Issam Moussa

Percutaneous recanalization of chronically occluded coronary arteries: A consensus document - Part II

In Part I of this article, the definitions, prevalence, and clinical presentation of chronic total occlusions (CTOs) were reviewed, the histopathology of CTOs was examined, efforts to replicate human CTOs with experimental models were appraised, and the clinical relevance and rationale for CTO revascularization were evaluated.1 In Part II, we summarize the technical approach to and outcomes after percutaneous coronary intervention (PCI) of occluded coronary arteries, describe the novel devices and drugs approved and undergoing investigation for CTO recanalization, and conclude with practical perspectives on managing the patient with 1 or more chronic coronary occlusions.nn### Patient Selection and Revascularization StrategiesnnPCI of CTOs constitutes as many as 20% of all angioplasty procedures at selected centers,2 although a rate of &10% is more typical,3–6 suggesting that CTO angioplasty is attempted in 50 000 to 100 000 patients per year in the United States. Many more CTOs are present for which PCI is never attempted, representing one of the most common causes for referral to bypass surgery rather than PCI.6–8 Furthermore, a large proportion of patients with CTOs are managed medically, the prognosis of whom may vary depending on the extent of viable myocardium and ischemia, concomitant atherosclerosis in other coronary and noncoronary vascular territories, and other comorbid conditions. The decision to attempt PCI of a CTO (versus continued medical therapy or surgical revascularization) requires an individualized risk/benefit analysis, encompassing clinical, angiographic, and technical considerations. Clinically, the patient’s age, symptom severity, associated comorbidities (eg, diabetes mellitus and chronic renal insufficiency), and overall functional status are major determinants of treatment strategy. Angiographically, the extent and complexity of coronary artery disease (eg, single-vessel versus multivessel disease, single versus multiple total occlusions, likelihood for complete revascularization), left ventricular function, and the presence and degree of valvular heart disease should be considered. The technical probability of achieving …

Percutaneous recanalization of chronically occluded coronary arteries: Procedural techniques, devices, and results

Gregg W. Stone,* MD, Antonio Colombo, MD, Paul S. Teirstein, MD, Jeffrey W. Moses, MD, Martin B. Leon, MD, Nicolaus J. Reifart, MD, Gary S. Mintz, MD, Angela Hoye, MBchB, David A. Cox, MD, Donald S. Baim, MD, Bradley H. Strauss, MD, PhD, Matthew Selmon, MD, Issam Moussa, MD, Takahiko Suzuki, MD, Hideo Tamai, MD, Osamu Katoh, MD, Kazuaki Mitsudo, MD, Eberhard Grube, MD, Louis A. Cannon, MD, David E. Kandzari, MD, Mark Reisman, MD, Robert S. Schwartz, MD, Steven Bailey, MD, George Dangas, MD, PhD, Roxana Mehran, MD, Alexander Abizaid, MD, and Patrick W. Serruys MD, PhD

Optimal ultrasound guided balloon angioplasty

In the early ’ 90ies an important discrepancy has been shown between angiographic and ultrasound findings after balloon angioplasty, but only in the last years, new strategies of aggressive balloon dilatation based on the ultrasound measurements have been applied. In the CLOUT study, upsizing of the balloon based on the ultrasound measurements was required in 73% of the lesions, ranging from 0.25 mm to 1.25 mm. An even more aggressive strategy was allowed by the availability of coronary stents, allowing focal treatment of the segments of residual lumen narrowing or severe dissection. The balloon was further upsized, matching the media-to-media diameter and, at least in the Milan and Washington experience, high inflation pressures were used. In the Tubingen study, the additional dilatation induced an increase in minimal lumen diameter from 1.95 ± 0.49 mm to 2.21 ± 0.47 mm and a decrease in residual diameter stenosis from 28.3 ± 14.9% to 18.1 ± 14.4%, both p 15 mm) and to lesions located in small vessels (<3.0 mm reference diameter). Balloon angioplasty was initially performed using an angiographically oversized balloon inflated until full balloon expansion was achieved and then an IVUS examination was performed. IVUS success criteria were defined as the presence of a true minimal lumen area ≥ 5.5 mm2 or of a minimal lumen cross-sectional area ≥ 50% of the vessel cross-sectional area at the lesion site. In this unfavourable lesion subset, at 5 months clinical follow-up, the cumulative incidence of major adverse cardiac events (death, Q-wave myocardial infarction, target lesion revascularization) was 28%, with an angiographic restenosis rate (≥50% diameter stenosis) of 27%.