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198 PART IV Wires Technique
microcatheter failed to traverse, however, following
laser debulking 5 out of the 6 lesions were successfully
dilated to achieve successful angiographic result of
83% [68].
When a CTO is caused by critical in-stent restenosis,
the ELCA is considered a safe and effective technology. Li and colleagues from Beijing, China,
reported retrospective analysis of 72 patients who
underwent CTO-PCI [69]. Stable angina was present
in 61% of the patients while acute coronary syndrome
was recorded in 39%. A previous MI was noted in
56%. Initial PCI was successful in 59 patients but
failed in 13. Among those who underwent successful
revascularization, 21 underwent ELCA and 38 underwent PCI without laser. When the 2 groups were compared the ELCA group had at baseline a higher J-CTO
score than the non-ELCA group 2.57 +/− 0.79 vs.
1.67 +/− 0.70. Procedure success was achieved in
85.7% in the ELCA group vs. 70.3% in the non-ELCA
(p=0.187). A shorter procedure time and less contrast
load were observed in the ELCA group. The investigators opined that ELCA is an effective treatment for
CTO caused by in-stent restenosis as it improved the
immediate angiographic stenosis without an increase
of peri-procedural complications or in the incidence
of 9-month major adverse coronary events.
In symptomatic/ischemic post CABGS patients with
angiographic demonstration of SVG – CTO, such occlusion may indeed account for the clinical picture, especially when the old bypass graft supplies a large or
critical myocardial territory. This scenario presents a
management dilemma. Overall, there is a consensus in
the field concerning the poor short- and long-term outcomes of CTO-PCI in these old vascular conduits [70].
This is reflected during the last decade by a strong
preference toward attempts at PCI of the diseased
recipient native coronary artery rather than targeted
revascularization of the SVG-CTO. However, in select
SVG-CTO patients with acute coronary syndrome and/
or impaired hemodynamic whose recipient artery
cannot be approached or recanalized, and the SVG
occlusion deemed responsible for the clinical manifestations, PCI of the complex lesion may need to be considered. We have introduced a dedicated CTO-SVG
percutaneous revascularization strategy termed SVG
Sculpturing [71]. It incorporates SVG cannulation with
firmly supportive guiding catheter, aggressive
guidewire[s] manipulation onto the occluded graft,
exchange with a maximal supporting guidewire intragraft injection of tissue plasminogen activator followed
by laser plaque ablation and thrombus dissolution. The
latter can be done with laser alone or in combination
with additional thrombectomy devices. Finally, the
resultant bypass graft clearance facilitates stent delivery
and adequate deployment.
The interplay between J-CTO score
and successful laser debulking
The J-CTO [Japanese Chronic TO] score is globally
recognized as an important assessment tool in con-
prediction of the level of difficulty to cross coronary
CTO and perform revascularization. The method consists of 5 baseline clinical and angiographic parameters
that together form a five-point scoring system.
Accordingly, a point is designated to the following
major factors that are associated with a lower probability of successful guidewire crossing within a time
limit of 30 minutes: blunt stump, calcification, bending
lesion >45 degrees, occlusion length of 20 mm or
longer, and a failed prior crossing attempt. Accordingly,
a J-CTO score of 0 is defined as easy procedure, 1 point
represents intermediate difficulty, 2 points are considered a difficult to cross grade, and a grade of 3–5 points
represent prediction of a very difficult challenge ahead.
This score is well correlated with success rate of 88%,
67%, 42%, and 10% respectively with an increased
score [72]. The Japanese CTO-PCI expert registry
included 2596 CTO-PCI patients, demonstrating that
the overall technical success rate of the procedure was
89.9% [6]. Of note, the impact of proctorship was especially important for operators planning revascularization in patients with score of 2 or higher. A multivariate
analysis revealed that severe calcification was a strong
predictor of procedure failure in CTO-PCI (odds ratio
3.264,95% confidence interval 1.739–6.125, p <.001).
Hence, when a CTO lesion resistant to crossing is
encountered, the small size 0.9 mm laser catheter
exhibits a marked low profile and flexibility; thus, it
provides advantage over other, larger size debulking
tools. It appears therefore, that cardiovascular lasers
can properly address each of the abovementioned
components of the J-CTO score.
Synergistic strategy combining laser
with other debulking technologies
Coronary laser atherectomy can be useful in synergism
with other debulking tools. For example, a strategy
termed RASER [RotAblation plus laser] had been introduced for CTO interventions. It first entails the
activation of rotational atherectomy to pulverize a heavy
burden of calcification in the CTO followed by exchange
for laser emission that provides additional plaque and
thrombus debulking which facilitates stent delivery and
deployment. Nevertheless, this order can be reversed in
instances whereby the rotational atherectomy cannot be
applied because its delicate guidewire, the RotaWire
(Boston Scientific, Boston, MA), is either incapable to
penetrate the proximal cap of the CTO lesion or fails to
CHAPTER 22 Laser Revascularization in Coronary CTO 199
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cross the entire length of the target lesion. Accordingly,
in such instances, the laser can be applied first to create
a “pilot channel” which then enables manipulation of
the RotaWire to ensure passage across the entire length
of the occlusion and tip placement distally. Then the
rotablator can be delivered for debulking [73].
