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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Chronic Total Occlusions Understand and remedy chronic total occlusions with the third edition of this comprehensive guide Chronic Total Occlusions offers the most comprehensive overview of chronic total occlusions (CTO) on the market, authored by two internationally recognized physician educators. It covers both the diagnostic modalities and treatment methods required to tailor a treatment program to individual cardiological patients with the greatest possible chance of success. Thorough and informed by the latest research and field data, the third edition of this guide is an indispensable resource for interventional cardiologists. In Chronic Total Occlusions: A Guide to Recanalization, Third Edition, readers will also find: * Full-color images to guide diagnosis of CTOs * Expert tips and tricks for key procedures involved in treating challenging cases * Clinical case studies illustrating specific scenarios and frequently encountered complications Chronic Total Occlusions: A Guide to Recanalization, Third Edition is a must-have for interventional cardiologists who want to maximize their patient outcomes.
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Chronic Total Occlusions
A Guide to Recanalization
Third Edition
EDITED BY
Ron WaksmanSection of Interventional Cardiology MedStar Washington Hospital Center Washington, DC, USA
Shigeru SaitoHeart Center, Cardiology & Catheterization Laboratories Shonan Kamakura General Hospital Kamakura City, Japan
This third edition first published 2024
© 2024 John Wiley & Sons Ltd
Edition History
1e, 2006; 2e, 2011 by John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Ron Waksman and Shigeru Saito to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging-in-Publication Data
Names: Waksman, Ron, 1952 - editor. | Saito, Shigeru, 1950 - editor.
Title: Chronic total occlusions : A Guide to Recanalization / edited by Ron Waksman, MedStar Washington Hospital Center, Washington, DC, USA, Shigeru Saito, Shonan Kamakura General Hospital, Kamakura City, Japan.
Description: Third edition. | Hoboken, NJ : Wiley-Blackwell, 2024. | Includes bibliographical references and index.
Identifiers: LCCN 2023021444 (print) | LCCN 2023021445 (ebook) | ISBN 9781119517276 (hardback) | ISBN 9781119517221 (pdf) | ISBN 9781119517313 (epub) | ISBN 9781119517337 (ebook)
Subjects: LCSH: Coronary heart disease. | Arterial occlusions.
Classification: LCC RC685.C6 C485 2023 (print) | LCC RC685.C6 (ebook) | DDC 616.1/23--dc23/eng/20230605
LC record available at https://lccn.loc.gov/2023021444
LC ebook record available at https://lccn.loc.gov/2023021445
Cover Images: © AYImages/Getty Images; Daria Serdtseva/Shutterstock; anek.soowannaphoom/Shutterstock; Arctic-Images/Getty Images
Cover Design: Wiley
Set in 9/11.5pt Minion by Integra Software Services Pvt. Ltd, Pondicherry, India
Contents
Cover
Title Page
Copyright Page
List of Contributors
Foreword
Preface
Part I Pathology, Indications, and Review of Clinical Trials
1 The Pathobiology of CTO
2 Pathology of Chronic Total Occlusions: Implications for Revascularization
3 Indications and Guidelines of PCI for CTO
Part II Imaging
4 CT Angiography: Application in Chronic Total Occlusions,
5 IVUS-Guided Recanalization of CTO
6 Optical Coherence Tomography to Guide the Treatment of Chronic Total Occlusions,
Part III Wires Technology
7 New Coronary Guidewire Technology in Chronic Total Occlusion Percutaneous Coronary Interventions
8 Tornus Catheter
9 Microcatheters: Characteristics and Use
Part IV Wires Technique
10 CTO Wires: Engineering 101 and Principles of Wire Manipulation
11 Use of Two Wires in the Treatment of CTO
12 Parallel-Wire Techniques
13 Transradial Approach for CTO Lesions
14 Subintimal Angioplasty in Coronary CTO
15 Antegrade Dissection and Re-Entry Techniques
16 3D Wiring Methods in CTO PCI
17 Antegrade Fenestration and Re-Entry: An Alternative Approach to Antegrade Dissection and Re-Entry
18 Retrograde CTO PCI: Step by Step
19 Retrograde CTO Intervention via Vein Grafts,
20 Tips and Tricks of the CART and Reverse CART Technique
21 Debulking of CTO
22 Laser Revascularization in Coronary CTO
23 How to Handle Subintimal Dissections
24 CTO: How to Minimize Contrast-Associated Acute Kidney Injury
25 Mechanical Support for CTO
26 Stent Grafts to Seal Coronary Perforation
27 Complications During Retrograde Approach for CTO
Part V Interesting Cases
28 Interesting Cases I–V
Index
End User License Agreement
List of Tables
CHAPTER 03
Table 3.1 Randomized controlled trials...
