Patient, Technique, and Device Selection for Coronary CTO Therapy: Clinical and Angiographic Considerations
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Introduction
Over the last decade, there has been remarkable progress in the percutaneous management of coronary artery disease (CAD) as an established alternative to coronary artery bypass surgery. When compared to dilatation of coronary lesions with balloons, the scaffolding properties of stents have resulted in increased safety and predictable results, with reduced rates of acute closure and late restenosis. Recently, the addition of antiproliferative agents on the surface of the metal stents (drug-eluting stents) has been shown to markedly attenuate the vascular responses of neointimal hyperplasia, resulting in a marked reduction in the rate of restenosis.1–5
Successful recanalization and percutaneous revascularization of coronary arteries with chronic total occlusion (CTO) is one of the “last frontiers” in coronary interventions. Conquering this objective will enable complete percutaneous revascularization in an increasing number of patients. Revascularization of CTOs carries multiple theoretical advantages, such as improvement in abnormal wall motion and left ventricular function and ultimately, increased long-term survival. In the long term, when the coronary disease may progress, having an open artery may increase tolerance to future coronary events. Reducing or abolishing myocardial ischemia improves electrical stability and reduces the predisposition to arrhythmic events. A recent review of the definitions, clinical relevance, indication for treatment, and results were recently summarized in a three-part consensus document.6–8
The histopathology of the chronically occluded coronary artery has been comprehensively described.9,10 Chronic coronary occlusion most often arises from thrombotic occlusion, followed by thrombus organization and fibrosis. Approximately half of all CTOs are < 99% stenotic when observed by histopathology, despite the angiographic appearance of total occlusion. The typical atherosclerotic plaques of CTO consist of intracellular and extracellular lipids, smooth muscle cells, extracellular matrix, and calcium. Collagens are the major structural components of the extracellular matrix. Another hallmark of CTOs is the extensive neovascularization, which occurs throughout the vessel wall.
Learning and mastering the skills to recanalize CTO is an advanced stage procedure that is best suited to an experienced operator. The variety of CTO cases is wide, and special expertise is needed to differentiate between different anatomic situations, to select the appropriate devices, to change strategies as the cases progress, and to keep it safe — avoiding and treating potential complications. The success rate of CTO treatment is related to the accumulative general percutaneous coronary intervention (PCI) experience of the operator, in general, and CTO cases, in particular. The operator who takes on CTOs should approach cases of increasing difficulty by progressing gradually from tapered to flush occlusions, from short occlusions to longer ones, from straight segments to more tortuous vessels, and with time, to being able to tackle longstanding complete CTOs.
Patient selection. The prevalence of CTO in the general population is not clear. It has been reported in the early nineties that a chronically occluded coronary artery has been found in around one third of patients undergoing angiography.11 Despite this high prevalence, recanalization of CTO has been reported to be attempted in only 8–15% of the patients undergoing PCI.12–14 The disparity between the frequency of CTO and percutaneous treatment underscores not only the technical and procedural complexities of this lesion subtype, but also the clinical uncertainties with regard to which patients benefit from CTO revascularization.6 CTO, usually in the setting of multivessel disease is one of the common causes for referral to bypass surgery.14–16 Many other patients are treated conservatively, without revascularization.
An operator’s decision on whether or not to attempt a CTO recanalization and to send the patient for surgical revascularization or medical treatment is dependent on many clinical and anatomical parameters. Clinically, the patient’s age, the setting, symptom severity and frequency, overall functional status, and associated comorbidities that may affect the procedural outcomes (like renal insufficiency or diabetes mellitus) are all important determinants in selecting the treatment strategy.
The extent and complexity of the CAD is one of the major determinants in the decision making. In a recent consensus document, Stone et al distinguished between single vessel CTO and CTO in the setting of multivessel disease.8 When the CTO represents the only significant lesion, a PCI attempt is recommended when the following conditions are present: 1) the occlusion is responsible for the symptoms; 2) the myocardial territory supplied by the occluded artery is viable; 3) there is reasonable likelihood of success. In patients with multivessel disease and 1 or more CTOs, the relative risks and benefits of each of the coronary lesions should be considered and weighed against surgical revascularization. Emphasis was put on the following parameters in which surgery should be considered as an alternative to PCI: 1) left main artery disease; 2) complex triple-vessel disease, especially in patients with insulin-dependent diabetes mellitus, severe left ventricular function, or renal insufficiency; 3) occluded proximal LAD; and 4) multiple CTOs with low anticipated success.
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All of my quteisons settled-thanks!
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