Manual of Coronary Chronic Total Occlusion Interventions

Emmanouil S. Brilakis, MD, PhD, FACC, FAHA, FESC, FSCAI Dr. Brilakis is Director of the Center for Complex Coronary Interventions at the Minneapolis Heart Institute and the Center for. After graduating from Lycee Leonin de Patissia, Dr. Brilakis received his medical degree from the National Kapodistrian University of Athens, Greece. He trained in Internal Medicine, Cardiovascular Diseases and Interventional Cardiology at the Mayo Clinic. He also completed a Masters in Clinical Research at the Mayo Clinic and a PhD in Clinical Research at the National Kapodistrian University of Athens, Greece. He served as Director of the VA North Texas Healthcare System Cardiac Catheterization Laboratories from 2004 to 2016. Dr. Brilakis leads a large clinical trial group investigating treatment of chronic total occlusions, prevention and treatment of saphenous vein graft disease, prevention and management of complications, intracoronary imaging, antiplatelet treatment optimization post coronary stenting, radiation safety in the catheterization laboratory, and implementation of novel technologies in healthcare. He is Associate Editor for Circulation and on the editorial board of several other journals and on the Board of Directors of the Cardiovascular Innovations Foundation. He has authored or co-authored over 600 manuscripts and the Manual of CTO Interventions, now in its 2nd edition. He and is lecturing and proctoring at several institutions in the United States and abroad.

Dedication

List of Contributors

Foreword

1. CTO Interventions: Definition, Prevalence, Indications, Guidelines

1.1 CTO Definition

1.2 Prevalence of CTOs

1.3 Indications and Potential Clinical Benefits of CTO PCI

1.4 Guidelines for CTO PCI

1.5 Appropriateness Use Criteria in CTO PCI

1.6 Contraindications to CTO PCI

1.7 Summary and Conclusions

References

2. Equipment

2.1 Sheaths

2.2 Guide Catheters

2.3 Microcatheters

2.4 Guidewires

2.5 Dissection/Re-Entry Equipment

2.6 Snares

2.7 “Uncrossable-Undilatable” Lesion Equipment

2.8 Intravascular Ultrasound

2.9 Complication Management Equipment

2.10 Radiation Protection

2.11 The “CTO cart”

References

3. The Basics: Timing, Dual Injection, Studying the Lesion, Access, Anticoagulation, Guide Support, Trapping

3.1 Timing

3.2 Dual Injection

3.3 Studying the Lesion

3.4 Vascular Access

3.5 Anticoagulation

3.6 Techniques to Increase Guide Catheter Support (Large Bore Guide, Active Guide Support, Guide Catheter Extensions, Anchor Techniques

3.7 Trapping

References

4. Antegrade Wire Escalation: The Foundation of CTO PCI

4.1 Special Situations

References

5. Antegrade Dissection/Re-entry

5.1 Knuckle Wire

5.2 CrossBoss

5.3 Stingray-Based Re-entry

5.4 Wire-Based Re-entry

References

6. The Retrograde Approach

6.1 Historical Perspective

6.2 Advantages of the Retrograde Approach

6.3 Special Equipment

6.4 Step-by-Step Description of the Procedure

6.5 Retrograde True Lumen Puncture

6.6 Retrograde Dissection/Re-entry

6.7 Antegrade Crossing

6.8 Special Retrograde CTO PCI Scenarios

References

7. Putting it all Together: The “Hybrid” Approach

7.1 Description of the “Hybrid” Algorithm

7.2 Impact of the “Hybrid” Approach

References

8. “Balloon Uncrossable” CTOs

8.1 Simultaneous Use of Strategies

References

9. “Balloon Undilatable” CTOs

9.1 Special Case Scenario: Stented “Balloon Undilatable” Lesions

References

10. Radiation Management During CTO PCI

10.1 Why is Radiation Management Important?

10.2 Essentials of Radiation Dose Management

10.3 Conclusions

References

11. Stenting of CTO Lesions

11.1 Stent Type

11.2 Stent Optimization

11.3 Antiplatelet Therapy After CTO Stenting

References

12. Complications

12.1 Acute Complications

12.2 Long-Term Complications

12.3 Conclusion

References

13. How to Build a Successful CTO Program

References

Appendix 1. Equipment Commonly Utilized in CTO Interventions

Appendix 2. Commonly Used Acronyms in CTO Interventions

Index