Table 3.2 Summary of Guidelines...
CHAPTER 06
Table 6.1 Advantages and disadvantages...
CHAPTER 07
Table 7.1 Overview of polymer...
Table 7.2 Overview of stiff...
CHAPTER 09
Table 9.1 Microcatheter specifications...
CHAPTER 09
Table 10.1 Variation in distal...
Table 10.2 Selected Coronary Guidewires...
CHAPTER 17
Table 17.1 Antegrade fenestration and...
CHAPTER 20
Table 20.1 “Comparison of CART...
CHAPTER 22
Table 22.1 Laser associated processes.
Table 22.2 Laser induced effects.
Table 22.3 Clinical and angiographic...
Table 22.4 Optimal ELCA catheter...
Table 22.5 CTO amenability to...
CHAPTER 23
Table 23.1 Commonly used polymer...
CHAPTER 25
Table 25.1 Hemodynamic effects of...
CHAPTER 26
Table 26.1 Covered stent specifications.
List of Illustrations
CHAPTER 01
Figure 1.1A Hematoxylin-eosin stained...
Figure 1.1B Elastin-trichrome stained...
Figure 1.2 CTO pathology variability:...
CHAPTER 02
Figure 2.1 Representative images of...
Figure 2.2 A representative case...
Figure 2.3 Lesion characteristics of...
Figure 2.4 (A) Representative images...
Figure 2.5 In-stent CTO...
Figure 2.6 Restenosis. Cross-sectional...
Figure 2.7 Neoatherosclerotic rupture. Cross...
Figure 2.8 The frequency of...
CHAPTER 04
Figure 4.1 Human chronic total...
Figure 4.2 (a) Human chronic...
Figure 4.3 (a) Low-power...
Figure 4.4 Cardiac CTA image...
Figure 4.5 Similar to Figure...
Figure 4.6 Conventional angiography image...
CHAPTER 05
Figure 5.1 (a) Mid-LAD...
Figure 5.2 (a) Distal RCA...
Figure 5.3 Concept of IVUS...
Figure 5.4 (a) Long RCA...
CHAPTER 06
Figure 6.1 (a) CTO of...
Figure 6.2 OCT demonstrating the...
Figure 6.3 Chronic total occlusion...
CHAPTER 07
Figure 7.1 Construction of the...
Figure 7.2 Illustration of the...
Figure 7.3 Illustration of the...
Figure 7.4 Illustration of the...
Figure 7.5 Illustration of the...
Figure 7.6 Illustration of the...
Figure 7.7 Illustration of the...
Figure 7.8 Illustration of the...
Figure 7.9 Illustration of the...
Figure 7.10 Illustration of the...
Figure 7.11 Illustration of the...
Figure 7.12 Illustration of the...
Figure 7.13 Illustration of the...
Figure 7.14 Illustration of the...
Figure 7.15 Illustration of the...
Figure 7.16 Illustration of the...
Figure 7.17 Illustration of the...
CHAPTER 08
Figure 8.1 Whole picture of...
Figure 8.2 Examples of shaft...
