Masahisa Yamane, Kenya Nasu, Masaaki Okutsu, Makoto Sekiguchi
Chronic total occlusion
Updated on August 26, 2021
Chronic total occlusion
The hybrid approach to CTO intervention
Updated on May 13, 2021 | 18 minutes reading
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Summary
The “hybrid” algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) was developed to guide selection of the optimal CTO crossing strategy in a stepwise fashion. Dual injection should be performed in nearly all CTO PCI procedures. Four angiographic lesion characteristics are assessed (1) proximal cap ambiguity, (2) quality of the distal vessel, (3) lesion length and (4) presence of collateral vessels suitable for the retrograde approach. Wire escalation is favored for <20 mm long lesions, whereas dissection and re-entry is favored for >20 mm long lesions. The antegrade approach is favored when the proximal cap is clear, and the retrograde approach is favored for lesions with an ambiguous proximal cap and/or diffusely diseased distal vessel, provided that appropriate collateral vessels are present. Early change of crossing strategy is recommended if the initially selected crossing strategy fails.
Rationale for the hybrid algorithm
Several techniques have been developed for crossing coronary chronic total occlusions (CTOs). These techniques can be classified according to the direction of wire advancement (antegrade and retrograde) and use of the subintimal space (intraplaque wiring vs. dissection and reentry) (Figure 1) 1, 2, 3
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References
- Brilakis ES, Grantham JA, Rinfret S, Wyman RM, Burke MN, Karmpaliotis D, Lembo N, Pershad A, Kandzari DE, Buller CE, Demartini T, Lombardi WL and Thompson CA. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5:367-79.
- Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. 2nd edition: Elsevier; 2017.
- Brilakis ES, Mashayekhi K, Tsuchikane E, Abi Rafeh N, Alaswad K, Araya M, Avran A, Azzalini L, Babunashvili AM, Bayani B, Bhindi R, Boudou N, Boukhris M, Bozinovic NZ, Bryniarski L, Bufe A, Buller CE, Burke MN, Buttner HJ, Cardoso P, Carlino M, Christiansen EH, Colombo A, Croce K, Damas de Los Santos F, De Martini T, Dens J, Di Mario C, Dou K, Egred M, ElGuindy AM, Escaned J, Furkalo S, Gagnor A, Galassi AR, Garbo R, Ge J, Goel PK, Goktekin O, Grancini L, Grantham JA, Hanratty C, Harb S, Harding SA, Henriques JPS, Hill JM, Jaffer FA, Jang Y, Jussila R, Kalnins A, Kalyanasundaram A, Kandzari DE, Kao HL, Karmpaliotis D, Kassem HH, Knaapen P, Kornowski R, Krestyaninov O, Kumar AVG, Laanmets P, Lamelas P, Lee SW, Lefevre T, Li Y, Lim ST, Lo S, Lombardi W, McEntegart M, Munawar M, Navarro Lecaro JA, Ngo HM, Nicholson W, Olivecrona GK, Padilla L, Postu M, Quadros A, Quesada FH, Prakasa Rao VS, Reifart N, Saghatelyan M, Santiago R, Sianos G, Smith E, J CS, Stone GW, Strange JW, Tammam K, Ungi I, Vo M, Vu VH, Walsh S, Werner GS, Wollmuth JR, Wu EB, Wyman RM, Xu B, Yamane M, Ybarra LF, Yeh RW, Zhang Q and Rinfret S. Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention. Circulation. 2019;140:420-433.
- 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, De Martini T, Di Mario C, 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, Stone GW and Chronic Total Occlusion Academic Research C. Definitions and Clinical Trial Design Principles for Coronary Artery Chronic Total Occlusion Therapies: CTO-ARC Consensus Recommendations. Circulation. 2021;143:479-500.
- Tajti P, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel M, Mahmud E, Choi JW, Burke MN, Doing AH, Dattilo P, Toma C, Smith AJC, Uretsky B, Holper E, Wyman RM, Kandzari DE, Garcia S, Krestyaninov O, Khelimskii D, Koutouzis M, Tsiafoutis I, Moses JW, Lembo NJ, Parikh M, Kirtane AJ, Ali ZA, Doshi D, Rangan BV, Ungi I, Banerjee S and Brilakis ES. The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention: Update From the PROGRESS CTO Registry. JACC Cardiovasc Interv. 2018;11:1325-1335.
- Maeremans J, Walsh S, Knaapen P, Spratt JC, Avran A, Hanratty CG, Faurie B, Agostoni P, Bressollette E, Kayaert P, Bagnall AJ, Egred M, Smith D, Chase A, McEntegart MB, Smith WH, Harcombe A, Kelly P, Irving J, Smith EJ, Strange JW and Dens J. The Hybrid Algorithm for Treating Chronic Total Occlusions in Europe: The RECHARGE Registry. J Am Coll Cardiol. 2016;68:1958-1970.
- 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;10:2135-2143.
- Galassi AR, Werner GS, Boukhris M, Azzalini L, Mashayekhi K, Carlino M, Avran A, Konstantinidis NV, Grancini L, Bryniarski L, Garbo R, Bozinovic N, Gershlick AH, Rathore S, Di Mario C, Louvard Y, Reifart N and Sianos G. Percutaneous recanalisation of chronic total occlusions: 2019 consensus document from the EuroCTO Club. EuroIntervention. 2019;15:198-208.
- Riley RF, Walsh SJ, Kirtane AJ, Michael Wyman R, Nicholson WJ, Azzalini L, Spratt JC, Kalra S, Hanratty CG, Pershad A, DeMartini T, Karmpaliotis D, Lombardi WL and Aaron Grantham J. Algorithmic solutions to common problems encountered during chronic total occlusion angioplasty: The algorithms within the algorithm. Catheter Cardiovasc Interv. 2019;93:286-297.
- Hirai T, Grantham JA, Sapontis J, Cohen DJ, Marso SP, Lombardi W, Karmpaliotis D, Moses J, Nicholson WJ, Pershad A, Wyman RM, Spaedy A, Cook S, Doshi P, Federici R, Nugent K, Gosch KL, Spertus JA, Salisbury AC and Group OCS. Impact of subintimal plaque modification procedures on health status after unsuccessful chronic total occlusion angioplasty. Catheter Cardiovasc Interv. 2018;91:1035-1042.