Table of Contents
GUIDELINE AND CONSENSUS
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 81-87

Updated algorithm of chronic total occlusion percutaneous coronary intervention from chronic total occlusion club China


1 Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
2 Department of Cardiology, Peking University First Hospital, Beijing, China
3 Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
4 Department of Cardiology, Peking University People's Hospital, Beijing, China
5 China

Date of Submission19-Apr-2021
Date of Acceptance30-Apr-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Jun-Bo Ge
Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2470-7511.320320

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  Abstract 


In 2018, the Chronic Total Occlusion Club China (CTOCC) presented a new CTO percutaneous coronary intervention (CTO PCI) algorithm. At the end of 2020, an updated CTOCC algorithm was proposed by this group after the adoption of innovative concepts and novel techniques in CTO PCI. The updated CTOCC algorithm summarizes the contemporary CTO PCI practices in China, in which simultaneous contralateral injection and careful angiographic review, along with strategic changes, are emphasized. Additionally, we provide some new recommendations for techniques such as the “move the cap” and “active greeting” techniques and investment procedures.

Keywords: Algorithm; Coronary occlusion; Percutaneous coronary intervention


How to cite this article:
Ge JB, Ge L, Huo Y, Chen JY, Wang WM, On Behalf of Chronic Total Occlusion Club. Updated algorithm of chronic total occlusion percutaneous coronary intervention from chronic total occlusion club China. Cardiol Plus 2021;6:81-7

How to cite this URL:
Ge JB, Ge L, Huo Y, Chen JY, Wang WM, On Behalf of Chronic Total Occlusion Club. Updated algorithm of chronic total occlusion percutaneous coronary intervention from chronic total occlusion club China. Cardiol Plus [serial online] 2021 [cited 2021 Nov 27];6:81-7. Available from: https://www.cardiologyplus.org/text.asp?2021/6/2/81/320320




  Background Top


Even though significant improvements in devices and techniques have been achieved in recent decades, percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) remains challenging. In 2018, the “Strategic roadmap of PCI for CTOs” was published by the CTO Club China (CTOCC).[1] Contrary to the hybrid algorithm,[2] both parallel wire and intravascular ultrasound (IVUS)-guided techniques were included in the CTOCC algorithm. During the 2 years since its release, the CTOCC algorithm has been promoted vigorously in China. As a result of this, not only the success rate of CTO PCI enhanced, and the rate of complications decreased,[3],[4],[5] but also the progress of standardized education and treatment for CTO PCI were greatly accelerated. Meanwhile, innovative concepts and new clinical evidence of CTO PCI have emerged worldwide.[6],[7] Based on the progress in this field, the CTOCC CTO PCI algorithm was revised, and the five updated recommendations are as follows [Figure 1].
Figure 1: Updated chronic total occlusion club China chronic total occlusion percutaneous coronary intervention algorithm.
IVUS: Intravascular ultrasound, CC: Collateral channel, BASE: balloon-assisted subintimal entry, ADR: Antegrade dissection reentry, CART: Controlled antegrade and retrograde tracking, RWE: Retrograde wire escalation, KWT: Kissing wire technique, AGT: Active greeting technique, eGFR: Estimated glomerular filtration rate


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  Updated Recommendation 1: Techniques Related to the “Vessel Structure” Concept Top


With the widespread acceptance of dissection and reentry techniques (DART), such as antegrade dissection reentry (ADR) and retrograde dissection reentry (RDR), the concept of “intraplaque” and “subintimal” revascularization has been largely accepted by the intervention community, and has essentially replaced the notion of “true lumen” and “false lumen.” These terms reflect a more thorough understanding of CTO pathophysiology, portraying a “vessel structure” perception where all intra-adventitia space is considered proper vessel structure.[7] The vessel structure concept plays a crucial role in contemporary CTO PCI where it serves as a basis for a series of novel techniques, including subintimal tracking and reentry (STAR) and its derivatives,[8],[9],[10],[11] limited antegrade subintimal tracking,[12] CrossBoss catheter, and Stingray balloon (Boston Scientific Company)-based ADR techniques,[13],[14] controlled antegrade and retrograde subintimal tracking (CART) and reverse CART.[15]