Noteworthy, a unique laser tool aimed for CTO
revascularization was in use 2 decades ago. This was
the laser wire system (distinct from the traditional
multifiber catheter). The system was constructed with
a 0.018-inch wire that delivered laser energy at the tip
for antegrade recanalization. The European TOTAL
(Laser in Total Occlusions) multi-center study investigators [74] demonstrated that the laser wire was as
effective and safe as standard guidewires and the
cumulative crossing success rate was 61% when the
laser wire preceded mechanical wire. In about half of
the patients, less than 30 minutes of fluoroscopy time
was needed for complete crossing. The investigators
concluded that the laser wire was a useful tool for
cases when a standard wire failed to cross and needed
to be replaced with a different mechanical modality.
In that conjunction, Perin and colleagues described
their experience with a “wireless” technique for laser
recanalization of CTOs in coronary and old saphenous vein grafts [75].
Contraindications and complications
There are several contraindications for performance
of laser in coronary interventions. These include lack
of patient consent, failure to calibrate the laser catheter, tight vessel bend, laser activation in the presence
of already existing dissection or a new dissection discovered during the intervention, existing or newly
formed perforation, and application in a vessel smaller
than the size of the treating catheter. Proper training,
adherence to principles of laser safety, and excellent
maintenance of all parts of the laser system are
mandatory.
The established PCI complications associated with
balloon angioplasty and debulking technologies can
occur during laser application as well. They include
dissection, perforation, distal embolization, “no
reflow” phenomenon, thrombosis, spasm and insufficient debulking [76]. Sintek and associates reported
that ELCA in CTO interventions is associated with a
2-fold increased risk of complications [77]. Clearly,
proper lesion preparation, adequate choice of catheters size, careful slow lasing debulking technique are
among critical factors that can assist in reduction of
complications [78]. Noteworthy, laser operators
should recognize that the flexible laser catheter easily
follows the anatomic route of the guidewire, hence
sub-intimal guidewire entry or external vessel protrusion of the guidewire with subsequent activation of
the laser can lead to perforation. Unwarranted potentiation effect of contrast medium on the laser induced
acoustic shock waves should be avoided by meticulous adherence to the principles governing the “saline
flush” technique [79].
Summary
Revascularization of CTO is recognized among the
most challenging coronary interventions. Maintaining
a status of one of the “last frontiers” in interventional
cardiology for a long time, PCI in these stenoses commonly encounters complex target morphology exhibiting marked resistance from calcifications, fibrotic
tissue, thrombus, and atherosclerotic material. CTOs
are present in 15–25% of all patients undergoing coronary angiography and, given the aging population, the
prevalence of hypertension and increasing rates of
diabetes mellitus and renal failure, a further increase
in the occurrence of CTOs is anticipated in the future.
The unique histopathologic features and complex
angiographic morphology of CTO impact the
treatment strategies. Noteworthy, an increased role
for PCI in contemporary CTO management represents an important paradigm shift. Nowadays, there is
growing acceptance that the utilization of the less
invasive, percutaneous revascularization is much
preferred by patients and cardiologists alike over the
traditional management of bypass surgery. Optimal
percutaneous CTO revascularization relies on tailored steps which include lesion crossing followed by
recanalization, debulking and subsequent stenting.
Lasers are a useful tool in the armamentarium of
interventionalists for the challenges CTO revascularization impose. Specifically, the excimer laser produces
ultraviolet, pulsed-wave light transmitted through
optic fibers to targeted atherosclerotic plaques. Lasers
are uniquely suited for revascularization of CTO
because of selective debulking effect on atherosclerotic plaque, fibrotic tissue and associated thrombus
without adverse effect on the vessel wall. Patients with
acute or chronic ischemic coronary syndromes frequently present with CTO that requires percutaneous
revascularization. The user-friendly, over-the-wire or
rapid-exchange laser catheters produce adequate
plaque debulking and thrombus dissolution. These
effects are critical for proper CTO recanalization
which further permits facilitation of stent delivery
and deployment with consequential restoration of
antegrade coronary flow. Overall, precise CTO lesion
and vessel preparation should be enhanced by precise
choice of catheter size and configuration and delivery
200 PART IV Wires Technique
of efficient and safe lasing techniques. Coronary laser
debulking of CTOs is associated with a high success
rate and, upon incorporation of proper lasing technique, accompanied by low complications rate.
References
1 Pefer P, Knudtson ML, Cheema AN, Galbraith PD,
Osherov AB, Yalonetsky S et al. Current perspectives on
coronary chronic total occlusions: The Canadian multicenter chronic total occlusions registry. J Am Coll Cardiol
2012; 59: 991–997.
2 Abela OG, Singh D, Abela GS. The resistant atherosclerotic
plaques: pathologic features and their impact on revascularization. In: Topaz O (ed). Debulking in Cardiovascular
Interventions and Revascularization Strategies-Between the
Rock and the Heart. 2022, London, UK: Elsevier. 29–60.
3 Yalonetsky S, Osherov AB, Strauss HB. The pathobiology
of CTO. In: Waksman R, Saito S (eds). Chronic Total
Occlusions -A Guide to Recanalization, 2nd ed. 2013,
Chichester, UK: Willey-Blackwell. 3–9.
