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When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion
When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion Mohsen Mohandes, Hugo Vinhas, Francisco Fern´andez, Cristina Moreno, Mauricio Torres, Jordi Guarinos PII: DOI: Reference:
S1553-8389(17)30391-3 doi: 10.1016/j.carrev.2017.10.004 CARREV 1151
To appear in:
Cardiovascular Revascularization Medicine
Received date: Revised date: Accepted date:
28 August 2017 5 October 2017 6 October 2017
Please cite this article as: Mohandes Mohsen, Vinhas Hugo, Fern´ andez Francisco, Moreno Cristina, Torres Mauricio, Guarinos Jordi, When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion, Cardiovascular Revascularization Medicine (2017), doi: 10.1016/j.carrev.2017.10.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion
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Decisive role of IVUS in CTO-PCI Authors:
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1 (Corresponding author): Mohsen Mohandes, MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007 Tarragona, Spain. TEL: 0034-977295817; Email: [email protected] 2. Hugo Vinhas, MD; Interventional Cardiology Unit, Hospital García de Orta, Almada,
Portugal. Email: [email protected]
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3. Francisco Fernández, MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007 Tarragona, Spain. Email: [email protected]
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4. Cristina Moreno MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007. Email: [email protected]
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5. Mauricio Torres MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007. Email:[email protected] 6. Jordi Guarinos MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007. Email: [email protected]
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Intravascular ultrasound (IVUS); Chronic total occlusion (CTO).
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Abstract
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Percutaneous coronary intervention of chronic total occlusion is a particular interventional area which requires high level of operator’s experience and the support of additional tools based on intracoronary image such as intravascular ultrasound in many cases to clarify difficulties during procedures and to increase success rate. Implantation of long stents in many cases, the presence of stump ambiguity, and the use of specific techniques in this kind of interventions, such as reverse controlled antegrade and retrograde subintimal tracking (CART) and reverse CART make necessary in many cases the use of intravascular ultrasound for a better understanding of the situation, for reducing eventual complications and increasing procedural success rate. We made a review of literature related to most challenging situations in which the use of intravascular ultrasound during chronic total occlusion percutaneous coronary intervention becomes rather indispensable to safely continue and finish the procedure. Besides, two complex percutaneous coronary interventions of chronic total occlusion with unfavourable anatomic features in which intravascular ultrasound was crucial for the procedural success are presented in this manuscript along with support of the literature.
ACCEPTED MANUSCRIPT 1. Introduction
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Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is a challenge and this type of procedure has been regarded as the last frontier in interventional cardiology.1 This statement is based on the fact that successful recanalization of CTOs is still considerably lower than those achieved in non-occluded or acutely occluded coronary arteries. 2 However, the advent of new techniques incorporated to interventional field during the last few years, the use of retrograde approach, incorporation of dedicated material and instrumentation have steadily increased CTO successful recanalization up to 75-90% in the hands of experienced and skilled operators. 3
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Some negative angiographic markers inherent to CTOs such as lesion length, stump ambiguity, ostial location and multivessel disease have been associated with failed PCI results 4 and make even more indispensable the use of specific techniques and dedicated tools such as intravascular ultrasound (IVUS) in order to assist interventionists to achieve a higher procedural success rate. In fact, IVUS in some circumstances is mandatory for a better understanding of intervention and ultimately for optimising procedural results.
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In-stent-CTO is a specific scenario in which it is highly important to steer the guidewire into stent lumen so that a suboptimised result of previous PCI such as stent malapposition or underexpansion might make the procedure more challenging and justify the use of IVUS to highlight the situation and to overcome some difficulties.
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Two challenging CTO-PCIs in which IVUS was crucial for the success rate are presented and review of literature related to some particular circumstances where IVUS could be decisive for procedural success has been done in this manuscript. 2. Cases’ description 2.1. Case 1
A 53-year-old man with hypertension and smoking as coronary risk factors was referred to our centre for coronary angiogram due to unstable angina. The coronary angiogram showed total occlusion of left anterior descending coronary artery (LAD) proximal segment receiving collaterals from right coronary artery (RCA). Echocardiographic examination revealed normal ejection fraction and a myocardial SPECT evidenced ischaemia in LAD territory, therefore percutaneous coronary intervention was scheduled. Bilateral injection using femoral and radial approach was used visualizing ambiguous stump in occluded segment (figure 1a and 1b; video 1a) therefore retrograde approach was attempted. We achieved LAD distal segment through a septal channel by Sion wire and Corsair 150 mm microcatheter (Asahi Intecc, Aichi, Japan). An IVUS catheter (Volcano, San Diego, United States) was positioned in
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left circumflex artery (LCX) intended to monitor retrograde wire penetration into the occluded segment using different guidewires (Gaia 1, Confianza pro 9; Asahi Intecc, Aichi, Japan) however the wires repeatedly entered in subintimal space. After several attempts and guided antegradely by IVUS a Confianza 12 (Asahi Intecc, Aichi, Japan) was able to penetrate retrogradely into the CTO segment and wire position within true lumen at the level of left main was verified by IVUS (figure 1c and 1d; video 1b and 1c). The wire and microcatheter Corsair reached ascending aorta where Confianza 12 was exchanged with an RG3 wire (Asahi Intecc, Aichi, Japan). The RG3 tip was antegradely snared and introduced into antegrade catheter lumen and externalised, then balloon predilatation was started over RG3 wire. Two drug eluting stents (DES; Onyx: 3x26 mm and Onyx: 2.25x26 mm; Medtronic, United States) were implanted in LAD ostialproximal and mid segment achieving successful final angiographic result, although LAD was narrow in mid and distal segment (figure 1e; video 1d). Absence of complication in donor artery and septal channels was verified as the last step before concluding the procedure.
