Reclassification of CTO Crossing Strategies in the ERCTO Registry According to the CTO-ARC Consensus Recommendations

Background: The CTO-ARC (Chronic Total Occlusion Academic Research Consortium) recognized that a nonstandardized definition of chronic total occlusion (CTO) percutaneous coronary intervention approaches can bias the complications' attribution to each crossing strategy. Objectives: The study sought to describe the numbers, efficacy, and safety of each final CTO crossing strategy according to CTO-ARC recommendations. Methods: In this cross-sectional study, data were retrieved from the European Registry of Chronic Total Occlusions between 2021 and 2022. Results: Out of 8,673 patients, antegrade and retrograde approach were performed in 79.2% and 20.8% of cases, respectively. The antegrade approach included antegrade wiring and antegrade dissection and re-entry, both performed with or without retrograde contribution (antegrade wiring without retrograde contribution: n = 5,929 [68.4%]; antegrade wiring with retrograde contribution: n = 446 [5.1%]; antegrade dissection and re-entry without retrograde contribution: n = 353 [4.1%]; antegrade dissection and re-entry with retrograde contribution: n = 137 [1.6%]). The retrograde approach included retrograde wiring (n = 735 [8.4%]) and retrograde dissection and re-entry (n = 1,073 [12.4%]). Alternative antegrade crossing was associated with lower technical success (70% vs 86% vs 93.1%, respectively; P < 0.001) and higher complication rates (4.6% vs 2.9% vs 1%, respectively; P < 0.001) as compared with retrograde and true antegrade crossing. However, alternative antegrade crossing was applied mostly as a rescue strategy (96.1%). Conclusions: The application of CTO-ARC definitions allowed the reclassification of 6.7% of procedures as alternative antegrade crossing with retrograde or antegrade contribution which showed higher MACCE and lower technical success rates, as compared with true antegrade and retrograde crossing

Procedural Impact of Advanced Calcific Plaque Modification Devices Within Percutaneous Revascularization of Chronic Total Occlusions.

Background: Significant calcifications within a coronary chronic total occlusion (CTO) increase procedural complexity and the risk for complications. Expert consensus documents recommend the use of advanced calcific plaque modification devices (ACPMDs) for calcified CTO percutaneous coronary intervention (PCI), whereas data on their procedural impact are limited. Objectives: The aim of this study was to describe trends, settings, and outcomes of PCI of severely calcified CTO performed with and without ACPMDs. Methods: Data from 15,329 CTO PCIs enrolled in the ERCTO (European Registry of Chronic Total Occlusion) between 2021 and 2023 were analyzed. On the basis of the presence of severe calcifications within the CTO, the study population was divided into 2 groups: nonsevere (n = 12,289) and severe (n = 3,040) calcium. Then, the severe group was divided into non-ACPMD (n = 2,253) and ACPMD (n = 787), according to the use of ACPMDs. Results: Compared with the non-ACPMD group, the ACPMD group had higher rates of antegrade wiring (77.9% vs 49.2%; P < 0.001) and technical success (97.6% vs 79.1%; P = 0.001) and lower rates of periprocedural and in-hospital major adverse cardiac and cerebrovascular events (MACCE) (1.8% vs 3.5%; P = 0.001). A severe amount of calcium was independently associated with technical failure (OR: 3.13; 95% CI: 2.43-4.09; P < 0.001) but not with MACCE (OR: 0.88; 95% CI: 0.58-1.35; P = 0.15). Furthermore, extraplaque crossing was independently associated with MACCE (antegrade dissection and re-entry without retrograde contribution: OR: 3.12; 95% CI: 1.79-4.20; P < 0.001; antegrade dissection and re-entry with retrograde contribution: OR: 3.12; 95% CI: 1.67-4.11; P = 0.049; retrograde dissection and re-entry: OR: 1.90; 95% CI: 1.25-2.86; P = 0.002). Conclusions: Applying ACPMDs in severely calcified CTO to PCI was associated with higher technical success and lower MACCE rates. The presence of severe coronary calcification on coronary angiography was a marker of clinical and procedural complexity and was associated with technical failure but not with MACCE

Drug-Coated Balloons in the European Registry of Chronic Total Occlusion:The ERCTO Registry

