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Complications

From all that has been discussed in the previous chapters of this book the reader will have already realized that chronic total occlusion (CTO) interventions are among the most complex percutaneous coronary interventions (PCIs). In this chapter we perform a thorough review of coronary and noncoronary complications that may occur in the course of CTO PCI. Awareness of the potential complications constitutes the cornerstone of their…

Stenting of Chronic Total Occlusion Lesions

11.1 Stent Type Restenosis rates after chronic total occlusion (CTO) stenting can be relatively high. Bare metal stents (BMS) significantly reduce restenosis compared to balloon angioplasty alone, yet the incidence of restenosis and reocclusion remains very high. In the Total Occlusion Study of Canada (TOSCA) 1 trial, the 6-month incidence of restenosis and reocclusion with BMS exceeded 50% and 10%, respectively. First-generation drug-eluting stents (DES) significantly…

Radiation Management During Chronic Total Occlusion Percutaneous Coronary Intervention

Radiation skin injury ( Fig. 10.1 ) is a rare complication of any invasive cardiac procedure, but is more likely to occur in the setting of complex procedures, such as chronic total occlusion (CTO) percutaneous coronary intervention (PCI), where large doses of radiation are often used. Radiation skin injury can lead to severe consequences for the patient, such as painful, nonhealing ulcers that may require months…

Putting It All Together: The Hybrid Approach

The optimal approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) continues to evolve. Although various CTO crossing techniques have been developed (antegrade wire escalation; antegrade dissection/reentry; and retrograde, as described in Chapter 4, Chapter 5, Chapter 6 ), there are different schools of thought about the relative merits and priority of each of those approaches. In January 2011 several high-volume CTO operators convened in…

The Retrograde Approach

6.1 Historical Perspective The retrograde technique differs from the standard antegrade approach in that the occlusion is approached from the distal vessel, advancing a wire against the original direction of blood flow (i.e., retrograde). The guidewire is advanced into the artery distal to the occlusion through either a bypass graft or through collateral channels. This approach differs from the antegrade approach, in which all equipment is…

Antegrade Dissection/Reentry

Antegrade dissection/reentry is a safe and efficient strategy for crossing long chronic total occlusions (CTOs), as outlined in the hybrid CTO crossing algorithm ( Chapter 7 ). Antegrade dissection takes advantage of the distensibility of the subintimal space for traversing the occlusion rapidly and safely, concentrating subsequent efforts in crossing back into the distal true lumen (reentry). In the past, distal true lumen reentry was problematic…

Antegrade Wire Escalation: The Foundation of Chronic Total Occlusion Percutaneous Coronary Intervention

Antegrade wire escalation is the simplest and most widely used chronic total occlusion (CTO) crossing technique. At least 50% of CTO interventions are currently successfully recanalized using antegrade wire escalation. Familiarity and confidence with this technique provides the foundation upon which all other CTO percutaneous coronary intervention (PCI) techniques (antegrade dissection/reentry and retrograde) are built. Wire escalation may be most helpful in short occlusions (i.e., <20…

The Basics: Timing, Dual Injection, Studying the Lesion, Access, Anticoagulation, Guide Support, Trapping, Pressure and Electrocardiogram Monitoring

3.1 Timing In general, chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) should not be performed ad hoc in order to : a. Allow time for thorough procedural planning and preparation for both the operator and the cardiac catheterization laboratory staff, which is essential for success. b. Minimize the amount of contrast administered and radiation dose. c. Minimize patient and operator fatigue. d. Allow time to…

Equipment

2.1 Introduction One of the most frequently asked questions about chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially from programs early in the learning curve, is, “what equipment do I really need?” Although many operators would like to have everything available, the reality is that equipment cost and space limitations require prioritization. Here are some criteria to use when deciding the must-haves for CTO PCI:…

When to Perform Chronic Total Occlusion Interventions

1.1 Chronic Total Occlusion Definition A coronary chronic total occlusion (CTO) is defined as 100% occlusion in a coronary artery with noncollateral thrombolysis in myocardial infarction (TIMI) 0 flow of at least 3 month duration. The duration of occlusion may be difficult to determine if there has been no prior angiogram demonstrating presence of the CTO. In such cases estimation of the occlusion duration is based…

Ventricular Assist Device Therapy in Advanced Heart Failure

Common Misconceptions ■ Left ventricular recovery is common after placement of left ventricular assist devices (LVAD). ■ Patients who are candidates for heart transplantation should never have an LVAD placed. ■ Palliative care consultation is inappropriate for patients being considered for a destination therapy LVAD. ■ The development of reliable left ventricular assist devices (LVADs) has revolutionized heart failure (HF) management. ■ In the cardiac intensive…

Temporary Mechanical Circulatory Support Devices

Common Misconceptions ■ An intraaortic balloon pump should be placed in all patients with acute myocardial infarction complicated by shock. ■ Impella has been demonstrated in randomized controlled trials to improve survival in cardiogenic shock. ■ Impella has been demonstrated in randomized controlled trials to improve survival in high-risk percutaneous coronary intervention. ■ Clinicians practicing in the cardiac intensive care unit are challenged with increasingly complex…

Invasive Hemodynamic Monitoring

Common Misconceptions ■ Invasive hemodynamic monitoring should be used in all patients in the Cardiac Intensive Care Unit (CICU). ■ The pulmonary capillary wedge pressure is always a surrogate for left ventricular end-diastolic pressure. ■ Mixed venous oxygen saturation can be sampled from any right heart chamber. ■ Hemodynamics is derived hydrodynamics, the physics of the motion and action of water. ■ The dimensions of hemodynamics…

Pericardial Tamponade

Common Misconceptions ■ Pericardial tamponade is an echocardiographic diagnosis. ■ Large, stable pericardial chronic effusions will not progress to cardiac tamponade. ■ Size is the critical factor in determining the hemodynamic effects of a pericardial effusion. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here

Temporary Cardiac Pacing

Common Misconceptions ■ The indication for a pacemaker is solely based on the patient’s heart rate. ■ Transcutaneous pacing may be performed on conscious patients without sedation. ■ A temporary transvenous pacemaker may be placed from the femoral vein without fluoroscopic guidance. Bradyarrhythmias ■ Bradyarrhythmias can be classified into five groups: ■ Sinus bradycardia ■ Sinus pause ■ Junctional rhythm ■ Sinoatrial (SA) exit block ■…

Central Venous and Arterial Access Procedures

Common Misconceptions ■ The Allen test allows accurate assessment of the arterial blood supply of the hand. ■ Dark blood color and the absence of pulsatility are sufficient to confirm venous access. ■ The absence of a femoral hematoma rules out the possibility of a retroperitoneal hemorrhage Central Venous Access: General Principles and Preparation ■ Patients in the Cardiac Intensive Care Unit (CICU) require reliable intravenous…

Antidysrhythmic Electrophysiology and Pharmacotherapy

Common Misconceptions ■ Lidocaine is used to prevent ventricular tachycardia following acute myocardial infarction. ■ Only β-blockers with β 2 selectivity precipitate bronchospasm. ■ Amiodarone should be avoided in patients with left ventricular dysfunction. ■ Cardiac arrhythmias are common in critically ill patients. ■ Patients with coronary artery disease (CAD), heart failure (HF), respiratory failure, or renal failure are at risk for different arrhythmias, and antidysrhythmic…