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2.2. Case 2
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A 69-year-old man with hypertension, dyslipidemia and type II diabetes was referred to our centre for coronary angiogram due to non-ST elevation acute coronary syndrome on February 2017. The patient had undergone a primary angioplasty on RCA distal segment with a 3.5x32 mm bare metal stent (BMS) with an aneurysmatic portion at that level 5 months earlier. The coronary angiogram of current episode showed RCA total occlusion before stent proximal end. An attempt in the same procedure failed to recanalise the artery because of inability to pass the guidewire into stent lumen. An echocardiographic examination revealed inferior akinesia with 54% ejection fraction. A myocardial SPECT was carried out depicting moderate ischaemia in inferior territory, therefore a second dedicated attempt to recanalise RCA was scheduled 2 weeks later. Bilateral injection by radial and femoral approach with AR2 8F guiding catheter for RCA engagement was used visualizing total occlusion of RCA from mid segment extending to in-stent portion and up to bifurcation into posterolateral (PL) and posterior descending (PD) branches (figure 2a; video 2a). Attempt with several guidewires for crossing the occluded segment failed due to subintimal wire penetration, therefore dilatation with a 2 mm balloon at low atmosphere in RCA mid segment was performed assuming the wire position in subintimal space and afterward an IVUS catheter (Volcano, San Diego, United States) was advanced over the wire (video 2b) and guided by IVUS penetration into true lumen with a new guidewire in mid segment before previous stent proximal end was attempted (figure 2b and 2c). Finally a confianza 12 was able to penetrate into true lumen (figure 2d; video 2c and 2d) and successfully
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entered into the stent lumen implanted in the previous procedure confirming inappropriate stent apposition (figure 2e; video 2e). Once correct wire position was verified by IVUS a Corsair microcatheter was advanced through the occluded segment up to distal part of the previous stent where the confianza 12 was exchanged with a floppy wire (figure 2f). After dilatation with 4 and 4.5 mm non-compliant balloons in in-stent segment two drug eluting stents (DES; (Onyx: 4.5x15 mm; Medtronic, Inc. Minneapolis, USA; and ISAR: 4x24 mm: B.Braun, Germany) in mid and distal segment of RCA overlapped with previous stent proximal end and a third DES (Onyx: 3x18 mm) overlapped with prior stent distal end and toward PL branch were implanted achieving good final angiographic result (figure 2g; video 2f). Minimum lumen area (MLA) assessed by IVUS in RCA distal and mid segment was 8.6 mm2 and 11.6 mm2 respectively.
3. Discussion
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The main finding of these two case reports described above is the decisive contribution of IVUS to successful percutaneous recanalization of two complex CTO enabling the operator in both cases to orient a specific wire into true lumen, a key point for success in a CTO-PCI.
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There are different scenarios in which IVUS has a positive contribution to CTO-PCI result (table 1) and can be summarized as follows:
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3.1. IVUS usefulness in ambiguous stump situations The presence of a blunt stump has been described as an angiographic marker associated with the degree of difficulty to cross a CTO in a Japanese multicentre registry5 and this feature decreases the chance of steering the wire into true lumen while dealing a CTO with an antegrade approach. Stumpless or ostial CTOs is a challenging situation due to the difficulty for angiographically stump location and with the guidewire often trending to slip into a side branch. IVUS probe can be placed in these circumstances in a side branch close to the bifurcation with occluded vessel trying to perform an IVUS guided stump penetration (figure 3). 6 The use of this technique has been associated with a high PCI success rate. 7
3.2. IVUS contribution in retrograde approach Retrograde approach through septal or epicardial channels in unfavourable anatomic cases for antegrade access has substantially increased procedural success rate. When
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retrograde approach is attempted retrograde wire can cross successfully CTO segment in approximately 35% of cases. Experienced operators use reverse controlled antegrade retrograde subinitmal tracking (reverse CART) with IVUS guidance in 65% and conventional CART technique in remaining 5% of cases. 8,9IVUS guidance in reverse CART technique allows operators to select a proper balloon size for antegrade dilatation and the ultimate retrograde wire monitoring into true lumen at the level of CTO proximal cap ensuring a lower rate of complication and optimising the final result.8
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Besides, when a reverse CART is being done antegrade dye injection should be avoided in order to prevent the extension of dissection and IVUS examination in these circumstances is highly useful for the identification of subintimal dissection and the selection of stent size (figure 4).
