considered for crossing CTO lesion.
- Route 4: For failed CTO lesion crossing in Routes 1–3, switching to a retrograde approach or the IVUS-guided antegrade approach is recommended.
- Route 5: For CTO lesions without a stump, IVUS-guided Routes 1–3 are recommended whenever an IVUS device is available.
- Route 6: For CTO lesions without a stump, unavailable IVUS equipment, or failed Route 5, an antegrade approach is recommended if there are no suitable collateral channels. For CTO lesioned vessels without severe diffused distal lesion and without major side branches near landing zone, ADR is recommended for antegrade intervention.
- Route 7: For CTO lesions without a stump, unavailable IVUS equipment, or failed Route 5, a retrograde approach is recommended with suitable collateral channels.
- Route 8: In Route 7, reverse CART technique is recommended for CTO lesions >20 mm in length. Retrograde wire escalation and kissing wire technique are recommended for short CTO lesions <20 mm. If the above-mentioned techniques have failed, reverse CART technique may be considered for crossing CTO lesion as early as possible.
- Route 9: For failed CTO lesion crossing in Route 8, ADR technique is recommended for CTO lesioned vessels without severe diffused distal lesions and without major side branches near landing zone. In select cases, an IVUS-guided antegrade approach may be helpful.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Consensus specialist panel
Jiyan Chen (Guangdong General Hospital, Guangzhou); Lianglong Chen (Union Hospital, Fuzhou); Shaoliang Chen (Nanjing First Hospital, Nanjing); Yundai Chen (Chinese PLA General Hospital, Beijing); Lianqun Cui (Shandong Provincial Hospital Affiliated to Shandong University, Jinan); Zhimin Du (The First Affiliated Hospital, Sun Yat Sen University, Guangzhou); Weiyi Fang (Shanghai Chest Hospital, Shanghai); Guosheng Fu (Sir Run Run Shaw Hospital, Hangzhou); Xianghua Fu (The Second Hospital of Hebei Medical University, Shijiazhuang); Wei Gao (Peking University Third Hospital, Beijing); Chuanyu Gao (Henan Provincial People's Hospital, Zhengzhou); Runlin Gao (Fuwai Hospital, Beijing); Hsienli Kao (National Taiwan University Hospital, Taipei); Lei Ge (Zhongshan Hospital, Shanghai); Junbo Ge (Zhongshan Hospital, Shanghai); Ning Guo (The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an); Lijun Guo (Peking University Third Hospital, Beijing); Wenyi Guo (Xijing Hospital, Xi'an); Yaling Han (General Hospital of Shenyang Military Region, Shenyang); Ben He (Shanghai Chest Hospital, Shanghai); Guoxiang He (Southwest Hospital, Chongqing); Yong He (West China Hospital, Chengdu); Lang Hong (The People's Hospital of Jiangxi Province, Nanchang); Tao Hu (Xijing Hospital, Xi'an); He Huang (Xiangtan City Central Hospital, Xiangtan); Chaolian Huang (Wangjing Hospital, Beijing); Dejia Huang (West China Hospital, Chengdu); Weijian Huang (The First Affiliated Hospital of Wenzhou Medical University, Wenzhou); Yong Huo (Peking University First Hospital, Beijing); Guoliang Jia (Dongguan Kanghua Hospital, Dongguan); Shaobin Jia (General Hospital of Ningxia Medical University, Yinchuan); Hong Jiang (Renmin Hospital, Wuhan University, Wuhan); Jun Jiang (The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou); Zening Jin (Anzhen Hospital, Beijing); Quanmin Jing (General Hospital of Shenyang Military Region, Shenyang); Lang Li (The First Affiliated Hospital of Guangxi Medical University, Nanning); Yan Li (Xijing Hospital, Xi'an); Yu Li (Anzhen Hospital, Beijing); Yue Li (The First Affiliated Hospital of Harbin Medical University, Harbin); Chengxiang Li (Xijing Hospital, Xi'an); Jianping Li (Peking University First Hospital, Beijing); Weimin Li (The First Affiliated Hospital of Harbin Medical University, Harbin); Xinming Li (Zhoupu Hospital, Shanghai); Zhanquan Li (Liaoning Provincial People's Hospital, Shenyang); Chun Liang (Changzheng Hospital, Shanghai); Bin Liu (The Second Hospital, Jilin University, Changchun); Jian Liu (Peking University People's Hospital, Beijing); Xuebo Liu (Tongji Hospital, Shanghai); Yingfeng Liu (Zhujiang Hospital of Southern Medical University, Guangzhou); Jinghua Liu (Anzhen Hospital, Beijing); Jianfang Luo (Guangdong General Hospital, Guangzhou); Shuzheng Lv (Anzhen Hospital, Beijing); Genshan Ma (Zhongda Hospital, Nanjing); Jianying Ma (Zhongshan Hospital, Shanghai); Likun Ma (Anhui Provincial Hospital, Hefei); Yitong Ma (The First Affiliated Hospital of Xinjiang Medical University, Urumqi); Jie Qian (Fuwai Hospital, Beijing); Juying Qian (Zhongshan Hospital, Shanghai); Shubin Qiao (Fuwai Hospital, Beijing); Chunguang Qiu (The First Affiliated Hospital of Zhengzhou University, Zhengzhou); Xinkai Qu (Shanghai Chest Hospital, Shanghai); Leisheng Ru (Bethune International Peace Hospital, Shijiazhuang); Chengxing Shen (The Sixth People's Hospital, Shanghai); Weifeng Shen (Ruijin Hospital, Shanghai); Haiming Shi (Huashan Hospital, Shanghai); Xiantao Song (Anzhen Hospital, Beijing); Xi Su (Wuhan Asia Heart Hospital, Wuhan); Ling Tao (Xijing Hospital, Xi'an); Zheng Wan (Tianjin Medical University General Hospital, Tianjin); Yan Wang (Xiamen Cardiovascular Hospital, Xiamen); Haichang Wang (Tangdu Hospital, Xi'an); Jian'an Wang (The Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou); Lefeng Wang (Beijing Chaoyang Hospital, Beijing); Weimin Wang (Peking University People's Hospital, Beijing); Meng Wei (The Sixth People's Hospital, Shanghai); Shangyu Wen (Daqing Oilfield General Hospital, Daqing); Yongjian Wu (Fuwai Hospital, Beijing); Bo Xu (Fuwai Hospital, Beijing); Yawei Xu (Shanghai Tenth People's Hospital, Shanghai); Hongbing Yan (Fuwai Hospital, Beijing); Yuejin Yang (Fuwai Hospital, Beijing); Bo Yu (The Second Affiliated Hospital of Harbin Medical University, Harbin); Zuyi Yuan (The First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an); Hesong Zeng (Tongji Hospital, Wuhan); Bin Zhang (Guangdong General Hospital, Guangzhou); Feng Zhang (Zhongshan Hospital, Shanghai); Qi Zhang (Shanghai East Hospital, Shanghai); Zheng Zhang (The First Hospital of Lanzhou University, Lanzhou); Dadong Zhang (Shanghai Yodak Cardiothoracic Hospital, Shanghai); Ruiyan Zhang (Ruijin Hospital, Shanghai); Xianxian Zhao (Changhai Hospital, Shanghai); Yujie Zhou (Anzhen Hospital, Beijing); Jianhua Zhu (The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou).
Xin Zhong (Zhongshan Hospital, Shanghai); Steve Huang (Zhongshan Hospital, Shanghai).
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Note: This consensus is simultaneously co-published in Chinese Journal of Intervention Cardiology 2018, vol. 3.
[Table 1], [Table 2]