Figure 8.3 Case presentation: coronary...
CHAPTER 09
Figure 9.1 Microcatheter characteristics...
Figure 9.2 Caravel....
Figure 9.3 Finecross...
Figure 9.4 Corsair and Corsair...
Figure 9.5 Corsair Pro XS...
Figure 9.6 Turnpike and Turnpike...
Figure 9.7 Turnpike LP...
Figure 9.8 Mamba and Mamba...
Figure 9.9 Tornus...
Figure 9.10 Turnpike gold.
Figure 9.11 Sasuke...
Figure 9.12 NHancer RX.
Figure 9.13 ReCross...
Figure 9.14 Angled SuperCross.
Figure 9.15 Venture RX...
CHAPTER 09
Figure 10.1 Components of a...
Figure 10.2 Measurement of guidewire...
Figure 10.3 Torque Transmission.Image...
Figure 10.4 Asahi ACT ONE...
Figure 10.5 Inner Coil Technology...
Figure 10.6 Guidewire lubricity vs...
Figure 10.7 Asahi SION blue...
Figure 10.8 BMW Universal II...
Figure 10.9 Samurai coronary guidewire...
Figure 10.10 Fielder XT series...
Figure 10.11 Fighter coronary guidewire...
Figure 10.12 Bandit Coronary Guidewire...
Figure 10.13 Confianza Pro 12...
Figure 10.14 Asahi Gaia coronary...
Figure 10.15 Asahi Gaia Next...
Figure 10.16 Judo coronary guidewire...
Figure 10.17 Commonly used coronary...
Figure 10.18 Antegrade dissection re...
Figure 10.19 Gladius MG and...
Figure 10.20 RG3 and R350...
Figure 10.21 Shaping the tip...
Figure 10.22 Change in guidewire...
Figure 10.23 Eight conceptual locations...
Figure 10.24 Guidewire escalation and...
CHAPTER 11
Figure 11.1 Example of the...
Figure 11.2 Use of a...
Figure 11.3 Example of parallel...
Figure 11.4 (a): Chronic occlusion...
Figure 11.5 Old occlusion of...
Figure 11.6 Mid LAD occlusion...
Figure 11.7 (a): Chronic occlusion...
Figure 11.8 Example of side...
Figure 11.9 Example of anchoring...
CHAPTER 12
Figure 12.1 Schematic demonstration of...
Figure 12.2 Example illustrating the...
Figure 12.3 Use of parallel...
Figure 12.4 Example illustrating the...
CHAPTER 13
Figure 13.1 (a) A 73...
Figure 13.2 (a) Proximal RCA...
Figure 13.3 (a, b) Middle...
Figure 13.4 (a) 6-Fr...
CHAPTER 14
Figure 14.1 Components of the...
Figure 14.2 Schematic representation of...
Figure 14.3 (a) Wire tip...
Figure 14.4 Algorithm for CTO...
Figure 14.5 Illustration for contemporary...
Figure 14.6 (a) Schematic representation...
Figure 14.7 Schematic representation of...
Figure 14.8 (a) Intravascular ultrasound...
CHAPTER 15
Figure 15.1 ReCross™ Catheter...
Figure 15.2 CROSSBOSS™ Catheter...
Figure 15.3 Example of a...
CHAPTER 16
Figure 16.1 Process of establishing...
Figure 16.2 CTO algorithm of...
Figure 16.3 How to achieve...
Figure 16.4 Sixty-four possibilities...
Figure 16.5 How to construct...
Figure 16.6 One more illustration...
Figure 16.7 Concept of sequential...
Figure 16.8 Video presentation of...
Figure 16.9 CTO lesions difficult...
Figure 16.10 Targets of 3D...
Figure 16.11 Techniques for effective...
Figure 16.12 The direction of...
Figure 16.13 Retrospective single-center...
Figure 16.14 For IVUS guided...
Figure 16.15 A. Fusion method...
