Chronic total occlusion

Abbreviations AMI, acute myocardial infarction Art, artery A-V, arteriovenous CL, caprolactone CTO, chronic total occlusion LA, D.L-lactide NA, not available FTCA, percutaneous transluminal coronary angioplasty FTFE. polytetrafluoroethylene P-S, Palmaz-Schatz PUR, polyurethane SPUU-PEO, segmented polyurethaneurea-polyethylene oxide. 

Hoye (148) 2004 BX Velocity Translute Human coronary art (chronic total occlusion) Sirolimus 1,4 xg/mm2 Bare Yes... 

Degertekin M, Sonmez K, Gencbay M, et al. Heparin-coated stent implantation in chronic total occlusion. 3rd International Congress on Coronary Artery Disease, Lyon, France, Oct 2-5, 2000 67. 

Hoye A, Tanabe K, Lemos PA, et al. Significant reduction in restenosis after the use of sirolimus-eluting stents in the treatment of chronic total occlusions. J Am Coll Cardiol 2004 43(1 I) 1954-1958. 

Ge L, lakovou I, Cosgrave J, et al. Immediate and mid-term outcomes of sirolimus-eluting stent implantation for chronic total occlusions. Eur HeartJ 2005 26(1 I) 1056-1062,... 

Heparin 50-75 mg/kg Preferred agent in the cases of chronic total occlusion... 

Abbreviations ACS, acute coronary syndrome ACT, activated clotting time BP, blood pressure CTO, chronic total occlusion i.v., intravenous MI, myocardial infarction NSTEMI, non-ST-segment elevation myocardial infarction PCI, percutaneous coronary intervention RCA, right coronaiy artery STEMI, ST-segment elevation myocardial ... 

Because of the frequency with which chronic total occlusion occurs, there has been intense interest in developing and studying new approaches. These efforts have been spurred on by the finding in multiple series that successful PCI of a chronic occlusion is associated with a survival benefit as well as improvement in LV function. In an early study, Suero et al. (6) evaluated in-hospital and longer-term outcome in 2007 consecutive patients undergoing PCI for a CTO from 1980 to 1999 (Fig. IA and IB). These were matched with patients... 

More recent series have also documented a survival advantage (7-9). Hoye et al. in 874 consecutive patients with a CTO found a five-year survival in 93.5% of patients with successful revascularization versus 88.0% in these patients with failed revascularization (p = 0.02). In a Canadian registry of 1458 patients at seven year, successful recanalization of a chronic total occlusion was associated with improved survival as well as lower rates of PCI and/or CABG (9). In addition to survival advantage, both regional and global left ventricular function is improved in patients with successful treatment of a chronic total occlusion (10). This improvement may depend on whether the patient had a prior infarction in the distribution of the occlusion (II). If prior infarction resulted in frank myocardial necrosis, then recanalization may not improve the function however, many patients with chronic occlusion have preservation of regional wall function. 

Despite the potential for improved outcome in patients treated percutaneously for chronic total occlusion, in many laboratories, these procedures are undertaken sparingly. Abbott et al. (12) analyzed 2000 patients undergoing PCI in four sequential waves of patients from 1997 to 2004. In this group, 5173 lesions were attempted. In the first cohort treated from 1997 to 1998, 9.6% of treated lesions were chronic total occlusions in the last cohort from 2004, the percentage of lesions treated that were chronic total occlusions had decreased to 5.7% (p < 0.0001) (Fig. 2). Procedural success declined from 79,7% to 71,4% during those same time periods, Procedural success rates such as this may be an over estimate because series of chronic total occlusion cases contain only patients in whom the... 

Long-term outcome of patients undergoing attempted PCI of a chronic total occlusion. (A) Outcome of chronic total occlusion versus non-chronic total occlusion patients, (B) Outcome of successful versus unsuccessful treatment of a chronic total occlusion. Successful... 

The most common reason for failure of a chronic total occlusion is inability to cross with aguidewire. The pathologic basis for this has been studied (15-17). Srivatsa et al, (15) evaluated the histologic correlates of angiographic total coronary artery occlusion in an autopsy series of 61 patients with... 