4 Xenogiannis I, Brilakis ES. Chronic total occlusions: the
impact of calcific deposits on the performance and outcomes of percutaneous coronary interventions. In: Topaz
O (ed). Debulking in Cardiovascular Interventions and
Revascularization Strategies-Between the Rock and the
Heart. 2022, London, UK: Elsevier. 439–454.
5 Willis SL. Debulking rock hard coronary lesions: “real
world” experience in a tertiary care medical center. In:
Topaz O (ed). Debulking in Cardiovascular Interventions
and Revascularization Strategies-Between the Rock and
the Heart. 2022, London, UK: Elsevier. 221–239.
6 Suzuki Y, Tsuchikane E, Katoh O, Muramatsu T, Muto M,
Kishi K et al. Outcomes of percutaneous coronary interventions for chronic total occlusion performed by highly
experienced Japanese specialists: the first report from the
Japanese CTO-PCI expert registry. JACC Cardiovasc
Interv 2017; 10: 2144–2154.
7 Suzuki Y, Muto M, Yamane M, Muramatsu T, Okamura
A, Igarashi Y et al. Independent predictors of retrograde
failure in CTO-PCI after successful collateral channel
crossing. Cath Cardiovasc Interv 2017; 90: E11–E18.
8 Karacsonyi J, Tajti P, Rangan BV, Halligan SC, Allen RH,
Nicholson WJ et al. Randomized comparison of a
CrossBoss first versus standard wire escalation strategy for
crossing coronary chronic total occlusions: the CrossBoss
first trial. JACC Cardiovasc Interv 2018; 11: 225–233.
9 Edwards JE. Atherosclerotic lesions: their distribution
and histopathology. In: Budinger TF (ed). Noninvasive
Techniques for Assessment of Atherosclerosis in Peripheral,
Carotid and Coronary Arteries. 1982, New York: Raven
Press. 1–13.
10 Srivatsa SS, Edwards WD, Boos CM et al. Histologic cor-
relates of angiographic chronic total coronary artery
occlusions: influence of occlusion duration on neovascularization channel patterns and intimal plaque composition. J Am Coll Cardiol 1997; 29: 955–963.
11 Topaz O. Thrombus debulking in revascularization of
atherosclerotic chronic total occlusions. In: Topaz O
(ed). Debulking in Cardiovascular Interventions and
Revascularization Strategies-Between the Rock and the
Heart. 2022, London, UK: Elsevier. 477–498.
12 Sianos G, Werner G, Galassi A et al. Recanalization of
chronic total coronary occlusions: 2012 consensus document from the EuroCTO club. Eurointervention 2012; 8:
139–145.
13 Ramunddal T, Hoebers LP, Henriques JP, Dworeck C,
Angerus O, Odenstedt J et al. Chronic total occlusions
in Sweden – a report from the Swedish Coronary
Angiography and Angioplasty Registry[SCAAR]. PLoS
One 2014; 9: e103850. doi: 10.1371.
14 Jeroudi OM, Alomar ME, Michael TT, El Sabagh A, Patel
VG, Mogahgah O et al. Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs
hospital. Cath Cardiovasc Interv 2014; 841: 637–643.
15 Claessen BE, van der Schaff RJ, Verouden NJ, Stegenga
NK, Engstrom AE, Sjauw KD et al. Evaluation of the effect
of a concurrent chronic total occlusion on long-term
mortality and left ventricular function in patients after
primary percutaneous coronary intervention. JACC
Cardiovasc Interv 2009; 2: 1128–1134.
16 Claessen BE, Dangas GD, Weisz G, Witzenbichier B,
Guagliumi G, Mockel M et al. Prognostic impact of a
chronic total occlusion in a non-infarct -related artery in
patients with ST-segment elevation myocardial infarction: 3 -year results from the HORIZONS-AMI trial. Eur
Heart J 2012; 33: 768–775.
17 Tajstra M, Pyka I, Gorol J, Pres D, Gierlotka M, Gadula-
Gacek E et al. Impact of chronic total occlusion of the
coronary artery on long-term prognosis in patients with
ischemic systolic heart failure: insights from the
COMMIT-HF registry. JACC Cardiovasc Interv 2016; 9:
1790–1797.
18 Strauss BH, Knudtson MI, Cheema A, Galbraith PD, Elbaz-
Greener G, Abuzeid W et al. The Canadian multicenter
CTO registry:10 year follow-up results of CTO revascularization. Circ Cardiovasc Interv 2021; 14: e010546.
19 Lombardi WL. The final frontier of percutaneous coro-
nary intervention-coronary chronic total occlusions.
Interv Cardiol Clin 2012; 1: 9–10.
20 Topaz O. Editorial. The impenetrable CTO: in support of
enhanced antegrade recanalization. Cath Cardiovasc
Interv 2009; 73: 955–960.
21 Topaz O. Editorial. CTO revascularization: obstacles and
options in balloon nonpenetrable lesions. Cath Cardiovasc
Interv 2017; 90: 21–22.
