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Recommended Readership: Interventional clinical and research cardiologists and interventional fellows. Bresnahan, Mayo Clinic Proceedings, Vol.

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Toggle navigation. New to eBooks. How many copies would you like to buy? Duckers , Elizabeth G. The first step in the hybrid algorithm is dual coronary injection, which allows the assessment of four key angiographic characteristics: 1 proximal cap ambiguity, 2 quality of the vessel distal to the occlusion, 3 lesion length, and 4 presence of adequate collateral vessels allowing adequate crossing strategy selection.


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Importantly, if the initially selected strategy fails to achieve satisfactory progress, early change is recommended to maximize the likelihood of success and minimize use of fluoroscopy and contrast. There is increasing evidence demonstrating that application of the hybrid algorithm is both safe and effective, 18,39,40 even among challenging patient and lesion subgroups. Although many early CTO operators were self-taught, there are currently many resources to facilitate training, such as print and online textbooks, 1 websites such as www.

The final and often most important step is proctorship, which is critical for successfully and safely developing the necessary skills for the procedure.

Editor’s Pick: Contemporary Use of Intracoronary Imaging in Percutaneous Coronary Intervention

Development of regional CTO centers of excellence will enhance the success and decrease the risk of the procedure. Excellent results can be achieved, with high success and low complication rates, among experienced centers and operators using all available techniques. Expanding the number of centers and operators that can achieve these outcomes will improve patient access to this procedure and improve clinical outcomes for an often challenging to treat group of patients.

Figure 1: "Hybrid" Algorithm for Crossing CTOs The algorithm starts with bilateral coronary injection and the evaluation of four key parameters to decide the initial procedural strategy antegrade vs. Strategies may change during the course of the procedure if stagnation or failure occurs. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. Share via:. Media Center ACC. Two patients 2. Although the use of DES for bifurcation lesions has resulted in improved outcomes compared with BMS, concern still remains because of late adverse events occurring at the ostium of the side branch.

Stent thrombosis as high as 3. A second wire is left in position in the side branch and jailed by the main vessel stent. The favorable modification of the angle of origin of the side branch and the angiographic reference offered by the jailed wire facilitates crossing of the side branch using the wire in the main vessel or a separate wire. After opening of the stent struts, a second stent is implanted right from the ostium with final kissing balloon dilatation.

Still, incomplete coverage of the side branch ostium remains a major limitation in case of too distal deployment of the side branch stent. Conversely, too proximal deployment of the side branch stent results in protrusion of stent struts into the main vessel.

Coronary Artery Stents

Here, the side branch stent is advanced into position followed by the parent vessel stent without deployment. It is then carefully positioned at the ostium and deployed first with only the proximal stent marker protruding into the main branch. Following removal of stent and guidewire from the side branch, the main vessel stent is deployed covering across the ostium of the side branch. The side branch is then rewired with final kissing balloon dilatation performed.

The crush technique, popularized by Colombo et al. Being that the second stent is already in position, there is no danger of impairing access to the main vessel. After withdrawal of the wire and stent delivery balloon from the side branch, the main vessel stent is subsequently deployed crushing the proximal part of the side branch stent thereby creating three layers of stent struts in the main vessel. Finally, kissing balloon dilatation is undertaken having to traverse through three layers of stent struts at the bifurcation to give the final result.

Simultaneous kissing stents. A—B —both stents are positioned side by side and are deployed simultaneously which also helps to minimize plaque shift. Kissing inflation C is not mandatory if a satisfactory result has been achieved by the simultaneous stent deployment. Crush stenting A—B —the side branch stent is positioned and deployed first with the proximal stent marker placed 2—3 mm proximal to the bifurcation within the main vessel.

Finally, kissing balloon dilatation is undertaken having to traverse through three layers of stent struts at the bifurcation—D to give the final result E—F. Culotte stenting A—D —The first stent is usually positioned in the vessel with the sharpest angulation usually the side branch and deployed using 12—14 atm pressure.

This traps the other wire placed within the main vessel behind the stent struts and a third wire is used to recross the struts of the first stent and enter distal main branch. After removal of the first main branch wire the struts of the stent are dilated with a balloon to enable passage of a second stent through the struts and into the main vessel. The procedure ends with kissing balloon inflation E which requires another wire passage through the stent struts.

The technique results in considerable stent burden at the side branch ostium F. The culotte technique was developed by Chevalier et al.

Herman Gist, MD - Interventional Cardiology

In its original description, it was recommended to insert the first stent in the vessel with the sharpest angulation usually the side branch and deployed using 12—14 atm pressure. Obviously, with modern flexible stents, a reversed order can be followed should an attempt to use a single stent be considered possible.

The procedure ends with kissing balloon postdilatation which requires another wire passage through the stent struts. The culotte technique for bifurcation lesions has been limited by high thrombosis and restenosis rates in the setting of BMS.

Coordinators: Duckers Henricus J., Nabel Elizabeth G., Serruys Patrick W.

Chevalier et al. Technical complexity and high rates of preprocedural events and restenosis in other registries led to the technique falling out of favor amongst interventional cardiologists. The simultaneous kissing stents SKS technique is best suited to easily accessible bifurcations with large proximal reference diameter containing plaque and when both branches are of similar diameter Fig. The procedure involves wiring the main and side branches which maintains access to both during the entire procedure. By having both stents parallel, this extends the carina of the bifurcation proximally.

This technique was developed to allow complete lesion coverage but is limited by its procedural complexity and the need to use three stents. Stents are deployed in each of the branch vessels with a third stent paced in the main vessel proximal to the bifurcation. A number of dedicated bifurcation stents have been developed and some are commercially available. However, they have failed to achieve widespread application in the management of bifurcation lesions. The main limiting factors relate to the inability to combine all the requirements of a dedicated device including flexibility, optimal scaffolding at the carina, and a capacity to rotate to fit the coronary anatomy in three dimensions.

These devices tend to be bulkier requiring two guide wires making wire entanglement a significant hindrance to the procedure. At 30 days and 6 months, the MACE rates were 2. This is followed by kissing balloon postdilatation.


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  • Initial procedural success rates of parent vessel and side branch were PCI has come a long way with numerous studies and reports extending the breadth and scope of coronary lesions treated by this route. Considerable credit must be given to DES that have relieved many of the concerns of BMS, particularly restenosis, and have extended the application of PCI to patients and lesions that would previously have been treated medically or with CABG. Although ULM PCI with DES is considered a strategy still in its infancy, recent reports and studies have shown general credence amongst interventional cardiologists; results of randomized trials comparing this to traditional CABG are eagerly awaited with the possibility of further propelling this treatment into mainstream cardiology.

    Furthermore, the benefits of DES for bifurcation lesions have been explicitly laid out with improved angiographic and clinical outcomes. Still, the issue of late stent thrombosis has yet to be fully elucidated and remains a cloud over the current success. Volume 19 , Issue 6. The full text of this article hosted at iucr. If you do not receive an email within 10 minutes, your email address may not be registered, and you may need to create a new Wiley Online Library account. If the address matches an existing account you will receive an email with instructions to retrieve your username.

    Journal of Interventional Cardiology Volume 19, Issue 6. Free Access. Address for reprints: Carlo Di Mario, M.