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Application of the "hybrid approach" to chronic total occlusion interventions: a detailed procedural analysis
Tesfaldet T Michael1, Owen Mogabgab, Eric Fuh
1VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas.
Insights
The hybrid approach to chronic total occlusion (CTO) percutaneous coronary interventions (PCI) often requires strategy changes, achieving high success rates (90.4%) and low complication rates (4.1%) in complex cases.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Chronic total occlusion (CTO) percutaneous coronary interventions (PCI) present significant challenges.
- The hybrid approach to CTO PCI emphasizes timely adjustments in crossing strategies.
- This approach aims to optimize procedural success, patient safety, and efficiency.
Purpose of the Study:
- To evaluate the clinical outcomes of the hybrid approach for CTO PCI.
- To assess the effectiveness and safety of dynamic strategy modifications during CTO PCI procedures.
Main Methods:
- Prospective analysis of 73 consecutive CTO PCI cases performed by a single operator.
- Detailed recording of step-by-step procedural data, including crossing techniques and strategy changes.
- Evaluation of technical success, procedural parameters, and complication rates.
Main Results:
- High technical success rate of 90.4% (66 out of 73 cases).
- Approximately 44% of cases required multiple (2-7) approach changes, with an average of 3.6 changes.
- Antegrade wire escalation, dissection/reentry, and retrograde crossing were frequently utilized techniques.
- Major complications occurred in only 4.1% of patients.
Conclusions:
- The hybrid approach necessitates strategy modifications in nearly half of CTO PCI cases.
- These strategy changes are associated with high procedural success and a low incidence of major complications.
- The hybrid approach represents an effective strategy for managing complex CTOs.
Objective:
To assess the outcomes of the "hybrid" approach to chronic total occlusion (CTO) percutaneous coronary interventions (PCIs).
Background:
The "hybrid approach" to CTO PCI advocates appropriate and early change of crossing strategy to maximize success, safety, and efficiency.
Methods:
We prospectively recorded and analyzed detailed step-by-step procedural data in 73 consecutive CTO PCI cases performed by a single operator between July 2011 and August 2012.
Results:
Technical success was achieved in 66 of 73 cases (90.4%). Mean patient age was 65 ± 7 years, and 30% had prior coronary artery bypass surgery. Dual injection was used in 78%. The primary approach was retrograde in 9 cases (12.5%) and antegrade in 64 cases (87.5%), of whom 25 cases (39.1%) underwent retrograde attempt after failed antegrade approach. The initial crossing approach was successful in 40 cases (54.8%), but 32 cases (44%) required 3.6 ± 1.4 approach changes (range 2-7). Antegrade wire escalation, antegrade dissection/reentry, and retrograde crossing were utilized in 97.2%, 46.6%, and 46.6% of cases, respectively. Among successful cases, the final CTO crossing technique was antegrade wire escalation in 50.0%, antegrade dissection/reentry in 24.2%, and retrograde in 25.8%. The mean procedure time, fluoroscopy time, and air kerma radiation exposure until CTO crossing or stopping the procedure were 66 ± 55 minutes, 25 ± 23 minutes, and 2.3 ± 1.9 Gray, respectively. Three patients (4.1%) had a major complication.
Conclusion:
In the "hybrid approach" to CTO PCI, changes in crossing strategy were needed in approximately half the cases, resulting in high success and low complication rates.