The updated CTOCC CTO PCI algorithm suggests that for solving the proximal cap ambiguity, techniques related to the “vessel structure” concept (such as the “move the cap” techniques)[16] may be rational choices when IVUS-guided techniques cannot be applied or have failed [Figure 2]. After “move the cap” techniques are performed, either ADR or RDR should be subsequently utilized. This recommendation is different from the APCTO Club algorithm,[17] in which only IVUS or the retrograde approach was recommended for solving the proximal cap ambiguity. “Move the cap” techniques include power knuckle [Figure 3], Scratch-and-Go [Figure 4],[16] balloon-assisted subintimal entry (BASE) [Figure 5],[16] Side-BASE [Figure 6],[18] Carlino method[19] [Figure 7], and dual-lumen microcatheter support puncture technique [Figure 8]. It should be pointed out that higher rate of late stent malapposition and higher incidence of perioperative myocardial infarction were frequently found in subintimal revascularization patients, compared to true lumen revascularization patients.[20],[21],[22] Thus, the updated CTOCC CTO PCI algorithm urges the operator to evaluate the CTO lesions' anatomy carefully and avoid compromising the large side branches before applying “move the cap” techniques.
Figure 2: Methods for solving proximal ambiguity.
Except for the IVUS-guided and retrograde approaches, “move the cap” techniques are the rational choices for solving proximal ambiguity. After “move the cap” techniques, either ADR or the retrograde approach could be attempted.
ADR: Antegrade dissection reentry, IVUS: Intravascular ultrasound


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Figure 3: Illustration of the power knuckle technique.
To increase the power of knuckling wire, one suitably sized balloon (with a 1:1 ratio of balloon size to target vessel size) could be used to anchor the microcatheter, and hence the backup support of the microcatheter will be significantly improved.


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Figure 4: Illustration of the Scratch-and-Go technique.
A, A stiff guidewire (such as the Conquest Pro 12, Gaia Second, or Third with 90° tip bend and 2–3 mm length) is manipulated into the vessel wall proximal to the proximal cap. To avoid perforation, only advancing 1–2 mm into the wall is required. B, The microcatheter over the stiff guidewire is advanced toward the vessel wall (only a minimal distance, usually 1 mm or less). The stiff guidewire is changed to a polymer-jacketed guidewire (such as the Fielder XT, Fighter, or Pilot 200). The polymer-jacketed wire is pushed (without rotation) to form a loop (knuckle wire technique). C, The knuckled wire is advanced into the dissection plane.


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Figure 5: Illustration of balloon-assisted subintimal entry.
1 or 1.2:1 ratio of balloon size to target vessel size) over a workhorse guidewire dilates the intended segment at 10–14 atm. B, After proximal vessel dissection, a polymer-jacketed guidewire (such as the Fielder XT, Fighter, or Pilot 200) with the microcatheter is advanced to the proximal cap. C, The wire is advanced by pushing, without rotation, to form a loop.


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Figure 6: Illustration of Side-BASE.
A, A balloon (sized 1:1 with the side branch) is advanced partly into the side branch and inflated at nominal pressure to develop a dissection in the proximal cap. B, With the side branch balloon inflated, the polymer wire is pushed in a loop (knuckle wire technique). C, The wire is advanced by pushing, without rotation.
BASE: Balloon-assisted subintimal entry


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Figure 7: Illustration of the Carlino method.
After the microcatheter is advanced into the proximal cap or vessel wall, a small amount (0.5–1.0 mL) of contrast medium is injected gently under cineangiography with a small (usually 3 mL) Luer lock syringe.


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Figure 8: Illustration of a dual-lumen microcatheter support puncture.
A dual-lumen microcatheter enables (1) enhancement of the second guidewire's penetration force, (2) straightening of the vessel, and (3) easier reshaping and switching of the second guidewire.


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  Updated Recommendation 2: Microcatheter Collateral Channel Tracking Failure Solutions Top


Microcatheter collateral channel tracking failure may occur in up to 22.5% of retrograde approach cases.[23] Our algorithm suggests that switching among different types of microcatheter, utilizing guide catheter extensions or the anchor balloon technique, and using a small balloon with low pressure to dilate the septal channel are often performed after the microcatheter failed to track the collateral channel. If the combined efforts of the above-mentioned techniques do not work, the operator may consider choosing a different collateral channel or changing the intervention strategy. In some cases, the operator may also attempt the kissing wire or microcatheter rendezvous techniques, if possible. Stingray-based ADR with the retrograde wire as a marker is also a reasonable choice.[23]


  Updated Recommendation 3: Active Greeting Technique Top


The retrograde wire technique has dramatically improved the success rate of CTO PCI.[24],[25] However, even with the aid of dedicated devices, the externalization of the retrograde guidewire may still prove to be both challenging and time-consuming. To solve this problem, active greeting technique (AGT) was proposed in 2018 by Professor Ge [Figure 9].[5] Regarding AGT, the utilization of antegrade guide extensions or a “;mother and child” guide catheter to actively converge toward the retrograde wire not only improves the success rate and efficiency of the index procedure but also protects the proximal vessel from injury. The AGT technique should be applied as early as possible when there is difficulty in manipulating the retrograde guidewire into the antegrade guide catheter during wire externalization.[5]
Figure 9: Illustration of active greeting technique.
A, Right coronary artery total occluded: Retrograde approach was performed through the septal channel. B, The antegrade guide extension is delivered as close as possible to the tip of the retrograde wire. C, The retrograde wire is manipulated into the antegrade guide extensions. To minimize the risk of proximal segment of target vessel injury, the antegrade guide extensions' advancement over a balloon catheter or microcatheter is preferred to advancement over a coronary wire alone. Sometimes, the inchworm technique should be performed.