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But in order to perform reverse CART technique it is mandatory to penetrate antegradely into CTO body and to prepare proximal cap. Our first case was characterised by a rather unidentifiable stump, thus antegrade wire advancement and proximal cap preparation was not technically feasible. Therefore, the chance for a successful PCI was practically limited to penetrate a retrograde wire into LAD proximal segment somewhere around the ambiguous stump and guided antegradely by IVUS. This was the challenging point of the procedure and IVUS in this case was absolutely decisive for step-by-step wire advancement in LAD from retrograde approach and in order to avoid damaging LAD proximal segment and left main due to an inadvertent wire penetration into subintimal space. 3.3. IVUS guided subintimal reentry
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When antegrade wire systematically goes into subintimal space, this can be dilated with 1.5-2 mm balloon and subsequent IVUS placement in false lumen in order to monitor and orient a second wire into true lumen can be done. This troublesome manoeuvre is called IVUS guided subinitimal re-entry 10 and to achieve success with this technique the IVUS probe should be positioned as more proximally as possible to the dissection entrance point and guided by IVUS try to reintroduce a second wire into true lumen. 11 Our second case was a long CTO segment of RCA comprising a previous malappositioned 32 mm in-stent CTO. The first challenge to be tackled in this case was the fact that the wire before stented segment had entered into subinitmal space and thanks to IVUS guidance a second specific wire could get into true lumen.
ACCEPTED MANUSCRIPT 3.4. IVUS in in-stent chronic total occlusion
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Although in-stent CTO can serve under fluoro as a marker for wire advancement but in some circumstances wire crossing is challenging especially when previous stent presents underexpanded or malaaposioned points. In these situations it is not unlikely that the wire could get out of stent through a stent strut and IVUS is essential to identify and eventually to prevent the problem. 12 In fact wire introduction into stent lumen in our case was quite challenging and tended to get out taking into account that the stent had been implanted in an aneurysmatic portion and was malappositioned. IVUS could verify the correct guidewire position within the prior stent lumen throughout its entire length and this step was crucial for ensuring the wire placement into true lumen beyond stent distal end and for the prevention of stent crush.
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Among instrumentation dedicated to CTO-PCI there is available Boston Scientific Coronary CTO Crossing System which consists of CrossBoss catheter, the Stingray balloon and the Stingray guidewire for controlled subintimal re-entry. 13 CrossBoss catheter has the particularity of having a hydrophilic coated shaft and a blunt 1.0x1.0 mm olive tip which unlike guidewires prevents the catheter tip from penetrating through the stent mesh. This characteristic makes possible the device use for in-stent CTO without guidewire advancement and its utilization in this scenario has been associated with a high PCI success rate. 14
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This technique could not be used in our second case because the guidewire penetrated in false lumen before the previous stent proximal end. 3.5. Long term outcome of IVUS guided stent sizing
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Determination of precise CTO-length is somehow difficult basing solely on angiographic findings. Although careful angiographic study in different views and through donor artery can help estimate the CTO length, very often vessel diameter beyond CTO distal cap angiographically seems narrow and diffusely diseased in part due to chronic hypoperfusion. Indeed repeat angiography in patients underwent successful CTO recanalization reveals greater increase of vessel diameter in distal portions of stented segment with regard to proximal part. 15 This feature could be extremely important in determining stent sizing during CTO procedure and IVUS can contribute to more precise vessel measurement and consequently stent size. IVUS guided CTO-PCI has shown significant less in-stent late lumen loss and less incidence of stent thrombosis in follow-up compared with CTO-PCI without IVUS support. 16
ACCEPTED MANUSCRIPT Conclusion
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This manuscript emphasises the key contribution of IVUS for step-by-step monitoring and advancement of guidewires during complex CTO-PCIs. IVUS in some challenging cases has a crucial role in clarifying problems, navigating precisely guidewires and ultimately in preventing complication and achieving a successful angiographic result. Conflict of interest
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All authors have none to declare
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Acknowledgement: The authors express theirs gratitude to all interventional cardiology department staff for their contribution to the performance of these procedures. All illustrations in this manuscript belong to cases performed in our cath lab.
Figures’s legends:
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Figure 1a and 1b: Bilateral injection through femoral and radial artery evidences LAD total occlusion in proximal segment without a clear stump.
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LAD: left anterior descending coronary artery.
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Figure 1c: IVUS catheter is positioned in LCX while a Confianza 12 is penetrating retrogradely into CTO segment and being advanced into ascending aorta. CTO: chronic total occlusion. LCX: left circumflex artery
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Figure 1d: IVUS confirms the position of Confianza 12, coming retrogradely, within true lumen at the level of left main. Figure 1e. Recanalisation of LAD after stent implantation although the artery mid and distal segment is thin. LAD: left anterior descending coronary artery. Figure 2a. Bilateral injection through femoral and radial artery shows RCA total occlusion in mid segment. A wire is positioned in a ventricular branch. The superior arrowhead shows the occlusion proximal cap and the inferior arrowhead points out the approximate level of stent proximal end implanted in a previous procedure. RCA: right coronary artery. Figure 2b. An IVUS catheter is advanced over a wire which is positioned in subintimal space and guided by IVUS a second wire is being intended to penetrate into true lumen.
ACCEPTED MANUSCRIPT Figure 2c. IVUS catheter is placed in false lumen and true lumen is being compressed at the right side.
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Figure 2d. IVUS shows the penetration of a second wire (Confianza 12) into true lumen at 3 o’clock.
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Figure 2e. The second wire could successfully enter into stent lumen verifying the stent malaapposition.
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Figure 2f. A Corsair microcatheter is advanced up to stent distal end. Figure 2g. RCA recanalization after implantation of 3 DES.
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RCA: right coronary artery; DES: drug eluting stent.