Background: Drug-coated balloons (DCBs) are increasingly used in percutaneous coronary intervention (PCI). Their application for chronic total occlusions (CTOs) is a promising option to limit stent length in diffuse disease and avoid stent underexpansion and malapposition in negatively remodeled distal vessel segments. Objectives: The aim of this study was to analyze CTO PCI procedures recorded in ERCTO (European Registry of Chronic Total Occlusion) to investigate frequency of use, patient and lesion characteristics, and in-hospital outcomes of DCBs. Methods: CTO cases entered into the database from 2016 to 2023 were examined and categorized according to DCB use. DCB-treated patients were further divided into 2 groups: DCBs only and DCBs in association with drug-eluting stents. To minimize the potential impact of confounding factors, 1:1 propensity score matching was applied. Results: Of 40,449 CTO PCIs performed at 184 centers, DCBs were used in 2,506 (6.2%), increasing from 3.4% (n = 185 of 5,498) in 2016 to 14.9% (n = 705 of 4,722) in 2023. In-hospital complications were infrequent, but DCB-treated CTOs had significantly lower rates of pericardial tamponade (0.1% [n = 2 of 2,506] vs 0.4% [n = 169 of 37,943]; P = 0.006). After propensity score matching, DCB use led to reduced drug-eluting stent length (44.2 ± 36.9 mm [95% CI: 42.7-45.7 mm] vs 58.1 ± 35.9 mm [95% CI: 56.7-59.5] mm; P &lt; 0.001). Contrast volume was lower in the DCB-treated patients (202.4 ± 109.8 mL [95% CI: 198.1-206.7 mL] vs 211.6 ± 123 mL [95% CI: 206.8-216.4 mL]; P = 0.005). Conclusions: The use of DCBs in CTO recanalization is increasing and is associated with a reduction in the length of stents implanted, as well as a decrease in contrast volume and a lower rate of pericardial tamponade.</p

The safety and feasibility of live-stream proctoring for CTO procedures.

peer reviewed[en] OBJECTIVE: To assess the technical feasibility of a new method of educational training, based on audio-video (AV) communication between an interventional cardiologist and the cath lab staff members in one location and a remote expert proctor. METHODS: Overall, 9 patients underwent a percutaneous coronary intervention (PCI) targeting a chronic total occlusion (CTO) between June 2021 and January 2022 at a single Belgian center using the virtual proctoring approach. For this assessment, the strategic planning of the CTO PCI and all the decisions throughout the intervention were the responsibility of the proctor. The operator was guided via an AV link, by the proctor throughout the procedure. RESULTS: The operator performed each procedural step, guided by the remote proctor, who had continuous access to all relevant interventional details. No major adverse cardiac events (MACE) occurred during the index hospitalization or within 6 months follow-up. CONCLUSIONS: A new method of virtual proctoring based on live AV communication is feasible, even in the case of highly complex CTO PCI procedures. This strategy also appears safe and may provide the patient the benefit of incremental expertise. This approach is facilitated by advances in AV communication and allows physicians to share expertise irrespective of location. It could increase global interaction between colleagues and facilitate sharing of knowledge, which are both key aspects in the development of CTO PCI. This preliminary experience could serve as a basis for future large studies to study the potential role and benefits of virtual proctoring for complex CTO PCI procedures

In-Stent CTO Percutaneous Coronary Intervention: Individual Patient Data Pooled Analysis of 4 Multicenter Registries

OBJECTIVES: The authors sought to examine the outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusions (CTOs). BACKGROUND: The outcomes of PCI for ISR CTOs have received limited study. METHODS: The authors examined the clinical and angiographic characteristics and procedural outcomes of 11,961 CTO PCIs performed in 11,728 patients at 107 centers in Europe, North America, Latin America, and Asia between 2012 and 2020, pooling patient-level data from 4 multicenter registries. In-hospital major adverse cardiovascular events (MACE) included death, myocardial infarction, stroke, and tamponade. Long-term MACE were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. RESULTS: ISR represented 15% of the CTOs (n = 1,755). Patients with ISR CTOs had higher prevalence of diabetes (44% vs. 38%; p \u3c 0.0001) and prior coronary artery bypass graft surgery (27% vs. 24%; p = 0.03). Mean J-CTO (Multicenter CTO Registry in Japan) score was 2.32 ± 1.27 in the ISR group and 2.22 ± 1.27 in the de novo group (p = 0.01). Technical (85% vs. 85%; p = 0.75) and procedural (84% vs. 84%; p = 0.82) success was similar for ISR and de novo CTOs, as was the incidence of in-hospital MACE (1.7% vs. 2.2%; p = 0.25). Antegrade wiring was the most common successful strategy, in 70% of ISR and 60% of de novo CTOs, followed by retrograde crossing (16% vs. 23%) and antegrade dissection and re-entry (15% vs. 16%; p \u3c 0.0001). At 12 months, patients with ISR CTOs had a higher incidence of MACE (hazard ratio: 1.31; 95% confidence intervals: 1.01 to 1.70; p = 0.04). CONCLUSIONS: ISR CTOs represent 15% of all CTO PCIs and can be recanalized with similar success and in-hospital MACE as de novo CTOs

Global Chronic Total Occlusion Crossing Algorithm: JACC State-of-the-Art Review

The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration

Global Chronic Total Occlusion Crossing Algorithm

The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.info:eu-repo/semantics/publishedVersio

Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention.

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training

Optimization of Design of High Pressure Compact and Light-Weight Liquid Heat Exchangers

Results of an experimental study with a support of DRET (France) of two designs of liquid heat exchangers made of multi-channel aluminium tubes are presented with the objective to develop a fuel-oil recuperator, compact and light (less than 3 Kg). It was demonstrated that the application of a combined approach to heat exchange enhancements using three-dimensional turbulators as semi-spherical craters and bulges on channel walls of internal paths allows to increase the specific heat output of the heat exchanger from 10.5 to 13.3 kW/kg.</jats:p