Approach for chronic total occlusion with intravascular ultrasound-guided reverse controlled antegrade and retrograde
Jian Dai1, Osamu Katoh, Eisho Kyo
1Department of Cardiology, Yue Yang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
Insights
Intravascular ultrasound (IVUS)-guided reverse controlled antegrade and retrograde subintimal tracking (CART) is safe and effective for complex coronary chronic total occlusion (CTO) percutaneous revascularization. This approach demonstrates high success rates and low complication rates in challenging CTO cases.
Area of Science:
- Interventional Cardiology
- Vascular Imaging
Background:
- Controlled antegrade and retrograde subintimal tracking (CART) and reverse CART are key techniques for percutaneous coronary chronic total occlusion (CTO) revascularization.
- These techniques present significant technical challenges and risks during interventional procedures.
Purpose of the Study:
- To evaluate the safety and efficacy of the intravascular ultrasound (IVUS)-guided reverse CART approach for CTO percutaneous revascularization.
- To highlight the latest technical developments associated with this IVUS-guided method.
Main Methods:
- A cohort of 49 patients with CTO, who previously failed antegrade and/or retrograde revascularization, underwent IVUS-guided reverse CART.
- Data collected from November 2006 to November 2012.
- Intravascular ultrasound (IVUS) was utilized to guide wire placement and assess vessel anatomy.
Main Results:
- The IVUS-guided reverse CART approach achieved high technical (95.9%) and procedural (93.9%) success rates.
- IVUS identified suboptimal wire positions in 61.7% of retrograde and 59.5% of antegrade wires, underscoring its utility.
- Minor technical complications occurred in 10.2% of cases, with a low rate of major adverse cardiac events (2.0% non-ST-elevation myocardial infarction), and no deaths or target vessel revascularizations.
Conclusions:
- The IVUS-guided reverse CART approach is a safe and effective strategy for complex CTO percutaneous revascularization.
- This method offers high success rates and a low complication profile, making it a feasible option for complex CTO.
- Careful patient selection and experienced operator handling are critical for successful outcomes.
Background:
Controlled antegrade and retrograde subintimal tracking (CART) or reverse CART techniques is the final step for percutaneous revascularization of coronary chronic total occlusion (CTO), but it still represents technical challenges and risk in interventional procedures.
Objectives:
Our purpose was to utilize intravascular ultrasound (IVUS)-guided reverse CART approach for percutaneous revascularization of CTO in our heart center, focusing on its safety, efficacy, and latest technical developments.
Methods:
From November 2006 to November 2012, 49 patients with CTO failed to antegrade and/or retrograde percutaneous revascularization of CTO from true lumen to true lumen were enrolled in and underwent IVUS guided reverse CART approach.
Results:
The mean J-CTO score of cases was 2.5. IVUS guidance was successfully implemented in 95.9%; IVUS identified that 61.7% of retrograde wires were located at intimal space, and 59.5% of antegrade wires were located at subintimal space. A Corsair channel dilator was used in 77.6% of cases. The success rates of technique and procedure were 95.9% and 93.9%, respectively; the technical minor complications were observed in 10.2% of cases, without significant clinic outcomes; 2.0% of cases occurred with a major adverse cardiac event of non-ST-elevation myocardial infarction; and no case occurred with target vessel revascularization or death. The mean length of stent implanted in a single CTO vessel was 51.3 mm. No patient appeared with radiation dermatitis and contrast-induced rise of creatinine.
Conclusions:
IVUS guided reverse CART approach is effective and safe for percutaneous revascularization of complex CTO, with a high success and a low complication rate. It is feasible to develop this approach for percutaneous revascularization of complex CTO. However, suitable case selection and lately device handling by experienced operators are the crucial points of success.