Figure 3. Identification of LAD stump by IVUS placed in a diagonal branch. Stump puncture guided by IVUS and successful final angiographic result. LAD: left anterior descending coronary artery.
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Figure 4. The sequence of IVUS images from distal to proximal part of a CTO segment including subintimal dissection in a CTO-PCI, using reverse CART technique.
ACCEPTED MANUSCRIPT Table 1: contribution of IVUS in different scenarios of CTO-PCI. Stumpless or ambiguous stump
Antegrade wire advancement into false lumen
In-stent CTO
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CTO length and stent sizing
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Retrograde wire location in ambiguous stump
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Reverse CARTH
IVUS probe positioning in a side branch close to CTO proximal cap allows to monitor a precise wire penetration into through lumen IVUS contributes to the verification of wire positioning into the vessel structure, proper balloon size and stent implantation from proximal to distal segment comprising false lumen portion Reverse CART in these circumstances is rather unfeasible. IVUS probe can be positioned in a side branch close to proximal cap and verify retrograde wire penetration into true lumen. This is extremely important when CTO proximal cap is near left main. IVUS probe can be positioned into false lumen as more proximal as possible and monitor the penetration of a second wire into true lumen (IVUS guided subintimal reentry) IVUS monitoring is crucial to verify wire navigation within stent lumen because guidewire in this scenario can easily go out through a stent strut. IVUS can determine vessel segment needing to be stented as well as stent proper size and eventually optimize its expansion and apposition.
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ACCEPTED MANUSCRIPT References 1. Gregg W. Stone, David E. Kandzari, Roxana Mehran, Antonio Colombo, Robert S.
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Schwartz, Steven Bailey, et al. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I. Cicrulation 2005; 112:2364-72. 2. Galassi AR, Tomasello SD, Reifart N, Werner GS, Sianos G, Bonnier H, et al. Inhospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry. EuroIntervention 2011;7:472-9. 3. Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv 2008;71: 8-19. 4. Mohandes M, Guarinos J, Rodríguez J, Bonet G, Fernández F, Rojas S, et al. Negative angiographic markers in percutaneous coronary intervention of chronic total occlusions. Arch Cardiol Mex 2017. pii: S1405-9940(17)30008-3. doi: 10.1016/j.acmx.2017.01.008. 5. Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y, Muramatsu T, et al. J-CTO Registry Investigators. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv 2011;4: 213-21. 6. Park Y, Park HS, Jang GL, Lee DY, Lee H, Lee JH, et al. Intravascular ultrasound guided recanalization of stumpless chronic total occlusion. Int J Cardiol 2011;148:174-8. 7. Ryan N, Gonzalo N, Dingli P, Cruz OV, Jiménez-Quevedo P, Nombela-Franco L, et al. Intravascular ultrasound guidance of percutaneous coronary intervention in ostial chronic total occlusions: a description of the technique and procedural results. Int J Cardiovasc Imaging 2017;33: 807-813. 8. Rathore S, Katoh O, Tuschikane E, Oida A, Suzuki T, Takase S. A novel modification of the retrograde approach for the recanalization of chronic total occlusion of the coronary arteries intravascular ultrasound-guided reverse controlled antegrade and retrograde tracking. JACC Cardiovasc Interv 2010; 3:155-64. 9. Surmely JF, Tsuchikane E, Katoh O, Nishida Y, Nakayama M, Nakamura S, et al. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique. J Invasive Cardiol 2006; 18:334-8. 10. Yamane M. Current percutaneous recanalization of coronary chronic total occlusion. Rev Esp Cardiol (Engl Ed) 2012; 65:265-77. doi: 10.1016/j.recesp.2011.10.026. Epub 2012. Review. English, Spanish. 11. Mohandes M, Guarinos J, Sans J, Bardaji A. Intravascular Ultrasound in Percutaneous Coronary Intervention for Chronic Total Occlusion. Int Cardiovasc Res J 2010; 4 : 101-6. 12. Mohandes M, Guarinos J, Moreno C, Rojas S, Bardají A. Crescent Moon Image as a Peculiar Complication During Percutaneous Coronary Intervention of an In- Stent Chronic Total Occlusion. Arq Bras Cardiol 2017; 109: 179-180. 13. Werner GS. The BridgePoint devices to facilitate recanalization of chronic total coronary occlusions through controlled subintimal re-entry. Expert Rev Med Devices 2011; 8: 23-9.
ACCEPTED MANUSCRIPT 14. Zhao L, Li LB, Wang ZH, Shi YF, Wu JD, Zhang JC, et al. Initial clinical experience of CrossBoss catheter for in-stent chronic total occlusion lesions: A case report. Medicine (Baltimore) 2016; 95: e5045. 15. Allahwala UK, Ward MR, Bhindi R. Change in the distal vessel luminal diameter following chronic total occlusion revascularization. Cardiovasc Interv Ther 2017; doi:
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16. Tian NL, Gami SK, Ye F, Zhang JJ, Liu ZZ, Lin S, et al. Angiographic and clinical comparisons of intravascular ultrasound- versus angiography-guided drugeluting stent implantation for patients with chronic total occlusion lesions: twoyear results from a randomised AIR-CTO study. EuroIntervention 2015; 10: 1409- 17.
