Matthew Finn

Application and outcomes of a hybrid approach to chronic total occlusion percutaneous coronary intervention in a contemporary multicenter US registry

BACKGROUND A hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) prioritizing and combining all available crossing techniques was developed to optimize procedural efficacy, efficiency, and safety, but there is limited published data on its outcomes. METHODS We examined the procedural techniques and outcomes of 1036 consecutive CTO PCIs performed using a hybrid approach between 2012 and 2015 at 11 US centers. RESULTS Mean age was 65 ± 10 years and 86% of the patients were men, with a high prevalence of diabetes mellitus (43%) and prior coronary artery bypass graft surgery (34%). Most target CTOs were located in the right coronary artery (59%), followed by the left anterior descending artery (23%) and the circumflex (19%). Dual injection was used in 71%. Technical success was achieved in 91% and a major procedural complication occurred in 1.7% of cases. The final successful crossing technique was antegrade wire escalation in 46%, antegrade dissection/re-entry in 26%, and retrograde in 28%. The initial crossing strategy was successful in 58% of the lesions, whereas 39% required an additional approach. Overall, antegrade wire escalation was used in 71%, antegrade dissection/re-entry in 36%, and the retrograde approach in 42% of procedures. Median contrast volume, fluoroscopy time, and air kerma radiation dose were 260 (200-360) ml, 44 (27-72) min, and 3.4 (2.0-5.4) Gray, respectively. CONCLUSION Application of a hybrid approach to CTO crossing resulted in high success and low complication rates across a varied group of operators and hospital practice structures, supporting its expanding use in CTO PCI.

Mother–Daughter–Granddaughter Double GuideLiner Technique for Delivering Stents Past Multiple Extreme Angulations

Failure to deliver stents and balloons past tortuous, calcific lesions because of inadequate support has long plagued interventional cardiologists. The mother–daughter technique using a GuideLiner Catheter (Vascular Solutions, Inc, Minneapolis, MN) is now commonly used to address these situations.1,2 Despite the improved support provided by the GuideLiner catheter, occasions arise in which a single GuideLiner is not adequate to facilitate the delivery of stents or balloons to target lesions. This is especially problematic when attempting percutaneous coronary intervention (PCI) on the retrograde limb of a bypassed coronary through a long saphenous vein graft (SVG). The double bend of the anastomosis into the retrograde coronary artery combined with the antegrade turn of the target branch is often uncrossable even with modern balloon and stent technology. We describe 2 cases of the mother–daughter–granddaughter double GuideLiner technique using a 6 Fr GuideLiner inside an 8 Fr GuideLiner to perform highly challenging PCI. Seventy-two-year-old man with a history of remote coronary artery bypass grafting with left internal mammary artery to left anterior descending and SVG to the first obtuse marginal (OM1) bypass, who later required left main, left anterior descending, and proximal left circumflex (LCX) complex bifurcation stenting, presented to his cardiologist with severe refractory chest pain. Subsequent angiography demonstrated that the left main, proximal LCX, and left anterior descending stents were totally occluded. The angiogram also showed a patent SVG to the OM1, with slow retrograde flow into a nearly occluded LCX and second obtuse marginal artery (OM2; Figure 2A and Data Supplement Movie I). ### Description of the Procedure for Case 1 Given the complexity of the turns required to gain access to the LCX, the mother–daughter–granddaughter double GuideLiner approach was used. The mother–daughter–granddaughter system was …

Morphological Patterns of In-Stent Chronic Total Occlusions: An Intravascular Ultrasound Study

This was a retrospective intravascular ultrasound (IVUS) study of mechanisms of in-stent restenosis (ISR) chronic total occlusions (CTOs). ISR CTOs were defined as TIMI (Thrombolysis In Myocardial Infarction) flow grade 0 within a stented lesion (including 5-mm margins) with estimated occlusion

Zero contrast retrograde chronic total occlusions percutaneous coronary intervention: a case series

Abstract Introduction Percutaneous coronary intervention (PCI) in patients with advanced chronic kidney disease (CKD) is associated with a high risk of contrast-induced nephropathy and resulting progression of CKD to need for renal replacement therapy. Chronic total occlusions (CTO) PCI is increasingly utilized in the treatment of refractory stable angina and ischaemic heart failure. Recent studies have described the feasibility of ‘minimal’ or ‘zero’ contrast PCI by employing intravascular imaging and intra-coronary physiology to guide successful stent implantation with resolution of ischaemia. We extended these techniques to CTO lesions via the retrograde approach. Case presentation Two patients with estimated glomerular filtration rate ≤15 mL/min who presented with angina symptoms and had subsequent positive stress tests were referred for CTO-PCI. The patients had diagnostic angiography with minimal contrast. After a recovery period, the patients underwent successful retrograde zero contrast CTO-PCI with the use of adjunctive intravascular ultrasound imaging. Discussion The described reports are the first two successful attempts at zero contrast retrograde procedures and demonstrate the feasibility of imaging and physiology-guided retrograde PCI without contrast administration in two patients with significant coronary artery disease requiring intervention. When indicated, zero contrast PCI offers the ability to treat obstructive coronary disease without worsening renal function in patients with severe CKD.

IMPACT OF AGE ON OUTCOMES OF PERCUTANEOUS CORONARY INTERVENTION IN CHRONIC TOTAL OCCLUSIONS: INSIGHTS FROM A MULTICENTER US REGISTRY

We sought to examine the effect of patient age on the outcomes of percutaneous coronary intervention (PCI) of chronic total occlusions (CTO). We examined clinical and angiographic data as well as outcomes of 1,216 CTO PCIs performed in 1,195 patients divided into three age groups (<65, 65-74 and

TCT-583 Intravascular Ultrasound Comparison of Intra-plaque Versus Subintimal Tracking in Percutaneous Intervention for Coronary Chronic Total Occlusions.

METHODS A number of 41 pt with 45 lesions were successfully treated by FFR-guided DCB-only PCI and underwent 6-month angiographic and OCT f/u. OCT analysis included manual tracing of dissections and plaques, which were entered into a dedicated software program. The algorithm enabled beyond the spread-out vessel reconstruction (Fig. 1) also the computation of volume, luminal surface area and length of dissections and plaques.