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  Updated Recommendation 4: The Investment Procedure Technique Top


DART are key components of the contemporary CTO PCI. It has been demonstrated that a high success rate is achieved with DART.[21],[26] However, due to either the guidewire's failure to enter the distal true lumen or the high risk of a major side branch being occluded, some procedures are aborted. For those challenging scenarios, no clear recommendations were present in either the hybrid or APCTO Club algorithms. A recent study has shown that suboptimal CTO revascularization with stenting may increase the incidence of myocardial infarction, cardiac death, and other long-term adverse events.[27] To avoid excessive stenting or prevent the side branch from becoming compromised, deferring stenting (usually 6–8 weeks after the first attempt) is a rational option. This is also known as the “investment procedure.”[28] The essence of the investment procedure technique relies on choosing a suitably sized balloon to be dilated in the occlusive lesion segment (subintimal plaque modification [SPM]) either when the guidewire is in the false lumen or during reentry to the true lumen in the far distal segment. SPM may change the anatomical structure of the occlusive lesion. Some vessels may heal well and lead to spontaneous revascularization after SPM.[29],[30] Our updated algorithm suggests that the investment procedure can be an option in some cases after weighing the risks and benefits.


  Updated Recommendation 5: Conditions for Terminating the Procedure Top


Prolonged procedure times, excessive contrast consumption, and high radiation exposure may contribute to the procedural complications associated with CTO PCI, and knowing when to abort the procedure is crucial to reducing these complications. Similar to the APCTO Club and EuroCTO Club algorithms,[17],[31] the operator should consider terminating the procedure when (1) the total procedure time exceeds 3 h; (2) the contrast volume exceeds four times the patient's estimated glomerular filtration rate; (3) radiation exposure exceeds 5 Gray (air kerma), and the procedure makes no progress. Furthermore, to limit radiation exposure, the updated CTOCC algorithm suggests that the frame rate should be lowered from 15 to 7.5 FPS during CTO PCI.[4]

So far, at least four algorithms have been published,[2],[17],[31],[32] besides the CTOCC algorithm. Those algorithms have some similarities but also significant differences, and a detailed comparison of various algorithms is beyond the scope of this article. The updated CTOCC algorithm summarizes the current CTO PCI practices in China, adopting innovative concepts and new clinical evidence in this field. To confirm the role of this algorithm, further studies are needed in future.

Expert Group Members (Sorted by the First Letter of Surname)

Yun-Dai Chen (Chinese PLA General Hospital), Ke-Fei Dou (Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College), Guo-Sheng Fu (Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University), Ning Guo (The First Affiliated Hospital of Xi'an Jiaotong University), Yong He (West China Hospital of Sichuan University), Tao Hu (Xijing Hospital, The Fourth Military Medical University), Jun Jiang (The Second Affiliated Hospital Zhejiang University School of Medicine), Cheng-Xiang Li (Xijing Hospital, The Fourth Military Medical University), Yan Li (Tangdu Hospital, The Fourth Military Medical University), Yue Li (The First Affiliated Hospital of Harbin Medical University), Jing-Hua Liu (Beijing Anzhen Hospital, Capital Medical University), Jian-Fang Luo (Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong), Jian-Ying Ma (Shanghai Institution of Cardiovascular Diseases; Zhongshan Hospital, Fudan University), Ju-Ying Qian (Shanghai Institution of Cardiovascular Diseases; Zhongshan Hospital, Fudan University), Lei-Sheng Ru (Bethune International Peace Hospital), Jian-An Wang (The Second Affiliated Hospital Zhejiang University School of Medicine), Bo Xu (Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College), and Qi Zhang (Shanghai East Hospital, Tongji University).

Academic Secretary

Xin Zhong (Shanghai Institution of Cardiovascular Diseases; Zhongshan Hospital, Fudan University), Yuan-Ji Ma (Shanghai Institution of Cardiovascular Diseases; Zhongshan Hospital, Fudan University), Hao Lu (Shanghai Institution of Cardiovascular Diseases; Zhongshan Hospital, Fudan University), and Shi-Xuan Huang (Shanghai DeltaHealth).

Financial support and sponsorship

Nil.

Conflicts of interest

Jun-Bo Ge, Yong Huo, Yun-Dai Chen and Jian-An Wang are Editorial Board members of Cardiology Plus. The article was subject to the journal's standard procedures.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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