ACCEPTED MANUSCRIPT Highlights
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The position of retrograde guidewire in an ambiguous stump CTO can be verified by IVUS located in a side branch close to proximal cap. When antegrade wire goes systematically into false lumen IVUS can be positioned in subintimal space and guide the penetration of a second wire into true lumen (IVUS guided subinitimal re-entry).
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S1553-8389(17)30391-3 doi: 10.1016/j.carrev.2017.10.004 CARREV 1151
To appear in:
Cardiovascular Revascularization Medicine
Received date: Revised date: Accepted date:
28 August 2017 5 October 2017 6 October 2017
Please cite this article as: Mohandes Mohsen, Vinhas Hugo, Fern´ andez Francisco, Moreno Cristina, Torres Mauricio, Guarinos Jordi, When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion, Cardiovascular Revascularization Medicine (2017), doi: 10.1016/j.carrev.2017.10.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion
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Decisive role of IVUS in CTO-PCI Authors:
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1 (Corresponding author): Mohsen Mohandes, MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007 Tarragona, Spain. TEL: 0034-977295817; Email: [email protected] 2. Hugo Vinhas, MD; Interventional Cardiology Unit, Hospital García de Orta, Almada,
Portugal. Email: [email protected]
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3. Francisco Fernández, MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007 Tarragona, Spain. Email: [email protected]
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4. Cristina Moreno MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007. Email: [email protected]
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5. Mauricio Torres MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007. Email:[email protected] 6. Jordi Guarinos MD, Interventional Cardiology Unit, Cardiology Division, Joan XXIII university hospital, Universitat Rovira Virgili, Calle Dr Mallafré Guasch 4, 43007. Email: [email protected]
ACCEPTED MANUSCRIPT Keywords
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Abstract
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Percutaneous coronary intervention of chronic total occlusion is a particular interventional area which requires high level of operator’s experience and the support of additional tools based on intracoronary image such as intravascular ultrasound in many cases to clarify difficulties during procedures and to increase success rate. Implantation of long stents in many cases, the presence of stump ambiguity, and the use of specific techniques in this kind of interventions, such as reverse controlled antegrade and retrograde subintimal tracking (CART) and reverse CART make necessary in many cases the use of intravascular ultrasound for a better understanding of the situation, for reducing eventual complications and increasing procedural success rate. We made a review of literature related to most challenging situations in which the use of intravascular ultrasound during chronic total occlusion percutaneous coronary intervention becomes rather indispensable to safely continue and finish the procedure. Besides, two complex percutaneous coronary interventions of chronic total occlusion with unfavourable anatomic features in which intravascular ultrasound was crucial for the procedural success are presented in this manuscript along with support of the literature.
ACCEPTED MANUSCRIPT 1. Introduction
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Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is a challenge and this type of procedure has been regarded as the last frontier in interventional cardiology.1 This statement is based on the fact that successful recanalization of CTOs is still considerably lower than those achieved in non-occluded or acutely occluded coronary arteries. 2 However, the advent of new techniques incorporated to interventional field during the last few years, the use of retrograde approach, incorporation of dedicated material and instrumentation have steadily increased CTO successful recanalization up to 75-90% in the hands of experienced and skilled operators. 3
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Some negative angiographic markers inherent to CTOs such as lesion length, stump ambiguity, ostial location and multivessel disease have been associated with failed PCI results 4 and make even more indispensable the use of specific techniques and dedicated tools such as intravascular ultrasound (IVUS) in order to assist interventionists to achieve a higher procedural success rate. In fact, IVUS in some circumstances is mandatory for a better understanding of intervention and ultimately for optimising procedural results.
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In-stent-CTO is a specific scenario in which it is highly important to steer the guidewire into stent lumen so that a suboptimised result of previous PCI such as stent malapposition or underexpansion might make the procedure more challenging and justify the use of IVUS to highlight the situation and to overcome some difficulties.
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Two challenging CTO-PCIs in which IVUS was crucial for the success rate are presented and review of literature related to some particular circumstances where IVUS could be decisive for procedural success has been done in this manuscript. 2. Cases’ description 2.1. Case 1
A 53-year-old man with hypertension and smoking as coronary risk factors was referred to our centre for coronary angiogram due to unstable angina. The coronary angiogram showed total occlusion of left anterior descending coronary artery (LAD) proximal segment receiving collaterals from right coronary artery (RCA). Echocardiographic examination revealed normal ejection fraction and a myocardial SPECT evidenced ischaemia in LAD territory, therefore percutaneous coronary intervention was scheduled. Bilateral injection using femoral and radial approach was used visualizing ambiguous stump in occluded segment (figure 1a and 1b; video 1a) therefore retrograde approach was attempted. We achieved LAD distal segment through a septal channel by Sion wire and Corsair 150 mm microcatheter (Asahi Intecc, Aichi, Japan). An IVUS catheter (Volcano, San Diego, United States) was positioned in
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left circumflex artery (LCX) intended to monitor retrograde wire penetration into the occluded segment using different guidewires (Gaia 1, Confianza pro 9; Asahi Intecc, Aichi, Japan) however the wires repeatedly entered in subintimal space. After several attempts and guided antegradely by IVUS a Confianza 12 (Asahi Intecc, Aichi, Japan) was able to penetrate retrogradely into the CTO segment and wire position within true lumen at the level of left main was verified by IVUS (figure 1c and 1d; video 1b and 1c). The wire and microcatheter Corsair reached ascending aorta where Confianza 12 was exchanged with an RG3 wire (Asahi Intecc, Aichi, Japan). The RG3 tip was antegradely snared and introduced into antegrade catheter lumen and externalised, then balloon predilatation was started over RG3 wire. Two drug eluting stents (DES; Onyx: 3x26 mm and Onyx: 2.25x26 mm; Medtronic, United States) were implanted in LAD ostialproximal and mid segment achieving successful final angiographic result, although LAD was narrow in mid and distal segment (figure 1e; video 1d). Absence of complication in donor artery and septal channels was verified as the last step before concluding the procedure.
