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Published on: January 18, 2018
The role for adjunctive image in pre-procedural assessment and peri-procedural management in chronic total occlusion
Rodrigo Estevez-Loureiro, Matteo Ghione, Kadriye Kilickesmez
1Royal Brompton Hospital, Sydney Street, London, Greater London SW3 6NP, UK. C.DiMario@rbht.nhs.uk.
Insights
Multislice computed tomography and intravascular ultrasound enhance chronic total occlusion (CTO) recanalisation by visualizing calcification and vessel path. Imaging use varies globally, but its increasing adoption suggests it
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
- Medical Technology
Background:
- Chronic total occlusions (CTOs) present complex challenges in coronary recanalisation.
- Non-invasive and invasive imaging modalities offer potential benefits for guiding these procedures.
- Current utilization of these imaging techniques varies significantly across different regions.
Purpose of the Study:
- To evaluate the role and impact of multislice computed tomography (CT) and intravascular imaging (IVUS, OCT) in guiding coronary CTO recanalisation.
- To explore the specific applications and limitations of each imaging modality in complex CTO cases.
- To analyze the global trends and factors influencing the adoption of advanced imaging in CTO interventions.
Main Methods:
- Review of multislice CT for detecting coronary calcification and assessing occlusion characteristics.
- Analysis of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) applications during CTO procedures, including guidewire navigation and stent deployment.
- Comparative assessment of imaging utilization rates in Japan, Europe, and the USA.
Main Results:
- Multislice CT excels in detecting calcium and assessing occlusion length, aiding in procedural planning.
- IVUS is valuable for identifying vessel path in challenging occlusions and optimizing stent placement.
- OCT has limitations in CTO due to contrast requirements and penetration depth; its use is less common.
- Imaging use ranges from over 90% in Japan to under 20% in Europe, with intermediate use in the USA.
Conclusions:
- Advanced imaging, particularly multislice CT and IVUS, provides crucial information for successful CTO recanalisation.
- The increasing global adoption of these techniques underscores their value as established tools for interventional cardiologists.
- Availability and cost are likely key drivers of the observed geographical disparities in imaging utilization.
Abstract:
Non invasive coronary angiography with multislice computed tomography has exquisite sensitivity to detect calcium and even the faintest late contrast filling of the distal vessel. Calcium burden and occlusion length are still valuable markers of duration, complexity and success of the recanalisation procedure. The ability to visualise the vessel also in the occluded segment, especially if calcified, can also help the operator to understand where to pierce the proximal cap in stumpless occlusions and to predict unusual courses, especially in very tortuous arteries. Imaging side by side CT images and angiography during the recanalisation procedure is an established practice in many active CTO laboratories and algorithms for co-registration are designed to overcome the challenges of systo-diastolic and respiratory motion. Intravascular ultrasound is used in almost all cases by the experienced Japanese CTO operators but most of the times its main use is a better identification of the diseased segment after predilatation to ensure complete stent cover and appropriate stent expansion, an application similar to other complex non occlusive lesions. The specificity of IVUS during CTO recanalisation is the identification of the vessel path in stumpless occlusions and the guidance of wire reentry especially during reverse Controlled Retrograde Anterograde Tracking. Optical coherence tomography has limitations in the setting of CTO recanalisation because of the need of forceful contrast flushing to clear blood, contraindicated in the presence of anterograde dissections, and the limited penetration. The variability in the use of both non-invasive and invasive imaging during CTO recanalisation is immense, going from more than 90% in Japan to less than 20% in Europe and intermediate penetration in the USA. Probably the explanation is almost only in availability and cost because all countries see a progressive increase of use suggesting that these methods are becoming an established tool for guidance of CTO recanalisation.