22 Christofferson RD, Lehmann KG, Martin GV et al. Effect
of chronic total coronary occlusion on treatment strategy.
Am J Cardiol 2005; 95: 1088–1091.
23 Onishi T, Onishi Y. Percutaneous coronary interventions
in resistant chronic total occlusions -a Japanese perspective.
In: Topaz O (ed). Debulking in Cardiovascular Interventions
and Revascularization Strategies-Between the Rock and the
Heart. 2022, London,UK: Elsevier. 456–476.
24 Rawlins J, Jehangir D, Talwar S, O’Kane P. Coronary inter-
vention with the excimer laser: review of the technology
and outcome data. Interv Cardiol Rev 2016; 11: 27–32.
25 Rana OA, Talwar S, O’Kane P. Excimer coronary laser
atherectomy during percutaneous coronary intervention
CHAPTER 22 Laser Revascularization in Coronary CTO 201
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
of complex lesions: balloon failures, chronic total occlusions and under-expanded stents. In: Topaz O (ed).
Lasers in Cardiovascular Interventions. 2015, London,
UK: Springer-Verlag. 31–53.
Harding SA, Wu EB, Lo S, Lim ST, Ge L et al. A new
26
algorithm for crossing chronic total occlusions from the
Asia Pacific chronic total occlusions club. JACC
Cardiovasc Interv 2017; 10: 2135–2143.
27
Galassi AR, Werner GS, Boukhris M, Azzalini L,
Mashayekhi K, Carlino M et al. Percutaneous recanalization of chronic total occlusions: 2019 consensus document from the EuroCTO club. EuroIntervention 2019; 15:
198–208.
28
Olorunfemi O, Alfonso CE. Revascularization of complex
coronary lesions: the importance of vessel and plaque preparation strategy. In: Topaz O (ed). Debulking in Cardiovas cular
Interventions and Revascularization Strategies-Between the
Rock and the Heart. 2022, London, UK: Elsevier. 181–220.
Tanabe M. Does successful chronic total occlusion revas-
29
cularization fail to improve long term survival? Cath
Diagn Ther 2017; 7(Suppl. 2): S95–S97.
Wu KZ, Huang ZH, Zhong ZH, Liao HT, Zhou Y, Luo BZ
30
et al. Successful treatment of complex coronary chronic
total occlusions improves midterm outcomes. Ann Transl
Med 2019; 7: 194–204.
31
Strauss BH, Shuvy M, Wijeysundera HC.
Revascularization of chronic total occlusions: time to
reconsider? J Am Coll Cardio 2014; 64: 1281–1289.
32 Sapontis J, Salisbury AC, Yeh RW, Cohen DJ, Hirai T,
Lombardi W et al. Early procedural and health status
outcome after chronic total occlusion angiography: a
report from the OPEN-CTO registry. JACC Cardiovasc
Interv 2017; 10: 1523–1534.
33
Wijeysundera HC, Noris C, Pefer P, Galbraith PD,
Knudtson MI, Wolff R et al. Relationship between initial
treatment strategy and quality of life in patients with
coronary chronic total occlusions. Eurointervention 2014;
9: 1165–1172.
34 Thakker P, Frogge N, Thangam M, Lasala J. Abrasion,
grinding, pulverization, vaporization, and extraction:
debulking options for percutaneous interventions of calcified coronary lesions. In: Topaz O (ed). Debulking in
Cardiovascular Interventions and Revascularization
Strategies-Between the Rock and the Heart. 2022,
London,UK: Elsevier. 71–100.
35 Einstein A. Zur Quantentheorie der Strahlung (On the
Quantum Theory of Radiation). Physikalische Zeitschrift
2017; 18: 121.
Topaz O. Plaque removal and thrombus dissolution with
36
pulsed wave lasers’ photoacoustic energy-biotissue interactions and their clinical manifestations. Cardiology
1996; 87: 384–391.
37 Topaz O, Minisi AJ, Mohanty L, Baily N, Titus JL. In-vivo
effect of coronary laser angioplasty on atherosclerotic
plaques: histopathologic analysis. Cardiovasc Pathol
2001; 10: 223–228.
38 Topaz O, Rozenbaum EA, Schumacher A, Luxenberg
MG. Solid-state, mid-infrared laser facilitated coronary
angioplasty: clinical and quantitative angiographic results
in 112 patients. Lasers Surg Med 1996; 19: 260–272.
Topaz O, McIvor M, Stone GW, Krucoff MW, Perin E,
39
Foschi AE et al. Acute results, complications and effect of
lesion characteristics on outcome with the solid-state,
pulsed-wave, mid-infra-red laser angioplasty system:
final multicenter report. Laser Surg Med 1998; 22:
228–239.
40
Topaz O, Ebersole D, Dahm J, Das T, Maydoon H, Perin
EC. Excimer laser revascularization: current indications,
applications and techniques. Lasers Med Sci 2001; 16:
72–77.
41
Topaz O. Laser debulking of complex and resistant ath-
erosclerotic plaques in acute coronary syndromes. In:
Topaz O (ed). Debulking in Cardiovascular Interventions
and Revascularization Strategies-Between the Rock and
the Heart. 2022, London, UK: Elsevier. 271–298.