Figure 16.16 Tip detection method...
Figure 16.17 Specifications of the...
Figure 16.18 Procedural flow up...
Figure 16.19 How to recognize...
Figure 16.20 Procedural details about...
Figure 16.21 Demonstration of the...
Figure 16.22 Angiographic and IVUS...
Figure 16.23 2nd-procedure: Pre...
Figure 16.24 AO-IVUS based...
Figure 16.25 Initial outcomes of...
Figure 16.26 The pros and...
Figure 16.27 Ideal reentry point...
Figure 16.28 Procedural details of...
Figure 16.29 Angiographic images in...
Figure 16.30 TD-ADR: Successful...
CHAPTER 17
Figure 17.1 Occlusive hematoma due...
Figure 17.2 AFR – step...
Figure 17.3 Approaches available when...
Figure 17.4 Case example of...
Figure 17.5 (continuation) Intravascular ultrasound...
Figure 17.6 The correct tip...
Figure 17.7 Role of AFR...
Figure 17.8 Application of intravascular...
Figure 17.9 Facilitated AFR. (A...
Figure 17.10 (continuation) AFR was...
CHAPTER 18
Figure 18.1 Management of collaterals...
Figure 18.2 Variations and troubleshooting...
CHAPTER 19
Figure 19.1 Lesion characteristics that...
Figure 19.2 Angiogram: dual injection...
Figure 19.3 Balloon-assisted tracking...
Figure 19.4 Acute angle of...
Figure 19.5 Hinge point at...
Figure 19.6 Final angiogram after...
CHAPTER 20
Figure 20.1 The CART Technique...
Figure 20.2 The Reverse CART...
CHAPTER 21
Figure 21.1 A long CTO...
Figure 21.2 Ostial LAD CTO...
CHAPTER 22
Figure 22.1 An elderly man...
Figure 22.2 Excimer laser debulking...
Figure 22.3 Cross section of...
Figure 22.4 CTO of RCA...
Figure 22.5 A patient with...
CHAPTER 23
Figure 23.1 CTO Crossing Strategies...
Figure 23.2 Intraplaque and Extraplaque...
Figure 23.3 Histopathology of the...
Figure 23.4 CrossBoss Catheter. The...
Figure 23.5 Utility of CCTA...
Figure 23.6 Move the cap...
Figure 23.7 Side BASE technique...
Figure 23.8 Wire Based Re...
Figure 23.9 Stingray LP balloon...
Figure 23.10 Recross device. This...
Figure 23.11 Antegrade fenestration and...
Figure 23.12 IVUS of Extraplaque...
Figure 23.13 Novel reentry microcatheter...
Figure 23.14 Aspiration of extraplaque...
CHAPTER 24
Figure 24.1 Proposed mechanisms of...
Figure 24.2 The rates of...
Figure 24.3 The in-hospital...
Figure 24.4 Briguori C, D...
Figure 24.5 The rates of...
Figure 24.6 Procedural strategies to...
CHAPTER 25
Figure 25.1 Risk categories to...
Figure 25.2 Prominent epicardial collateral...
Figure 25.3 Protected PCI algorithm...
Figure 25.4 Effects of Impella...
Figure 25.5 Percutaneous access in...
Figure 25.6 LAVA ECMO configuration...
Figure 25.7 Impella supported RCA...
Figure 25.8 Loss of pulsatility...
Figure 25.9 LAVA ECMO configuration...
Figure 25.10 Single access technique...
Figure 25.11 Reperfusion sheath for...
Figure 25.12 Reperfusion sheath for...
Figure 25.13 Classifications of acute...
Figure 25.14 Dry closure for...
CHAPTER 26
Figure 26.1 Stent design of...
CHAPTER 27
Figure 27.1 Dissection of donor...
Figure 27.2 Late cardiac tamponade...
Figure 27.3 Reduction in blood...
