Abstract
There remains a pressing need in the interventional cardiology community to narrow the existing gap in the success rates, safety, and efficiency of chronic total occlusion percutaneous coronary intervention (CTO-PCI) relative to non CTO-PCI. Success rates for non CTO-PCI are high (>98 %). The success rates of CTO-PCI at experienced CTO-PCI centers are catching up (>90 %) but are likely much lower (50–70 %) at the vast majority of other PCI centers. Complication rates appear to be equal between CTO and non-CTO procedures at experienced CTO centers but may not be at others. CTO-PCI is associated with higher procedural time, contrast use, radiation exposure and supply cost than non CTO PCI even at experienced CTO-PCI centers. Thus, a wide variability in the CTO-PCI cases being attempted persists in large part due to these gaps. This chapter provides an overview of the new expanded hybrid approach, commonly employed by successful CTO operators.
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Video 11.1
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques: A more than 20 mm RCA CTO with a very ambiguous proximal cap, largely because of the presence of several ipsilateral bridge collaterals (AVI 2565 kb)
Video 11.2
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques: A more than 20 mm RCA CTO with a very ambiguous proximal cap, largely because of the presence of several ipsilateral bridge collaterals (AVI 2629 kb)
Video 11.3
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques.: Retrograde approach with a Sion through the large epicardial CC from the LCX to the PLV (AVI 1695 kb)
Video 11.4
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques. Failure to connect into the distal RCA, with sub-intimal tracking in the last few mm (AVI 1890 kb)
Video 11.5
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques.: Antegrade bailout with BASE (Balloon-Assisted Sub-intimal Entry). After dilating the proximal RCA segment with a 3.0 mm balloon, a very tiny injection was performed with 1 cc of contrast, showing a dissection plane (AVI 4155 kb)
Video 11.6
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques. A Fielder XT is knuckled into the dissection plane, with the support of a CrossBoss (AVI 2440 kb)
Video 11.7
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques. The CrossBoss is advanced to the distal RCA for re-entry (AVI 4499 kb)
Video 11.8
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques. A Stingray ballon is in place, but an antegrade hematoma is compressing the true lumen. Suction of blood from the Stingray ports did not improve visualization (AVI 3274 kb)
Video 11.9
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques. A first stick is performed through the port pointing upward, as the common position of a Stingray following a CrossBoss is following the greater curvature of the artery (AVI 2766 kb)
Video 11.10
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques. Successful swap with a Pilot 200 shaped as the StingRay wire (AVI 5915 kb)
Video 11.11
Balloon-assisted sub-intimal entry (BASE) and blind stick techniques. Final result after DES deployment (AVI 1871 kb)
Video 11.12
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system: Angulated but short CTO of the OM (white arrow), that used to be grafted by a sequential SVG to OM and diagonal, which was stented in the past, with occlusion of the first latero-lateral anastomosis (AVI 3092 kb)
Video 11.13
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system. CrossBoss at the proximal cap; failure to start the dissection. The distal OM is irrigated by a distal epicardial collateral channel from the diagonal branch (AVI 1212 kb)
Video 11.14
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system. Knuckled Pilot 200 to start the dissection (AVI 12585 kb)
Video 11.15
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system. The knuckled wire is in the vessel structure, and the CrossBoss is advanced to create a dryer dissection plane (AVI 3936 kb)
Video 11.16
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system. Poor retrograde filling of the OM branch, likely from an hematoma caused by the knuckled wire; the StingRay is visualized from a wrong view (Right Anterior Oblique) (AVI 3152 kb)
Video 11.17
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system. Both wings of the StingRay balloon are overlapped in the Left Anterior Oblique view. Because of poor distal vessel filling, the direction of the stick is ambiguous (AVI 3540 kb)
Video 11.18
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system:. A blind stick technique is performed; first, the port pointing upward is punctured; a strong resistance is encountered. Then, the port pointing downward is punctured; a ‘pop and release’ sensation is felt (AVI 10947 kb)
Video 11.19
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system:. A Pilot 200 (swap technique) is used to track the second hole created by the StingRay; it advances without resistance (AVI 6476 kb)
Video 11.20
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system. Retrograde injection that confirms that the Pilot 200 is in the true lumen (AVI 1977 kb)
Video 11.21
Knuckle-Boss and Blind Stick and Swap technique using the CrossBoss and StingRay Antegrade dissection re-entry system. Final result post dilation and stenting (AVI 1819 kb)
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Sapontis, J., Marso, S.P., Lombardi, W.L., Grantham, J.A. (2016). How to Fix Common Problems Encountered in CTO PCI: The Expanded Hybrid Approach. In: Rinfret, S. (eds) Percutaneous Intervention for Coronary Chronic Total Occlusion. Springer, Cham. https://doi.org/10.1007/978-3-319-21563-1_11
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DOI: https://doi.org/10.1007/978-3-319-21563-1_11
Publisher Name: Springer, Cham
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