42
Topaz O. Editorial. Excimer laser-the great plaque
modifier. Cardiovasc Revasc Med 2019; 20: 271–272.
Topaz O, Vetrovec GW. Interventional rounds: rescue
43
revascularization of tandem occluded intracoronary
stents: technique and equipment. Cath Cardiovasc Diagn
1996; 39: 185–190.
44
Topaz O, Bailey NT, Mohanty PK. Application of
solid-state, pulsed-wave, mid-infrared laser for percutaneous revascularization in heart transplant patients. J
Heart Lung Transplant 1998; 17: 505–510.
45 Topaz O, Cowley MJ, Mohanty PK, Vetrovec GW.
Interventional rounds: percutaneous revascularization
modalities for heart transplant recipients. Cath Cardiovasc
Interv 1999; 46: 227–237.
46
Topaz O, Minisi AJ, Bernardo NL, Alimar R, Ereso A,
Shah R. Effectiveness of excimer laser angioplasty in
patients with acute coronary syndromes in those withversus-those without normal left ventricular ejection
fraction. Am J Cardiol 2003; 91: 797–802.
Ben-Dor I, Waksman R. Laser atheroablation in chal-
47
lenging coronary lesions. In: Topaz O (ed). Lasers in
Cardiovascular Interventions. 2015, London, UK:
Springer-Verlag. 97–102.
48
Moskowitz WB, Titus JL, Topaz O. Excimer laser ablation
for valvular angioplasty in pulmonary atresia and intact
ventricular septum-clinical and histopathologic findings.
Lasers Surg Med 2004; 35: 327–335.
49 Topaz O. Editorial. On the hostile massive thrombus and
means to eradicate it. Cath Cardiovasc Intervent 2005; 65:
280–281.
50 Topaz O, Minisi AJ, Bernardo NL et al. Alterations of
platelet aggregation kinetics with ultraviolet laser
emission: the stunned platelet phenomenon. Thromb
Haemost 2001; 86: 1087–1093.
51 Topaz O. Editorial. Ischemic coronary syndromes and
SVG interventions – do 2b/3a inhibitors miss the target?
Cath Cardiovasc Interven 2007; 69: 630–631.
52 Moritz MW, Ombrellino M, Agis H. Laser treatment of
venous system. In: Topaz O (ed). Lasers in Cardiovascular
Interventions. 2015, London, UK: Springer-Verlag. 321–336.
53 Taylor KD, Reiser C. From laser physics to clinical uti-
lization: design and ablative properties of cardiovascular laser catheters. In: Topaz O (ed). Lasers in
Cardiovascular Interventions. 2015, London, UK:
Springer-Verlag. 1–14.
202 PART IV Wires Technique
54 Taylor K, Harlan K, Branan N. Small 0.7mm diameter laser
catheter for chronic total occlusions, small vessels, tortuous
anatomy, and balloon resistant lesions-development and
initial experience. Eurointervention 2006; 2: 265–269.
55 Topaz O, Perin EC, Jesse RL et al. Power thrombolysis in
acute coronary syndromes. Angiology 2003; 54:
457–468.
56 Alharbi W, Bilodeau L. Excimer laser revascularization of
calcified lesions. In: Topaz O (ed). Lasers in Cardiovascular
Interventions. 2015, London, UK: Springer-Verlag.
83–95.
57 Topaz O, Ebersole D, Das T, Alderman E, Madyoon H,
Vora K et al. Excimer laser angioplasty in acute myocardial infarction-the CARMEL multicenter study. Am J
Cardiol 2004; 93: 694–791.
58 Topaz O, Bernardo NL, Shah R et al. Effectiveness of
excimer laser coronary angioplasty in acute myocardial
infarction or in unstable angina pectoris. Am J Cardiol
2001; 87: 849–855.
59 Das T. Excimer laser angioplasty for CTOs. Endovasc
Today 2003; 10: 1–4.
60 Topaz O. Laser. In: Topol EJ (ed). Textbook of Interventional
Cardiology, 4th ed. 2003, Philadelphia: WB Saunders.
675–703.
61 Topaz O, Polkampally PR, Rizk M et al. Excimer laser deb-
ulking for percutaneous coronary intervention in left main
coronary artery disease. Lasers Med Sci 2009; 24: 955–960.
62 Topaz O, Polkampally PR, Topaz A et al. Utilization of
excimer laser debulking for critical lesions unsuitable for
standard renal angioplasty. Lasers Surg Med 2009; 41:
622–627.
63 Strauss BH, Elbaz-Greener G. Chronic total occlusion:
biology and revascularization. In: Topaz O (ed). Debulking
in Cardiovascular Interventions and Revascularization
Strategies-Between the Rock and the Heart. 2022,
London,UK: Elsevier. 413–438.
64 Sapontis J, Grantham JA, Marso SP. Excimer laser ather-
ectomy to overcome intraprocedural obstacles in chronic
total occlusion percutaneous intervention: case examples. Cath Cardiovasc Interv 2015; 85: E83–E89.
65 Ojeda S, Azzalini L, de Lezo JS, Johal GS, Gonzalez R,
Barmen N et al. Excimer laser coronary atherectomy for
uncrossable coronary lesions. A multicenter registry. CCI
2021; 98: 1241–1249.