CHAPTER 28
Figure 28.1 (a) Bilateral coronary...
Figure 28.2 (a, b) CTO...
Figure 28.3 (a) Retrograde guidewire...
Figure 28.4 (a) LCA and...
Figure 28.5 (a) RCA and...
Guide
Cover
Title Page
Copyright Page
Table of Contents
List of Contributors
Foreword
Preface
Begin Reading
Index
End User License Agreement
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List of Contributors
Khaldoon Alaswad, MD, FACC, FSCAIHenry Ford Hospital & Health System, Detroit, MI, USA Wayne State University, Michigan, USA
Salman Allana, MDMinneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis, MN, USA
Lorenzo Azzalini, MD, PhD, MScDivision of Cardiology Department of Medicine, University of Washington Seattle, WA, USA
Mir Babar Basir, DO, FACC, FSCAIHenry Ford Hospital Detroit, MI, USA
Craig Basman, MDDepartment of Cardiology, Lenox Hill Hospital New York, NY, USA
Nelson L. Bernardo, MDSection of Interventional Cardiology MedStar Washington Hospital Center Washington, DC, USA
Emmanouil S. Brilakis, MD, PhDMinneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis, MN, USA
Nicholas Burke, MDMinneapolis Heart Institute and Foundation Minneapolis, MN, USA
Mauro Carlino, MD, PhD, MScDivision of Interventional Cardiology Cardio-Thoracic-Vascular Department San Raffaele Scientific Institute Milan, Italy
Diljon S. Chahal, MDUniversity of Maryland School of Medicine Baltimore, MD, USA
Niccolò Ciardetti, MDStructural Interventional Cardiology Department of Clinical and Experimental Medicine Careggi University Hospital, Italy
George D. Dangas, MD, PhDMount Sinai Medical Center, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA
Gabby Elbaz-Greener, MDDepartment of Cardiology, Hadassah Medical Center & The Faculty of Medicine, Hebrew University of Jerusalem Jerusalem, Israel
Matthew C. Evans, MDMedical University of South Carolina Charleston, SC, USA
Aloke V. Finn, MDCVPath Institute, Gaithersburg, MD, USA; University of Maryland School of Medicine Baltimore, MD, USA
Philippe Généreux, MDCardiovascular Research Foundation New York, NY, USA
Luis Gruberg, MD, FACCMather Hospital Donald and Barbara Zucker School of Medicine New York, NY, USA
Ankur Gupta, MD, PhDPiedmont Heart Institute Atlanta, GA, USA
Hidehiko Hara, MDMinneapolis Heart Institute and Foundation Minneapolis, MN, USA
Thomas Hovasse, MDInstitut Cardiovasculaire Paris Sud (ICPS) Massy, France
John D. Hung, MBChB, PhD, MRCPConsultant Cardiologist, Liverpool Heart and Chest Hospital Liverpool University Foundation Trust, UK
Hideaki Kaneda, MD, PhDOkinaka Memorial Institute for Medical Research Tokyo, Japan
Kathleen E. Kearney, MDUniversity of Washington Medical Center Seattle, WA, USA
Carson Keck, MDMedical University of South Carolina Charleston, SC, USA
Michael Kim, MDDepartment of Cardiology, Lenox Hill Hospital New York, NY, USA
Chad Kliger, MDLenox Hill Hospital/Northwell Health Hofstra School of Medicine, New York, NY, USA
Arber Kodra, MDDepartment of Cardiology, Lenox Hill Hospital New York, NY, USA
Takao Konishi, MDCVPath Institute, Gaithersburg, MD, USA
Selcuk Kucukseymen, MDStructural Interventional Cardiology Department of Clinical and Experimental Medicine Careggi University Hospital, Italy
Katherine J. Kunkel, MD HonorHealth Scottsdale Shea Medical Center Scottsdale, AZ, USA
Rahul Kurup, MD, PhDSouth West Sydney Local Health District (Campbelltown and Liverpool Hospitals) and Sydney Medical School University of Sydney, NSW, Australia
Tak Kwan, MDDepartment of Cardiology, Lenox Hill Hospital New York, NY, USA
