Masahisa Yamane, Kenya Nasu, Masaaki Okutsu, Makoto Sekiguchi
Chronic total occlusion
Updated on August 26, 2021
Chronic total occlusion
Chronic total occlusions
Updated on May 13, 2021 | 14 minutes reading
Summary
Chronically occluded coronary lesions make up about 20% of all coronary lesions, but because a lesion is totally occluded it is often considered differently from a non-occlusive lesion regarding the indication of an intervention. There are numerous studies including a recent randomized trial to support the rationale of reopening a chronic total coronary occlusion (CTO) if viability and ischaemia are demonstrated in the territory distal to the CTO. The reluctance of many operators to attempt a CTO as a target lesion is rather based on the complexity of the procedure, and the limited success rate than on any evidence that a CTO is a benign lesion. However, recent developments in the technical approach, both in strategy as well as available tools, have led to a greatly improved success rate for the recanalization of a CTO which is now above 90% in experienced hands. Furthermore, persistent patency and low lesion recurrence can be achieved through the use of drug-eluting stents (DES). To achieve these improvements in technical success, operators need to undertake specialised training, and must become familiar with the specific tools and techniques of CTO intervention.
Definition and classification
A chronic total occlusion (CTO) describes a completely occluded coronary...
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References
- Stone GW, Colombo A, Teirstein PS, Moses JW, Leon MB, Reifart NJ, Mintz GS, Hoye A, Cox DA, Baim DS, Strauss BH, Selmon M, Moussa I, Suzuki T, Tamai H, Katoh O, Mitsudo K, Grube E, Cannon LA, Kandzari DE, Reisman M, Schwartz RS, Bailey S, Dangas G, Mehran R, Abizaid A, Serruys PW. Percutaneous recanalization of chronically occluded coronary arteries: Procedural techniques, devices, and results. Catheter Cardiovasc Interv. 2005;66:217-36.
- Di Mario C, Werner GS, Sianos G, Galassi AR, Büttner J, Dudek D, Chevalier B, Lefevre T, Schofer J, Koolen J, Sievert H, Reimers B, Fajadet J, Colombo A, Gershlick A, Serruys PW, Reifart N. European perspective in the recanalisation of Chronic Total Occlusions (CTO): Consensus document from the EuroCTO Club. EuroIntervention. 2007;3:30-43.
- Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Osherov AB, Yalonetsky S, Gannot S, Samuel M, Weisbrod M, Bierstone D, Sparkes JD, Wright GA and Strauss BH. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. Journal of the American College of Cardiology. 2012;59:991-7.
- Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis. Am Heart J. 2010;160:179-87.
- Colmenarez HJ, Escaned J, Fernández C, Lobo L, Cano S, del Angel JG, Alfonso F, Jimenez P, Bañuelos C, Gonzalo N, Garcia E, Hernández R, Macaya C. Efficacy and safety of drug-eluting stents in chronic total coronary occlusion recanalization: a systematic review and meta-analysis. J Am Coll Cardiol. 2010;55:1854-66.
- Werner GS, Surber R, Ferrari M, Fritzenwanger M, Figulla HR. The functional reserve of collaterals supplying long-term chronic total coronary occlusions in patients without prior myocardial infarction. Eur Heart J. 2006; 27:2406-12.
- Suero JA, Marso SP, Jones PG, Laster SB, Huber KC, Giorgi LV, Johnson WL, Rutherford BD. 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. J Am Coll Cardiol. 2001;38:409-14.
- Werner GS, Ferrari M, Heinke S, Kuethe F, Surber R, Richartz BM, Figulla HR. Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions. Circulation. 2003;107:1972-7.
- Rathore S, Matsuo H, Terashima M, Kinoshita Y, Kimura M, Tsuchikane E, Nasu K, Ehara M, Asakura Y, Katoh O, Suzuki T. Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008: impact of novel guidewire techniques. JACC Cardiovasc Interv. 2009;2:489-97.
- Sianos G, Barlis P, Di Mario C, Papafaklis MI, Büttner J, Galassi AR, Schofer J, Werner G, Lefevre T, Louvard Y, Serruys PW, Reifart N. European experience with the retrograde approach for the recanalisation of coronary artery chronic total occlusions. A report on behalf of the euroCTO club. EuroIntervention. 2008;4:84-92.
- Surmely JF, Katoh O, Tsuchikane E, Nasu K, Suzuki T. Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv. 2007;69:826-32.
- Tsuchikane E, Katoh O, Kimura M, Nasu K, Kinoshita Y, Suzuki T. The first clinical experience with a novel catheter for collateral channel tracking in retrograde approach for chronic coronary total occlusions. JACC Cardiovasc Interv. 2010;3:165-71.
- Morino Y, Kimura T, Hayashi Y, Muramatsu T, Ochiai M, Noguchi Y, Kato K, Shibata Y, Hiasa Y, Doi O, Yamashita T, Morimoto T, Abe M, Hinohara T, Mitsudo K; J-CTO Registry Investigators. In-hospital outcomes of contemporary percutaneous coronary intervention in patients with chronic total occlusion insights from the J-CTO registry (Multicenter CTO Registry in Japan). JACC Cardiovasc Interv. 2010;3:143-51.