66 Topaz O. Editorial. Debulking uncrossable lesions with
excimer laser: the interplay between device performance
and limitations. Cath Cardiovasc Interv 2021; 98:
1250–1251.
67 Anantharam B, Shaukat N, Ehtisham J. Use of excimer
laser coronary atherectomy for the revascularization of
coronary artery chronic total occlusions after failure to
cross with balloon. Circulation 2013; 128: Abstract
16634.
68 Mohandes M, Rojas S, Moreno C, Fernandez F, Fuerrtes
M, Guarinos J. Excimer laser in percutaneous coronary
intervention of device uncrossable chronic total and
functional occlusions. Cardiovasc Revasc Med 2020; 21:
657–660.
69 Li H, Ai H, Zheng N, Tang G, Yang G, Zhao Y et al. The
therapeutic effects of excimer laser coronary atherectomy therapy for in-stent restenosis chronic total occlusions. Cardiovasc Disord 2021; 21: 399–408.
70 Eliaz R, Topaz O, Danenberg HD. The spectrum of clinical
presentations and management options for the treatment
of degenerative atherothrombotic disease of saphenous
vein grafts. In: Topaz O. (ed) Cardiovascular Thrombus.
From Pathology and Clinical Presentations to Imaging,
Pharmacotherapy and Interventions. 2018, London, UK:
Elsevier Academic Press. 377–398.
71 Topaz O. The thrombus containing lesion. In: Topol EJ,
Teirstein PS (eds). Textbook of Interventional Cardiology,
7th ed. 2015, Philadelphia: Elsevier. 439–463.
72 Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y,
Muramatsu T et al. Predicting successful guidewire
crossing through chronic total occlusion of native
coronary lesions within 30 minutes: the J-CTO score as
a difficulty grading and time measurement tool. JACC
Cardiovasc Interv 2011; 4: 213–221.
73 Rawlins J, Din J, Talwar S, O’Kane P. Coronary interven-
tion with the excimer laser: review of the technology and
outcome data. Interv Cardiol Rev 2016; 11: 27–32.
74 Serruys PW, Hamburger JN, Kooler JJ et al. The TOTAL
trial. Euro Heart J 2000; 21: 1797–1805.
75 Perin EC, Leite-Sarmento R, Silva GV et al. “Wireless”
laser recanalization of chronic total coronary occlusions.
J Invas Cardiol 2001; 13: 401–405.
76 Banerjee S, Alaiti A. Complications of percutaneous coro-
nary interventions in calcified lesions: causes, recognition,
management and how to avoid. In: Topaz O (ed). Debulking
in Cardiovascular Interventions and Revascularization
Strategies-Between the Rock and the Heart. 2022, London,UK:
Elsevier. 311–220.
77 Sintek M, Coverstone E, Bach R, Zajarias A, Lasala J,
Kurz H et al. Excimer laser coronary angioplasty in coronary lesions: use and safety from the NCDR/CATH regis try. Cir Cardiovasc Interv 2021; 14(7): e010061. doi:
10.1161/CIRCINTERVENTIONS.120.010061.
78 Topaz O. Editorial. Whose fault is it? Notes on “true”
versus “pseudo” laser failure. Cath Cardiovasc Diagn
1995; 36: 1–4.
79 Tcheng JE. Saline infusion in excimer laser coronary
angioplasty. Semin Interv Cardiol 1996; 1: 135–141.
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CHAPTER 23
How to Handle Subintimal
Dissections
Pratik B. Sandesara* & William J. Nicholson
Emory Heart and Vascular Center, Division of Cardiology, Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
* Corresponding author
Introduction
A chronic total occlusion (CTO) is present in up to
20% of patients undergoing diagnostic coronary
angiography [1]. Successful CTO percutaneous
coronary intervention (PCI) improves anginal
symptoms, quality of life, left ventricular ejection
fraction, arrhythmias, and possibly mortality [2].
Significant advances in techniques and equipment
have led to contemporary CTO PCI success rates
exceeding 90% at experienced centers [2–4]. An
algorithmic approach to CTO PCI using novel
crossing strategies has led to improved success and
decreased complication rates [5–8]. There are 4
CTO crossing strategies that can be used (Figure
23.1): (1) antegrade wiring (AW), (2) antegrade dissection and re-entry (ADR), (3) retrograde wiring
(RW), (4) retrograde dissection and re-entry (RDR)
[9]. While antegrade wiring is the most commonly
used CTO crossing technique, more anatomically
complex CTOs require leveraging the extraplaque
space (formerly “subintimal” space) [3, 10]. In this
chapter, we provide an overview of the contemporary dissection and re-entry techniques for CTO
revascularization.
Histopathology of CTOs
Coronary arteries consist of 3 concentric layers –
intima, media, and adventitia. These layers are separated by the internal and external elastic lamina.