Thierry Lefèvre, MD, FESC, FSCAIInstitut Cardiovasculaire Paris Sud (ICPS) Massy, France
John R. Lesser, MDMinneapolis Heart Institute and Foundation Minneapolis, MN, USA
Gabriel Maluenda, MDMedStar Washington Hospital Center Washington, DC, USA
Anbukarasi Maran, MDMedical University of South Carolina Charleston, SC, USA
Carlo Di Mario, MD, PhD, FESC, FACC, FSCAI, FRCPStructural Interventional Cardiology, Department of Clinical and Experimental Medicine Careggi University Hospital, Italy
Francesca Maria Di Muro, MDStructural Interventional Cardiology, Department of Clinical and Experimental Medicine Careggi University Hospital, Italy
Alessio Mattesini, MDStructural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Italy
Michael Megaly, MD, MSWillis Knighton Heart Institute, Shreveport, LA, USA
Ilan Merdler, MD, MHAMedStar Washington Hospital Center Washington, DC, USA
Asaad Nakhle, MDHenry Ford Hospital Detroit, MI, USA
Giulia Nardi, MDStructural Interventional Cardiology Department of Clinical and Experimental Medicine Careggi University Hospital, Florence, Italy
William J. Nicholson, MDEmory Heart and Vascular Center, Division of Cardiology Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
Atsunori Okamura, MDCardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
Ji Eun Park, MDUniversity of Maryland School of Medicine Baltimore, MD, USA
Apurva Patel, MDDepartment of Cardiology, Lenox Hill Hospital New York, NY, USA
Ashish Pershad, MD, MSDepartment of Interventional Cardiology Chandler Regional Medical Center, Gilbert, AZ, USA
Sudhir Rathore, MDFrimley Health NHS Foundation Trust Surrey, UK
Pavan Reddy, MDSection of Interventional Cardiology MedStar Washington Hospital Center Washington, DC, USA
Shigeru Saito, MD, FACC, FSCAI, FJCCHeart Center, Cardiology & Catheterization Laboratories Shonan Kamakura General Hospital Kamakura city, Japan
Negar Salehi, MDMount Sinai Medical Center New York, NY, USA
Pratik B. Sandesara, MDEmory Heart and Vascular Center, Division of Cardiology Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
Robert S. Schwartz, MDMinneapolis Heart Institute and Foundation Minneapolis, MN, USA
James C. Spratt, MD, PhDConsultant Cardiologist, Professor of Interventional Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
Bradley H. Strauss, MD, PhDSchulich Heart Centre, Sunnybrook Health Sciences Centre University of Toronto, Toronto, ON, Canada
Takahiko Suzuki, MDToyohashi Heart Centre, Toyohashi, Japan
Yutaka Tanaka, MD, PhDShonan Kamakura General Hospital, Kamakura City, Japan
Jasleen Tiwana, MDUniversity of Washington Medical Center Seattle, WA, USA
On Topaz, MD, FACC, FACP, FSCAIProfessor of Medicine, Duke University School of Medicine Durham, NC, USA
Etsuo Tsuchikane, MD, PhDToyohashi Heart Center, Toyohashi, Japan
Ron Waksman, MD, FACCSection of Interventional Cardiology MedStar Washington Hospital Center Washington, DC, USA
Luiz Fernando Ybarra, MDLondon Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, ON Canada
Foreword
Welcome to the world of chronic total occlusion (CTO) intervention, an exciting and rapidly evolving field within interventional cardiology. This book is the third edition within the last 14 years of the popular Chronic Total Occlusions, a testimonial to the advancement in the field and the interest of interventional cardiologists to win the battle to safely and effectively treat CTOs. The book continues to serve as a comprehensive guide for both novice and experienced practitioners who seek to enhance their understanding and skills in the management of CTOs.