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2.2. Case 2
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A 69-year-old man with hypertension, dyslipidemia and type II diabetes was referred to our centre for coronary angiogram due to non-ST elevation acute coronary syndrome on February 2017. The patient had undergone a primary angioplasty on RCA distal segment with a 3.5x32 mm bare metal stent (BMS) with an aneurysmatic portion at that level 5 months earlier. The coronary angiogram of current episode showed RCA total occlusion before stent proximal end. An attempt in the same procedure failed to recanalise the artery because of inability to pass the guidewire into stent lumen. An echocardiographic examination revealed inferior akinesia with 54% ejection fraction. A myocardial SPECT was carried out depicting moderate ischaemia in inferior territory, therefore a second dedicated attempt to recanalise RCA was scheduled 2 weeks later. Bilateral injection by radial and femoral approach with AR2 8F guiding catheter for RCA engagement was used visualizing total occlusion of RCA from mid segment extending to in-stent portion and up to bifurcation into posterolateral (PL) and posterior descending (PD) branches (figure 2a; video 2a). Attempt with several guidewires for crossing the occluded segment failed due to subintimal wire penetration, therefore dilatation with a 2 mm balloon at low atmosphere in RCA mid segment was performed assuming the wire position in subintimal space and afterward an IVUS catheter (Volcano, San Diego, United States) was advanced over the wire (video 2b) and guided by IVUS penetration into true lumen with a new guidewire in mid segment before previous stent proximal end was attempted (figure 2b and 2c). Finally a confianza 12 was able to penetrate into true lumen (figure 2d; video 2c and 2d) and successfully
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entered into the stent lumen implanted in the previous procedure confirming inappropriate stent apposition (figure 2e; video 2e). Once correct wire position was verified by IVUS a Corsair microcatheter was advanced through the occluded segment up to distal part of the previous stent where the confianza 12 was exchanged with a floppy wire (figure 2f). After dilatation with 4 and 4.5 mm non-compliant balloons in in-stent segment two drug eluting stents (DES; (Onyx: 4.5x15 mm; Medtronic, Inc. Minneapolis, USA; and ISAR: 4x24 mm: B.Braun, Germany) in mid and distal segment of RCA overlapped with previous stent proximal end and a third DES (Onyx: 3x18 mm) overlapped with prior stent distal end and toward PL branch were implanted achieving good final angiographic result (figure 2g; video 2f). Minimum lumen area (MLA) assessed by IVUS in RCA distal and mid segment was 8.6 mm2 and 11.6 mm2 respectively.
3. Discussion
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The main finding of these two case reports described above is the decisive contribution of IVUS to successful percutaneous recanalization of two complex CTO enabling the operator in both cases to orient a specific wire into true lumen, a key point for success in a CTO-PCI.
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There are different scenarios in which IVUS has a positive contribution to CTO-PCI result (table 1) and can be summarized as follows:
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3.1. IVUS usefulness in ambiguous stump situations The presence of a blunt stump has been described as an angiographic marker associated with the degree of difficulty to cross a CTO in a Japanese multicentre registry5 and this feature decreases the chance of steering the wire into true lumen while dealing a CTO with an antegrade approach. Stumpless or ostial CTOs is a challenging situation due to the difficulty for angiographically stump location and with the guidewire often trending to slip into a side branch. IVUS probe can be placed in these circumstances in a side branch close to the bifurcation with occluded vessel trying to perform an IVUS guided stump penetration (figure 3). 6 The use of this technique has been associated with a high PCI success rate. 7
3.2. IVUS contribution in retrograde approach Retrograde approach through septal or epicardial channels in unfavourable anatomic cases for antegrade access has substantially increased procedural success rate. When
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retrograde approach is attempted retrograde wire can cross successfully CTO segment in approximately 35% of cases. Experienced operators use reverse controlled antegrade retrograde subinitmal tracking (reverse CART) with IVUS guidance in 65% and conventional CART technique in remaining 5% of cases. 8,9IVUS guidance in reverse CART technique allows operators to select a proper balloon size for antegrade dilatation and the ultimate retrograde wire monitoring into true lumen at the level of CTO proximal cap ensuring a lower rate of complication and optimising the final result.8
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Besides, when a reverse CART is being done antegrade dye injection should be avoided in order to prevent the extension of dissection and IVUS examination in these circumstances is highly useful for the identification of subintimal dissection and the selection of stent size (figure 4).