Dynamic wave registry of four separate time intervals. Attempts at CTO recanalization have been decreased. Abbreviation CTO, chronic total occlusion. 

Abbreviations-. CT, computed tomography CTO, chronic total occlusion. 

Ilb/llla platelet glycoprotein inhibitors are widely used in some institutions, particularly in the setting of complex interventions. F-lowever, in the setting of chronic total occlusion, these agents should not be used until the occlusion has... 

Recently, there has been in the use of other pharmacologic agents to modify the chronic total occlusion and render it more suitable for treatment (38-40). An animal model has been developed for testing these new approaches. In this rabbit model, thrombin is injected into an isolated portion of the femoral artery. After recovery, during the next two to four month, the thrombus is replaced by collagen which results in a chronic total occlusion. 

Ivanhoe RJ, Weintraub WS, Douglas JS Jr., et al. Percutaneous transluminal coronary angioplasty of chronic total occlusions. Primary success, restenosis and long-term clinical follow-up. Circulation 1992 85 106-1 15. 

Suero JA, Marso SR Jones PG, et al. Procedural outcomes and long term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries a 20 year experience. JACC 2001 38 409-414. 

Hoye A, van Domburg RT, Sonnenschein K, Serruys, FW. Percutaneous coronary intervention for chronic total occlusions the Thoraxcenter experience 1992-2002. Eur Heart J 2005 26 2630-2636. 

Ermis C, Boz A, Tholakanahalli V et al. Assessment of percutaneous coronary intervention on regional and global left ventricular function in patients with chronic total occlusions. Can J Cardiol 2005 21 275-280. 

I I Chung CM, Nakamura S, Tanaka K, et al. Effect of recanalization of chronic total occlusions on global and regional left ventricular function in patients with or without previous myocardial infarctions. Catheter Cardiovasc Interv2003 60 368-374. 

Suzuki S, Furui S, Kohtake H, et al. Radiation exposure to patient s skin during percutaneous coronary intervention for various lesions including chronic total occlusion. Circulation 2006 70 44-48. 

I 6 Meier B. Chronic total occlusions, In Topol EJ editor Textbook of Interventional Cardiology 4th Edition Philadelphia PA Saunders 2003 303-3 I 6,... 

I 8 Katsuragawa M, Fujiwara H, Miyamae M, et al. Histologic studies in percutaneous transluminal coronary angioplasty for chronic total occlusion comparison of tapering and abrupt types of occlusion and short and long occluded segments, JACC 1993 21 604-61 I. 

I 9 Strauss BH, Segev A, Wright GA, et al, Microvessels in chronic total occlusions pathways for successful guidewire crossing J Interv Cardiol 2005 18 425-436,... 

Fung A, Hamburger JN, The chronic total occlusion In Ellis S and Holmes 3rd Edition Strategic Approaches in Coronary Interventions. 2005 366-373,... 

Olivari Z, Rubertelli P Piscione p et al. TOAST-GISE Investigators. Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions data from a multicenter, prospective, observational study (TOAST-GISE). J Am Coll Cardiol 2003 41 1672-1678. 

Zidar FJ, Kaplan BM, O Neill WW, et al. Prospective randomized trial of prolonged intracoronary urokinase infusion for chronic total occlusions in native arteries. J Am Coll Cardiol 1996 27 1406-1412. 

Abbas AE, Brewington SD, Dixon SR, et al. Intracoronary fibrin-specific thrombolytic infusion facilitates percutaneous recanalization of chronic total occlusion. JACC 2005 46 793-798. 

Segev A, Nili N, Qiang B, et al. Human-grade purified collage-nase for the treatment of experimental arterial chronic total occlusion. Cardiovasc Revasc Med 2005 6 65-69. 

In summary, bivalirudin use during PPI is safe and may prove to have an advantage over heparin. However, we caution the use of bivalirudin during PPI procedures attempting to cross and treat chronic total occlusions where the risk of perforation is substantial with an indication for immediate reversal of anticoagulation. There is no known antidote to bivalirudin. 

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