Contrast modulation in chronic total occlusion percutaneous coronary intervention

Area of Science:

• Cardiovascular Interventions
• Interventional Cardiology
• Medical Device Technology

Background:

• Contrast media injection techniques have evolved for coronary chronic total occlusions (CTO) percutaneous coronary intervention (PCI).
• Early methods like Contrast-guided Subintimal Tracking and Re-entry (STAR) used large contrast volumes, leading to vessel injury and restenosis.
• Subsequent techniques, including the microchannel and Carlino techniques, utilize smaller, gentler injections to modify plaque compliance.

Purpose of the Study:

• To provide a historical overview of contrast modulation in CTO PCI.
• To explain the pathophysiological basis of these techniques.
• To offer technical recommendations for performing contrast modulation maneuvers.

Main Methods:

• Historical review of contrast modulation techniques in CTO PCI.
• Description of the evolution from STAR to microchannel and Carlino techniques.
• Discussion of plaque modification and guidewire advancement principles.

Main Results:

• The Carlino technique, using minimal contrast (<0.5 mL), facilitates guidewire and microcatheter advancement in difficult CTOs.
• This technique is widely adopted by hybrid operators, achieving high success rates.
• Low incidence of complications is associated with the Carlino technique.

Conclusions:

• Contrast modulation has significantly advanced CTO PCI by improving plaque negotiation.
• The Carlino technique represents a refined approach, enhancing safety and efficacy.
• Understanding the historical context and technical nuances is crucial for optimal CTO recanalization.