- Sakakura K, Nakano M, Otsuka F, Yahagi K, Kutys R, Ladich E, Finn AV, Kolodgie FD, Virmani R. Comparison of pathology of chronic total occlusion with and without coronary artery bypass graft. Eur Heart J. 2014;35:1683-93.
- Kirschbaum SW, Rossi A, Boersma E, Springeling T, van de Ent M, Krestin GP, Serruys PW, Duncker DJ, de Feyter PJ, van Geuns RJ. Combining magnetic resonance viability variables better predicts improvement of myocardial function prior to percutaneous coronary intervention. Int J Cardiol. 2012;159:192-7.
- Farooq V, Serruys PW, Bourantas CV, Zhang Y, Muramatsu T, Feldman T, Holmes DR, Mack M, Morice MC, Stahle E, Colombo A, de Vries T, Morel MA, Dawkins KD, Kappetein AP, Mohr FW. Quantification of incomplete revascularization and its association with five-year mortality in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial validation of the residual SYNTAX score. Circulation. 2013;128:141-51.
- Werner GS, Martin-Yuste V, Hildick-Smith D, Boudou N, Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen EH, Escaned J, di Mario C, Hovasse T, Teruel L, Bufe A, Lauer B, Bogaerts K, Goicolea J, Spratt JC, Gershlick AH, Galassi AR, Louvard Y and investigators Et. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur Heart J. 2018;39:2484-93.
- George S, Cockburn J, Clayton TC, Ludman P, Cotton J, Spratt J, Redwood S, de Belder M, de Belder A, Hill J, Hoye A, Palmer N, Rathore S, Gershlick A, Di Mario C, Hildick-Smith D, British Cardiovascular Intervention S and National Institute for Cardiovascular Outcomes R. Long-term follow-up of elective chronic total coronary occlusion angioplasty: analysis from the U.K. Central Cardiac Audit Database. J Am Coll Cardiol. 2014;64:235-43.
- Escaned J, Collet C, Ryan N, De Maria GL, Walsh S, Sabate M, Davies J, Lesiak M, Moreno R, Cruz-Gonzalez I, Hoole SP, Ej West N, Piek JJ, Zaman A, Fath-Ordoubadi F, Stables RH, Appleby C, van Mieghem N, van Geuns RJ, Uren N, Zueco J, Buszman P, Iniguez A, Goicolea J, Hildick-Smith D, Ochala A, Dudek D, Hanratty C, Cavalcante R, Kappetein AP, Taggart DP, van Es GA, Morel MA, de Vries T, Onuma Y, Farooq V, Serruys PW and Banning AP. Clinical outcomes of state-of-the-art percutaneous coronary revascularization in patients with de novo three vessel disease: 1-year results of the SYNTAX II study. Eur Heart J. 2017;38:3124-34.
- Harding SA, Wu EB, Lo S, Lim ST, Ge L, Chen JY, Quan J, Lee SW, Kao HL and Tsuchikane E. A New Algorithm for Crossing Chronic Total Occlusions From the Asia Pacific Chronic Total Occlusion Club. JACC Cardiovasc Interv. 2017;10:2135-43.
- Lee SW, Lee PH, Ahn JM, Park DW, Yun SC, Han S, Kang H, Kang SJ, Kim YH, Lee CW, Park SW, Hur SH, Rha SW, Her SH, Choi SW, Lee BK, Lee NH, Lee JY, Cheong SS, Kim MH, Ahn YK, Lim SW, Lee SG, Hiremath S, Santoso T, Udayachalerm W, Cheng JJ, Cohen DJ, Muramatsu T, Tsuchikane E, Asakura Y and Park SJ. Randomized Trial Evaluating Percutaneous Coronary Intervention for the Treatment of Chronic Total Occlusion. Circulation. 2019;139:1674-83.
- Ybarra LF, Rinfret S, Brilakis ES, Karmpaliotis D, Azzalini L, Grantham JA, Kandzari DE, Mashayekhi K, Spratt JC, Wijeysundera HC, Ali ZA, Buller CE, Carlino M, Cohen DJ, Cutlip DE, Martini TD, Mario CD, Farb A, Finn AV, Galassi AR, Gibson CM, Hanratty C, Hill JM, Jaffer FA, Krucoff MW, Lombardi WL, Maehara A, Magee PFA, Mehran R, Moses JW, Nicholson WJ, Onuma Y, Sianos G, Sumitsuji S, Tsuchikane E, Virmani R, Walsh SJ, Werner GS, Yamane M, Stone GW, Rinfret S and Stone GW. Definitions and Clinical Trial Design Principles for Coronary Artery Chronic Total Occlusion Therapies: CTO-ARC Consensus Recommendations. Circulation. 2021;143:479-500.