Handbook of Chronic Total Occlusions PDF

Preface

Remarkable progress has been achieved over the past few years in the area of chronic total occlusion (CTO) revascularization. Occurrence of a CTO within a patient's coronary anatomy has been traditionally considered with skepticism from interventional cardiologists. This has been due to the indications and outcomes of percutaneous revascularization as well as the technical difficulties encountered in CTO procedures. Several advances have occurred in all these areas and we had the pleasure to work with a team of worldwide experts in order to present them in a concise and practical way through the present handbook.

The first part of this handbook presents the thought process regarding clinical indications, angiographic stratification of technical difficulty, and the overall planning required before a CTO revascularization in undertaken. The basis interventional concepts of vascular access, guide catheter and wire selection, and manipulation are presented. This part is very critical, since successful wire crossing is the most important step for subsequent equipment passage and a successful procedure. Presentation of these topics extends throughout many chapters, all of which include many case examples with step-by-step explanations of the techniques undertaken. All these three topics are interrelated, since any one of them can ultimately affect wire crossing; all chapters clearly discuss alternative approaches, and corrective pathways and justify the technical options demonstrated in the case examples in a way to promote the necessary synergy among them.

Special attention has been paid to the active support, intravascular ultrasound guidance, and retrograde techniques that have been pioneered by Japanese operators over the past few years. We believe that the careful selection of examples and the painstaking instructions through every single detail of technical principles and related ‘tips and tricks' are seminal to CTO procedure teaching.

Following successful crossing, it is still possible that subsequent equipment may not be able to advance through the occlusion. Succeeding in this step is equally important to guidewire crossing of the CTO, and is therefore analyzed at length in this handbook. The instruction provided starts from the importance of vascular access and guide catheter selection, and proceeds to active support techniques (e.g. anchoring balloon) and use of special catheters (e.g. Tornus, excimer laser, etc.), always using telling case examples. The issue of debulking is also presented, including indications and technical suggestions. Finally, the role of drugeluting stent implantation is presented from two authors in order to best represent the global thought process regarding the long-term procedural outcome.

An operator tackling a CTO lesion needs to be prepared throughout the procedure to deal with certain specific complications. Steps towards avoiding complications by appropriately choosing when to interrupt a CTO procedure (and when to retry later) are discussed in a dedicated chapter. A more rounded review of CTO-specific complications includes many technical details on the ways to manage various types of perforations, as well as the reversal of anticoagulation issues.

Since CTO lesions can also be encountered in the peripheral vascular circulation, we have included dedicated chapters on iliofemoral occlusions, with technical details both on wire crossing as well as on appropriate use of assisting devices (e.g. for distal lumen reentry), again with step-by-step instruction through many selected case examples.

Several ‘niche' devices for both coronary and peripheral CTO lesions are presented concisely in dedicated chapters that analyze the current indications, device description, and their technical details utilized in the case demonstrations.

Finally, our general approach for CTO procedure training is outlined with respect to program and individual requirements. Traditionally, training for CTO has been difficult; recent advances can be disseminated though participation in focused courses, preceptorship programs, wider inclusion of CTO in the formal training curriculum, use of simulation, and the work towards building a ‘CTO team' of doctors, assisting physicians (trainees) nurses, and technologists within the cardiac catheterization laboratory.

Clearly, we could have expanded each one of the above topics to a much greater length. However, we felt that the concise handbook type of presentation was the most appropriate for the first introduction of this entire subject to the busy interventional cardiology community. We hope that the readers find that we lived up to their expectations.