The presence of CTOs was initially observed during coronary angiography procedures in the mid-20th century. In the early days of percutaneous coronary intervention (PCI), CTOs were considered challenging to treat due to technical difficulties and lack of suitable equipment and often were referred for surgical revascularization or medical treatment. However, the interventional cardiologist was not satisfied with these alternatives to PCI and strongly believed that successful revascularization of CTOs can relieve symptoms, improve cardiac function, and potentially reduce the need for more invasive procedures like coronary artery bypass grafting (CABG). Others questioned the utility of reanalyzing CTO percutaneously and its impact on mortality and quality of life. With the lack of definitive data from randomized clinical trials, the debate was ongoing. But simultaneously skilled operators from around the globe, with industry support, continued to advance the field and reported several important breakthroughs through the past three decades. Among these were the development of specialized guidewires with improved flexibility and penetration power, which allowed for more successful attempts at crossing CTOs.
In the 1990s, the retrograde approach was introduced in the US by Kahn and Hartzler, and in Japan by the co-editor of this book, Dr. Saito. Navigating and crossing the occlusion via native collaterals and saphenous vein grafts expanded the possibilities for CTO intervention and improved success rates. Finally, dedicated devices and tools were developed specifically for crossing and treating these challenging lesions. These devices include CTO-specific guidewires, microcatheters, and specialized balloon catheters, as well as devices and techniques to seal perforations.
With the advancement of techniques, devices, and operator experience, the success rates of CTO interventions have significantly improved and now stand in the high 90s success rate, with an acceptably low rate of procedural complications.
A key to the success of the procedure is adequate training courses – a dedicated CTO program within the hospital. These programs comprise skilled interventional cardiologists who have extensive experience in performing CTO interventions.
CTO interventions often require a multidisciplinary approach involving collaboration among interventional cardiologists, imaging specialists, and cardiac surgeons. A team-based approach ensures comprehensive evaluation, appropriate patient selection, and optimal treatment strategies for CTO patients.
To stay updated with the latest advancements and techniques in CTO interventions, interventional cardiologists in the USA participate in continuing medical education activities. These include conferences, workshops, case discussions, and comprehensive textbooks, which provide opportunities to learn from experts and share experiences with peers.
It is important to note that the future of CTO interventions is dynamic and subject to ongoing innovation. These potential developments hold the promise of further improving patient outcomes, expanding the eligibility for CTO interventions, and reducing the complexity and invasiveness of procedures.
Advancements in imaging techniques, such as the integration of intravascular ultrasound and optical coherence tomography to enhance lesion visualization and guide treatment strategies, add to this bright future. Furthermore, the development of novel devices and tools, including bioresorbable scaffolds and drug-eluting balloons, may further improve outcomes by promoting vessel healing and reducing restenosis rates.
Ongoing innovation in this field is expected to drive these developments. Artificial intelligence (AI) is poised to play a crucial role in improving CTO interventions. AI algorithms can aid in lesion assessment, procedural planning, and complication management, offering real-time decision support and enhancing procedural precision.
The third edition of this comprehensive CTO intervention guide aims to provide an in-depth exploration of the principles, techniques, and tools employed in the field. Leading experts from around the world have contributed their knowledge and experience to create a resource encompassing the entire spectrum of CTO management. From fundamental physiology and lesion assessment to procedural planning, equipment selection, and complication management, each chapter delves into key aspects of CTO intervention, emphasizing evidence-based practice and innovation within the CTO community.
Our intent is not only to educate and empower interventional cardiologists but also to foster a culture of collaboration and innovation within the CTO community. In this book, you will find invaluable insights and pearls of wisdom gained from years of clinical practice and research. Additionally, we highlight the importance of a multidisciplinary approach, acknowledging the critical role of imaging specialists, nurses, technicians, and other healthcare professionals in optimizing patient outcomes.
