Advances in percutaneous coronary intervention for chronic total occlusions: current antegrade dissection and reentry te
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Neth Heart J https://doi.org/10.1007/s12471-020-01509-8
Advances in percutaneous coronary intervention for chronic total occlusions: current antegrade dissection and reentry techniques and updated algorithm T. Berkhout · B. E. Claessen · M. T. Dirksen
Accepted: 13 October 2020 © The Author(s) 2020
Abstract Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) is considered relatively complex with low success rates and high complication rates. Treating a CTO with PCI using the hybrid algorithm increases success rates with acceptable complication rates. An essential part of the hybrid algorithm is antegrade dissection and reentry (ADR). In PCI of a non-CTO coronary lesion, the guidewire over which the stent is advanced and placed stays within the true lumen of the coronary artery. ADR techniques make it possible to cross the lesion through the wall of the coronary artery, the subintimal space, thus creating a small bypass within the architecture of the coronary artery and restoring antegrade blood flow. ADR increases success rates, especially in more difficult CTO procedures. In the last decade, new materials and techniques have been introduced in quick succession, which are summarised in this review. Consequently an updated ADR algorithm is presented, which can support the CTO operator during an ADR procedure. Keywords Humans · Coronary angiography · Coronary occlusions, therapy · Percutaneous coronary intervention, methods · Decision support techniques · Clinical competence
Compared to non-CTO coronary lesions, CTOs are considered relatively complex, with lower success rates and higher complication rates [1]. It is known that patients with CTO have higher mortality than patients without CTO [2]. In addition to increased prevalence of comorbidities, potential explanations for the finding of increased mortality include an increased incidence of ventricular arrhythmia [3] and ‘double jeopardy’ if patients suffer a myocardial infarction, as the infarct-related artery may also supply collaterals to the CTO, resulting in a larger area of subtended myocardium. The threshold for revascularisation of CTO is higher than for non-CTO lesions, but percutaneous coronary intervention (PCI) of a CTO should be considered when a patient has symptoms, documented ischaemia or left ventricular dysfunction [4, 5]. In recent years, the field of CTO-PCI has evolved considerably as many new materials and techniques have been introduced. This article aims to provide an overview of the most important contemporary antegrade dissection and reentry (ADR) techniques, where the CTO is crossed through the subintimal space (SIS) instead of the intraluminal route. Moreover, we propose an updated algorithm to guide the interventional cardiologist in performing CTO-PCI.
Introduction
Modern PCI for CTO
A coronary chronic total occlusion (CTO) is defined as the absence of antegrade transluminal flow (thrombolysis in myocardial infarction (TIMI) grade 0 flow) for an estimated duration of more than 3 months.
Historically, CTO
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