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But in order to perform reverse CART technique it is mandatory to penetrate antegradely into CTO body and to prepare proximal cap. Our first case was characterised by a rather unidentifiable stump, thus antegrade wire advancement and proximal cap preparation was not technically feasible. Therefore, the chance for a successful PCI was practically limited to penetrate a retrograde wire into LAD proximal segment somewhere around the ambiguous stump and guided antegradely by IVUS. This was the challenging point of the procedure and IVUS in this case was absolutely decisive for step-by-step wire advancement in LAD from retrograde approach and in order to avoid damaging LAD proximal segment and left main due to an inadvertent wire penetration into subintimal space. 3.3. IVUS guided subintimal reentry
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When antegrade wire systematically goes into subintimal space, this can be dilated with 1.5-2 mm balloon and subsequent IVUS placement in false lumen in order to monitor and orient a second wire into true lumen can be done. This troublesome manoeuvre is called IVUS guided subinitimal re-entry 10 and to achieve success with this technique the IVUS probe should be positioned as more proximally as possible to the dissection entrance point and guided by IVUS try to reintroduce a second wire into true lumen. 11 Our second case was a long CTO segment of RCA comprising a previous malappositioned 32 mm in-stent CTO. The first challenge to be tackled in this case was the fact that the wire before stented segment had entered into subinitmal space and thanks to IVUS guidance a second specific wire could get into true lumen.
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Although in-stent CTO can serve under fluoro as a marker for wire advancement but in some circumstances wire crossing is challenging especially when previous stent presents underexpanded or malaaposioned points. In these situations it is not unlikely that the wire could get out of stent through a stent strut and IVUS is essential to identify and eventually to prevent the problem. 12 In fact wire introduction into stent lumen in our case was quite challenging and tended to get out taking into account that the stent had been implanted in an aneurysmatic portion and was malappositioned. IVUS could verify the correct guidewire position within the prior stent lumen throughout its entire length and this step was crucial for ensuring the wire placement into true lumen beyond stent distal end and for the prevention of stent crush.
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Among instrumentation dedicated to CTO-PCI there is available Boston Scientific Coronary CTO Crossing System which consists of CrossBoss catheter, the Stingray balloon and the Stingray guidewire for controlled subintimal re-entry. 13 CrossBoss catheter has the particularity of having a hydrophilic coated shaft and a blunt 1.0x1.0 mm olive tip which unlike guidewires prevents the catheter tip from penetrating through the stent mesh. This characteristic makes possible the device use for in-stent CTO without guidewire advancement and its utilization in this scenario has been associated with a high PCI success rate. 14
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This technique could not be used in our second case because the guidewire penetrated in false lumen before the previous stent proximal end. 3.5. Long term outcome of IVUS guided stent sizing
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Determination of precise CTO-length is somehow difficult basing solely on angiographic findings. Although careful angiographic study in different views and through donor artery can help estimate the CTO length, very often vessel diameter beyond CTO distal cap angiographically seems narrow and diffusely diseased in part due to chronic hypoperfusion. Indeed repeat angiography in patients underwent successful CTO recanalization reveals greater increase of vessel diameter in distal portions of stented segment with regard to proximal part. 15 This feature could be extremely important in determining stent sizing during CTO procedure and IVUS can contribute to more precise vessel measurement and consequently stent size. IVUS guided CTO-PCI has shown significant less in-stent late lumen loss and less incidence of stent thrombosis in follow-up compared with CTO-PCI without IVUS support. 16
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This manuscript emphasises the key contribution of IVUS for step-by-step monitoring and advancement of guidewires during complex CTO-PCIs. IVUS in some challenging cases has a crucial role in clarifying problems, navigating precisely guidewires and ultimately in preventing complication and achieving a successful angiographic result. Conflict of interest
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All authors have none to declare
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Acknowledgement: The authors express theirs gratitude to all interventional cardiology department staff for their contribution to the performance of these procedures. All illustrations in this manuscript belong to cases performed in our cath lab.
Figures’s legends:
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Figure 1a and 1b: Bilateral injection through femoral and radial artery evidences LAD total occlusion in proximal segment without a clear stump.
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LAD: left anterior descending coronary artery.
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Figure 1c: IVUS catheter is positioned in LCX while a Confianza 12 is penetrating retrogradely into CTO segment and being advanced into ascending aorta. CTO: chronic total occlusion. LCX: left circumflex artery
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Figure 1d: IVUS confirms the position of Confianza 12, coming retrogradely, within true lumen at the level of left main. Figure 1e. Recanalisation of LAD after stent implantation although the artery mid and distal segment is thin. LAD: left anterior descending coronary artery. Figure 2a. Bilateral injection through femoral and radial artery shows RCA total occlusion in mid segment. A wire is positioned in a ventricular branch. The superior arrowhead shows the occlusion proximal cap and the inferior arrowhead points out the approximate level of stent proximal end implanted in a previous procedure. RCA: right coronary artery. Figure 2b. An IVUS catheter is advanced over a wire which is positioned in subintimal space and guided by IVUS a second wire is being intended to penetrate into true lumen.
ACCEPTED MANUSCRIPT Figure 2c. IVUS catheter is placed in false lumen and true lumen is being compressed at the right side.
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Figure 2d. IVUS shows the penetration of a second wire (Confianza 12) into true lumen at 3 o’clock.
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Figure 2e. The second wire could successfully enter into stent lumen verifying the stent malaapposition.
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Figure 2f. A Corsair microcatheter is advanced up to stent distal end. Figure 2g. RCA recanalization after implantation of 3 DES.