Atherosclerosis and plaque formation occurs in the
intima. CTOs develop after thrombotic occlusion
and subsequent deposition of calcium, proteoglycan, and collagen [11]. The proximal and distal
caps are comprised of higher concentration of
dense collagen-rich fibrous tissue [11]. Short duration CTOs are comprised of soft plaque with loose
fibrous tissue and microvascular channels whereas
longer duration and post CABG CTOs consist of
dense fibrous tissue and large fibro-calcific areas
without neovascular channels [12]. As a result,
shorter duration CTOs are more likely to allow wire
passage through intimal plaque (“intraplaque”
tracking) into the distal true lumen whereas hard
plaque is more likely to deflect the guidewire into
the extraplaque space [11]. The extraplaque space
or formerly the subintimal space refers to the space
between the internal elastic lamina and tunica
media. There are three anatomical locations of
importance for CTO PCI (Figure 23.2): (1)
Intraplaque space (wire tracking within the occlusive intimal plaque) (2) extraplaque space (wire
tracking outside the plaque but within the adventitia), and (3) outside the adventitia (perforation or
vessel exit) [11, 13]. Contemporary dissection and
re-entry techniques involve blunt dissection in the
extraplaque space to circumvent resistant and long
CTO segments. The extraplaque space has low
resistance to longitudinal and radial dissections
which makes traversing long, calcified CTO segments easier [11] (Figure 23.3). The adventitia is
more distensible and has more tensile strength than
the intima and media which allows for the blunt
dissection within the vessel architecture although
penetrative wires can still exit the vessel [14].
Chronic Total Occlusions: A Guide to Recanalization, Third Edition. Edited by Ron Waksman and Shigeru Saito.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
203
204 PART IV Wires Technique
Figure 23.1 CTO Crossing Strategies. The 4 contemporary
CTO crossing strategies are illustrated: (1) Antegrade
Extraplaque crossing strategies
Although several crossing strategies exist, they are
complementary and often multiple techniques are
needed for successful CTO PCI. AW or antegrade
wire escalation (AWE) remains the most commonly
used CTO crossing technique [3, 4, 10]. AWE
involves starting with low-tip-load, tapered, polymer-jacketed guidewires followed by escalation to
stiffer polymer jacketed or higher tip load non polymer jacketed guidewires to penetrate resistant proximal cap or areas of resistance within the CTO
segment. After advancing through resistant areas,
de-escalation to softer guidewire is recommended.
In anatomically complex CTOs with vessel tortuosity, long occlusion length and calcification, AWE is
less effective and alternate crossing strategies such as
ADR and retrograde approach might be needed.
Dissection and re-entry techniques (antegrade or
retrograde) involve blunt dissection in the extraplaque space to traverse resistant CTO segments and
re-entering the vessel beyond the distal cap. ADR
can be utilized after intentional or unintentional
wiring, (2) Antegrade dissection and re-entry, (3)
Retrograde wiring, (4) Retrograde dissection and re-entry.
extraplaque guidewire position or after failure of retrograde approach. Factors favoring ADR include
long occlusion length ≥ 20 mm, calcification, tortuosity, ambiguous vessel course and presence of large
caliber (≥ 2 mm) distal re-entry zone without major
side branches within the occluded segment or at the
distal cap [7]. Primary retrograde approach should
be considered to help resolve proximal cap ambiguity, bifurcation, or major branch at distal cap and
failed antegrade approach [7].
Contemporary ADR
Contemporary ADR is useful to cross long calcified or
tortuous CTO segments safely using blunt dissection
through the extraplaque space followed by targeted
distal vessel re-entry. ADR involves three main steps:
(1) creating an antegrade dissection and entering the
extraplaque space, (2) crossing the CTO body and, (3)
targeted distal vessel reentry beyond the distal cap.
For successful ADR, management of extraplaque
space and re-entry zone is of utmost importance.
CHAPTER 23 How to Handle Subintimal Dissections 205
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Figure 23.2 Intraplaque and Extraplaque space. This figure shows the anatomic locations of importance for CTO PCI:
intraplaque space and extraplaque space.
206 PART IV Wires Technique
Figure 23.3 Histopathology of the extraplaque space.
Panel A shows proximal true lumen. Panel B shows CTO
site. Panel C shows distal true lumen site collapsed by
Large dissection planes and subsequent large hematoma development in the extraplaque space can lead
to distal vessel compression and limit the efficacy of
re-entry. It is important to limit the size of extraplaque
space and minimize hematoma size to maintain distal
visualization. This can be accomplished by avoiding
antegrade contrast injections to prevent hydraulic dissections, using Trapliners to assist in efficient equipment exchanges or traditional guide extension
catheters to block inflow from the guide catheter/systemic pressures and limiting the size of the knuckle
used for blunt dissection. Time efficiency is key, and
some operators favor an upfront ADR approach to
minimize hematoma formation. Strong guide catheter
support is important for ADR cases to allow delivery
of equipment. Femoral access, large guide catheters (7
Fr or 8 Fr), guide catheter extensions or Trapliners
and side-branch anchoring techniques can be used to
increase support.
extraplaque hematoma. Panel D shows extraplaque
dissection in radial (Solid line) and longitudinal (dotted
line) planes.
Starting a dissection and entering
the extraplaque space
If the proximal CTO cap is well defined and not
ambiguous, AWE should be used to penetrate the
proximal cap. If the initial guidewire enters the extraplaque space, a “knuckle” wire can then be used to
blunt dissect around the CTO in the extraplaque space.
