1. CTO anatomy, histology and physiopathology
2. CTO definitions and epidemiology
3. Clinical indication and patient selection for CTO recanalization
4. Clinical presentation and revascularization strategies
5. Collateral circulation role and its assessment
6. Factors related to the success and failure of recanalization: clinical and angiographic predictors
7. Basic principles and material for CTO recanalization
8. Antegrade technique (a cases with oriented approach)
9. The CROSSER catheter
10. Other devices fro antegrade approach
11. The retrograde approach
12. Stent for CTO lesions
13. The PCI strategy after crossing and dilating the lesion: which stent size to use, how to treat small vessels, how to treat bifurcation lesions and how to treat ostial lesions
14. When to stop procedure, retry or perform a second attempt
15. CTO procedural complications
16. Radiation exposure
17. Contrast medium use during PCI: how to decrease the risk of contrast induced nephropathy (CIN)
18. Operator training and CTO center organization and requirements: the EuroCTO Club
Approximately 30 to 40% of patients with coronary artery disease shows at angiography at least one occluded artery. Only 7 to 15% of chronic total occlusion (CTO) are treated with percutaneous coronary intervention. Thus, the majority of occluded vessels are not treated with coronary angioplasty but with coronary artery by-pass graft or medical therapy. Various studies have indicated the presence of CTO as the most important factor for selecting bypass as the choice of coronary vascular revascularisation.
CTO lesions treatment still represents the last obstacle for the interventionalist. There is increasing evidence that successful occluded coronary vessel revascularisation of subtending viable myocardium is associated with survival enhancement, improvement of left ventricular function and quality of life. Although the most important factor of procedural failure is due to the inability to cross the occlusion with the guide wire and to reach the distal true lumen end, other factors may prevent balloon crossing and final recanalisation. Remarkable progress has been achieved over the past few years pioneered by Japanese interventional cardiologists. New guide wires, techniques and dedicated devices have led to higher procedural success rate. Nowadays more than 80% of recanalization may be achieved in the hands of expert operators. Even in this lesion subset, drug eluting stents significantly reduce the incidence of restenosis and reocclusions, also providing improved long-term patency to these complex procedures.
Considering all the dynamic changes and difficulties about these procedures, my intention with this handbook was to provide a meaningful and concise practical guide to the interventional cardiologist. Improving their skills of CTO revascularisation and their good overall experience in the coronary angioplasty field.
The first part of the handbook deals with anatomy and histopathology of CTO, also its epidemiology and definition.
The second part deals with clinical indication to CTO revascularisation, including non-invasive functional imaging based patient selection, the role of collateral circulation and recanalization success related predictive factors.
The third part deals with basic principles and different materials for CTO recanalisation. Different antegrade approaches, different devices and retrograde approaches are described with practical case-based scenarios in detail.
The fourth part describes the use of stents, the percutaneous coronary intervention (PCI) strategy after crossing the lesion, including long segments treatment, bifurcations and small vessels. Also when to stop procedures and when to perform a second attempt.
Finally, the fifth part describes procedural complications and how to deal with them, radiation and contrast media exposure, operator training and organization of CTO centres.
I believe that careful and practical case-based scenario selection with details of technical principles and related ?tips and tricks? are seminal to CTO revascularisation teaching procedures. Nowadays, we can recanalize CTOs with a high rate of success. Patients referred for cardiac surgery usually have concomitant problems such as valvular disease, aortic aneurysm, iliac artery occlusion or moderate renal dysfunction. Of course, recanalisation success is based on a careful review of the film, concentration and by following your ?Mentor?s? advice. Indeed, even after two years recommended training and sufficient work as an independent primary operator one should refrain from engaging in PCI of complex CTOs without appropriate supervision. In order to maintain competence interventionalists should carry out a minimum of 50 CTOs per year, this will result in a model where only a limited number of operators and centres would be allowed to perform CTO treatment.
Unless you know what you are doing, as my Mentor Masahiko Ochiai would always tell me at the beginning of my career in these complex procedures, ?you should hold the wire and do nothing more?.
Last but not least, I would like to thank Corrado Tamburino for using his skills and putting a great deal of energy into establishing our interventional cardiology centre. Moreover, I would like to thank my fellows: Salvatore Davide Tomasello, who has been collaborating with me on these coronary complex procedures at the catheterization laboratory over these past years. As well as being involved in various research projects and developments in the field of revascularization of CTO, he also assisted preparing some case presentations and writing many chapters in this book. Luca Costanzo, who has been involved in CTO revascularization research and development over these past years. As well as assisting me to prepare all case presentations and writing some chapters in this book. Giombattista Barrano for having prepared most of the drawings and graphs Without them this work would never have been possible.