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RCA: right coronary artery; DES: drug eluting stent.
Figure 3. Identification of LAD stump by IVUS placed in a diagonal branch. Stump puncture guided by IVUS and successful final angiographic result. LAD: left anterior descending coronary artery.
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Figure 4. The sequence of IVUS images from distal to proximal part of a CTO segment including subintimal dissection in a CTO-PCI, using reverse CART technique.
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Antegrade wire advancement into false lumen
In-stent CTO
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CTO length and stent sizing
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Retrograde wire location in ambiguous stump
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Reverse CARTH
IVUS probe positioning in a side branch close to CTO proximal cap allows to monitor a precise wire penetration into through lumen IVUS contributes to the verification of wire positioning into the vessel structure, proper balloon size and stent implantation from proximal to distal segment comprising false lumen portion Reverse CART in these circumstances is rather unfeasible. IVUS probe can be positioned in a side branch close to proximal cap and verify retrograde wire penetration into true lumen. This is extremely important when CTO proximal cap is near left main. IVUS probe can be positioned into false lumen as more proximal as possible and monitor the penetration of a second wire into true lumen (IVUS guided subintimal reentry) IVUS monitoring is crucial to verify wire navigation within stent lumen because guidewire in this scenario can easily go out through a stent strut. IVUS can determine vessel segment needing to be stented as well as stent proper size and eventually optimize its expansion and apposition.
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Schwartz, Steven Bailey, et al. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I. Cicrulation 2005; 112:2364-72. 2. Galassi AR, Tomasello SD, Reifart N, Werner GS, Sianos G, Bonnier H, et al. Inhospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry. EuroIntervention 2011;7:472-9. 3. Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv 2008;71: 8-19. 4. Mohandes M, Guarinos J, Rodríguez J, Bonet G, Fernández F, Rojas S, et al. Negative angiographic markers in percutaneous coronary intervention of chronic total occlusions. Arch Cardiol Mex 2017. pii: S1405-9940(17)30008-3. doi: 10.1016/j.acmx.2017.01.008. 5. Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y, Muramatsu T, et al. J-CTO Registry Investigators. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv 2011;4: 213-21. 6. Park Y, Park HS, Jang GL, Lee DY, Lee H, Lee JH, et al. Intravascular ultrasound guided recanalization of stumpless chronic total occlusion. Int J Cardiol 2011;148:174-8. 7. Ryan N, Gonzalo N, Dingli P, Cruz OV, Jiménez-Quevedo P, Nombela-Franco L, et al. Intravascular ultrasound guidance of percutaneous coronary intervention in ostial chronic total occlusions: a description of the technique and procedural results. Int J Cardiovasc Imaging 2017;33: 807-813. 8. Rathore S, Katoh O, Tuschikane E, Oida A, Suzuki T, Takase S. A novel modification of the retrograde approach for the recanalization of chronic total occlusion of the coronary arteries intravascular ultrasound-guided reverse controlled antegrade and retrograde tracking. JACC Cardiovasc Interv 2010; 3:155-64. 9. Surmely JF, Tsuchikane E, Katoh O, Nishida Y, Nakayama M, Nakamura S, et al. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique. J Invasive Cardiol 2006; 18:334-8. 10. Yamane M. Current percutaneous recanalization of coronary chronic total occlusion. Rev Esp Cardiol (Engl Ed) 2012; 65:265-77. doi: 10.1016/j.recesp.2011.10.026. Epub 2012. Review. English, Spanish. 11. Mohandes M, Guarinos J, Sans J, Bardaji A. Intravascular Ultrasound in Percutaneous Coronary Intervention for Chronic Total Occlusion. Int Cardiovasc Res J 2010; 4 : 101-6. 12. Mohandes M, Guarinos J, Moreno C, Rojas S, Bardají A. Crescent Moon Image as a Peculiar Complication During Percutaneous Coronary Intervention of an In- Stent Chronic Total Occlusion. Arq Bras Cardiol 2017; 109: 179-180. 13. Werner GS. The BridgePoint devices to facilitate recanalization of chronic total coronary occlusions through controlled subintimal re-entry. Expert Rev Med Devices 2011; 8: 23-9.
ACCEPTED MANUSCRIPT 14. Zhao L, Li LB, Wang ZH, Shi YF, Wu JD, Zhang JC, et al. Initial clinical experience of CrossBoss catheter for in-stent chronic total occlusion lesions: A case report. Medicine (Baltimore) 2016; 95: e5045. 15. Allahwala UK, Ward MR, Bhindi R. Change in the distal vessel luminal diameter following chronic total occlusion revascularization. Cardiovasc Interv Ther 2017; doi:
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16. Tian NL, Gami SK, Ye F, Zhang JJ, Liu ZZ, Lin S, et al. Angiographic and clinical comparisons of intravascular ultrasound- versus angiography-guided drugeluting stent implantation for patients with chronic total occlusion lesions: twoyear results from a randomised AIR-CTO study. EuroIntervention 2015; 10: 1409- 17.
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The position of retrograde guidewire in an ambiguous stump CTO can be verified by IVUS located in a side branch close to proximal cap. When antegrade wire goes systematically into false lumen IVUS can be positioned in subintimal space and guide the penetration of a second wire into true lumen (IVUS guided subinitimal re-entry).
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