Alternatively, the CrossBoss catheter (Bridgepoint
Medical/Boston Scientific, Minnesota) which is part of
the Bridgepoint system can be used for blunt microdissection. The CrossBoss catheter is a metal-braided,
over-the-wire catheter with a 1 mm rounded, atraumatic hydrophilic-coated distal tip with a torque
device on the proximal end (Figure 23.4). The catheter
is delivered to the proximal cap over a wire. Once the
proximal cap is engaged or the catheter is advanced
beyond the proximal cap after penetrating the cap with
another guidewire, the catheter is advanced using a
CHAPTER 23 How to Handle Subintimal Dissections 207
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Figure 23.4 CrossBoss Catheter. The CrossBoss catheter is a
metal-braided, over-the-wire catheter with a 1
rounded, atraumatic hydrophilic-coated distal tip with a
torque device on the proximal end.
mm
“fast-spin” technique where the catheter is rotated rapidly using the proximal torque device to progress. The
guidewire is retracted and left within the CrossBoss
catheter to prevent blood entry and thrombus formation within the catheter. A potential advantage of
CrossBoss catheter over knuckle wire is that it creates a
smaller and controlled dissection in the extraplaque
space. However, it can be bulky and difficult to advance
in the presence of ambiguous, blunt, or calcified proximal cap, significant tortuosity, and ambiguous vessel
course in the presence of bridging collaterals. With the
availability of dedicated knuckle wires and refinement
in techniques to minimize hematoma formation, the
CrossBoss catheter is infrequently used in contemporary ADR.
Polymer jacketed guidewires (Table 23.1) are most
commonly used as knuckle wires for blunt dissection
in both antegrade and retrograde direction. If the initial guidewire used for antegrade wiring is in the
extraplaque space, a micro catheter is advanced within
the extraplaque space. The original guidewire is then
removed, and a polymer jacketed wire is advanced
through the microcatheter and pushed until it forms a
loop. The tip of the guidewire can be shaped as an
umbrella handle to facilitate knuckling. The knuckle
can be rotated as it is pushed in the antegrade direction only (avoid rotating the knuckle in the retrograde
direction to minimize risk of entanglement). Often,
the operator needs to push hard to advance the
knuckle and use the microcatheter for support. The
knuckle can be withdrawn and re expressed as needed
Table 23.1
used as knuckle wires.
Commonly used polymer jacketed guidewires
Guidewire Tip load
(g)
Fielder XT (Asahi Intecc) 0.8 Small
Fighter (Boston Scientific) 1.5 Small
Bandit (Teleflex) 0.8 Small
Gladius Mongo (Asahi Intecc) 3 Small
Pilot 200 (Abbott Vascular) 4.1 Large
Knuckle
size
to advance through the extraplaque space. If there is
difficulty in forming a knuckle, microcatheter position in the extraplaque space within vessel architecture should be confirmed. The position of the knuckle
wire within the vessel architecture should be confirmed in orthogonal views prior to tracking with the
microcatheter to avoid following wire exit with the
microcatheter. Limiting extraplaque hematoma formation is key for successful reentry in the distal true
lumen. Using guide extension or Trapliner to block
blood entry into the extraplaque space and avoiding
antegrade injections after dissection to prevent
hydraulic propagation (removing the contrast injection syringe from the antegrade guide manifold) are
important once antegrade dissection is started.
Troubleshooting getting started:
Proximal cap disambiguation
Starting a proximal dissection can often be difficult,
especially in the setting of an ambiguous or impenetrable proximal cap. The options for proximal cap disambiguation include use of coronary computed
tomographic angiography (CCTA) (Figure 23.5) or
intravascular ultrasound (IVUS) (Figure 23.5) to
identify the proximal cap and “move the cap” technique [15] (Figure 23.6). The move the cap techniques
include: (1) scratch-and-go, (2) balloon-assisted
subintimal entry (BASE), (3) side-BASE and (4)
Carlino (extraplaque contrast injection) [8].
The “scratch-and-go” technique (Figure 23.6)
involves using a stiff-tapered tip wire to penetrate the
intimal layer proximal to the ambiguous or impenetrable cap to access the extraplaque space [8]. After confirming wire position within the vessel architecture
using cine angiography without contrast injection (in
order to visualize vessel calcification), the microcatheter tip is advanced 1 to 2
space. Then the stiff wire is exchanged for a polymer
jacketed wire and knuckled. It’s important to not
advance the stiff wire for long distances and not track
equipment until wire position within the vessel architecture is confirmed in order to avoid vessel perforation with the subsequently tracked micro catheter.
The BASE power knuckle technique (Figure 23.6) is
another tool to gain access into the extraplaque space
and relies on having sufficient vessel length proximal
to the proximal cap to inflate a balloon (likely not feasible in ostial or very proximal lesions) [8]. A workhorse wire is advanced to the proximal cap and then a
1:1 sized preferably noncompliant (NC) balloon is
advanced into the vessel over the wire and placed
proximal to the proximal cap. A microcatheter is
placed next to the balloon with a polymer jacketed
wire inside. The NC balloon is inflated and deflated
mm into the extraplaque
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