I would like to extend my special thanks to Jason Wermers for his guidance and assistance in the editorial management process of this book. Dr. Saito and I extend our deepest gratitude to all the contributors who generously shared their expertise and experiences, making this book a comprehensive and valuable resource. We hope that it serves as a guide and source of inspiration for healthcare professionals worldwide who are dedicated to improving patient care through the successful management CTOs.
Ron Waksman, MD, FESC,MSCAI, FACC
Professor of Medicine (Cardiology), Georgetown University
Associate Director, Cardiology
Director, Cardiovascular Research and Advanced Education
MedStar Heart and Vascular Institute
MedStar Washington Hospital Center
Washington, DC, USA
Preface
The first therapeutic PCI was performed by Dr. Gruentzig in 1981. The basic idea was to widen a stenotic lesion in a coronary artery by balloon dilation. The key concept at this time was to guide the burst-resistant balloon to the lesion site, preceded by a delicate atraumatic guidewire. The structure of PCI balloon catheter consists of several small parts, which is considered both feasible and best in the current technology at the time.
The complex procedure of PCI is first broken down into its component and functional parts. Then, the aggregate of the parts performs the necessary actions on the stenotic lesion to achieve a good overall result. This concept of first breaking it down into parts and then examining the results as an aggregate of parts is very important. Smaller units of functional parts are easier to improve and bring new functionality to. PCI for chronic total occlusions has also become easier with the use of improved combinations of functional components.
The first time I personally performed PCI for a chronic total occlusion was in 1985 or 1986. The patient was a man in his 50s suffering from exertional angina pectoris due to a chronic totally occluded lesion in his right coronary artery. I reported at an academic conference that I had reopened this patient using a Hartzler LPS (ACS) balloon (2.0 mm), and that six months later, the patient was still good on angiography. To my surprise, one of the leading PCI operators at the time stood up and said, “One-vessel occlusion of the right coronary artery does not affect the prognosis in any way, and unnecessary PCI is unacceptable”. At that time, Dr. Gerald Dorros (who was active in Milwaukee at that time), who was invited to the conference at that time, stood up and said in front of everyone, “A young doctor is presenting such a wonderful treatment, and it is unacceptable for a doctor not to recognize it.” This was the moment when I embarked on the long road of PCI for chronic total occlusion. Looking back, the success of the PCI of the right coronary CTO at that time was because I could use a Hartzler LPS balloon catheter. And what I have learnt from this experiences is that, before opening the door for a new world, there will be many obstacles, and we have to overcome them.
At that time, PCI for CTO was performed using only antegradde approach without contralateral dye injection. However, as the technique was limited to that, the success rate was slow to improve even with the evolution of balloons and wires.
This situation was broken in the 1990s with the introduction of wires with improved torque control and penetrating power, the importance of contralateral dye injection was emphasized. Although the introduction of Intravascular ultrasound (IVUS) in antegrade approach improved the success rate, the wire was advanced into the false lumen and could not enter in the true lumen.
In the 2000s, the retrograde approach was started, and wires and various devices have been developed to make this approach easier. With the introduction of the retrograde approach, more complex CTO lesions were confronted with PCI than ever before. In the 2010s, Complex high-risk indicated percutaneous coronary interventions (CHIP-PCI) were started. PCI for CTO has thus evolved significantly due to (1) technical developments of operators, (2) introduction of more sophisticated and advanced devices, and (3) improved patient’s management strategies This book documents everything of PCI for CTO from the past to the future.
Shigeru Saito, MD, Shonan Kamakura General Hospital.
Part I Pathology, Indications, and Review of Clinical Trials
CHAPTER 2 Pathology of Chronic Total Occlusions: Implications for Revascularization
Takao Konishi1, Ji Eun Park2, Diljon S. Chahal2 & Aloke V. Finn1,2,*
1 CVPath Institute, Gaithersburg, MD, USA 2
