Rev Esp Cardiol.

2020;73(12):1011–1017

Original article

Percutaneous coronary intervention in aorto-ostial coronary chronic total

occlusion: outcomes and technical considerations in a multicenter registry
Soledad Ojeda,a,* Aurora Luque,a Manuel Pan,a Barbara Bellini,b Iosif Xenogiannis,c
Adrián Lostalo,a Matteo Montorfano,b Francisco Hidalgo,a Giuseppe Venuti,d Alessio La Manna,d
Mauro Carlino,b Emmanouil S. Brilakis,c and Lorenzo Azzalinib,e
a
Departamento de Cardiologı´a, Hospital Reina Sofı́a, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
b
Interventional Cardiology Division, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
c
Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, United States
d
Division of Cardiology, A.O.U. ‘‘Policlinico-Vittorio Emanuele’’, University of Catania, Catania, Italy
e
Cardiac Catheterization Laboratory, The Mount Sinai Hospital, New York, NY, United States

Article history: ABSTRACT

Received 10 November 2019
Accepted 15 January 2020 Introduction and objectives: Percutaneous coronary intervention (PCI) for aorto-ostial chronic total
Available online 4 March 2020
coronary occlusion (CTO) can be a particularly challenging lesion subset. The aim of this study was to
analyze the technical aspects and outcomes of aorto-ostial CTO PCI in a multicenter registry.
Keywords: Methods: Patients undergoing aorto-ostial CTO PCI at 4 centers between February 2013 and December
Chronic total coronary occlusion
2018 were included. Success rates, as well as procedural aspects and outcomes, were analyzed.
Percutaneous coronary intervention
Results: A total of 103 patients were included. Mean age was 64  10 years and the mean J-CTO score was
Retrograde approach
3.1  1.1. Thirty-one lesions (30.4%) were flush ostial CTOs. Technical and procedural success were achieved
in 79 (76.7%) and 78 (75.7%) of the patients, respectively. The retrograde approach was the most frequent
successful crossing technique (n = 49; 62.0%), especially in flush vs nonflush aorto-ostial CTOs (82.6% vs
53.5%; P = .02). The only variable independently associated with technical failure was the absence of
interventional collaterals (OR, 12.38; 95%CI, 4.02-38.15; P < .001). Coronary perforation occurred in
4 patients (3.9%) requiring covered stent implantation (without subsequent cardiac tamponade) and
2 patients (1.9%) had a stroke (one of which was a transient ischemic attack). During a median follow-up of
31 months, 3 (2.9%) patients died from cardiovascular causes and 13 (12.6%) required repeat target vessel
revascularization.
Conclusions: Aorto-ostial occlusions represent a challenging subset for PCI. However, an acceptable
success rate with favorable outcomes during follow-up can be achieved by experienced operators. The
presence of interventional collaterals allowing the use of the retrograde approach is key for achieving
procedural success.
C 2020 Sociedad Española de Cardiologı́a. Published by Elsevier España, S.L.U. All rights reserved.

Tratamiento percutáneo de oclusiones coronarias crónicas aorto-ostiales:

resultados y consideraciones técnicas de un registro multicéntrico

RESUMEN

Palabras clave: Introducción y objetivos: La intervención coronaria percutánea (ICP) de oclusiones coronarias totales
Oclusión coronaria total crónica crónicas (OTC) aorto-ostiales constituye un reto como subgrupo. El objetivo de este estudio es analizar
Intervención coronaria percutánea los aspectos técnicos y resultados tras la ICP de OTC aorto-ostiales en un registro multicéntrico.
Abordaje retrógrado
Métodos: Se incluyó a los pacientes de 4 centros con una OTC aorto-ostial tratados con ICP entre febrero
de 2013 y diciembre de 2018. Se analizaron las tasas de éxito, los aspectos del procedimiento y los
resultados.
Resultados: Se incluyó a 103 pacientes. La media de edad fue 64  10 años y la puntuación J-OTC, 3,1  1,1.
Habı́a 31 OTC (30,4%) con ausencia total de muñón. El éxito técnico y del procedimiento se obtuvo en 79
(76,7%) y 78 (75,7%) de los pacientes respectivamente. El abordaje retrógrado fue la técnica de cruce exitosa
más frecuente (n = 49; 62,0%), especialmente en OTC sin muñón (el 82,6 frente al 53,5%; p = 0,02). La ausencia
de colaterales intervencionistas fue la única variable asociada con fallo técnico (OR = 12,38; IC95%, 4,02-
38,15; p < 0,001). En 4 pacientes (3,9%) se produjeron perforaciones coronarias, todas tratadas exitosamente
con stent cubierto (sin tamponamiento) y 2 pacientes (1,9%) sufrieron un accidente cerebrovascular (1 fue
transitorio). Tras una mediana de seguimiento de 31 meses, 3 pacientes (2,9%) murieron por causa
cardiovascular y 13 (12,6%) requirieron nueva revascularización del vaso diana.

* Corresponding author: Departamento de Cardiologı́a, Hospital Reina Sofı́a, Avda. Menéndez Pidal s/n, 14004 Córdoba, Spain.
E-mail address: soledad.ojeda18@gmail.com (S. Ojeda).

https://doi.org/10.1016/j.rec.2020.01.008
1885-5857/ C 2020 Sociedad Española de Cardiologı́a. Published by Elsevier España, S.L.U. All rights reserved.
1012 S. Ojeda et al. / Rev Esp Cardiol. 2020;73(12):1011–1017

Conclusiones: Las OTC aorto-ostiales representan un subgrupo técnicamente complejo. Sin embargo,
operadores expertos pueden obtener una tasa de éxito aceptable con resultados favorables al
seguimiento. La presencia de colaterales intervencionistas, que permiten el acceso retrógrado, parece ser
clave para que el procedimiento sea exitoso.
C 2020 Sociedad Española de Cardiologı́a. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

clopidogrel (75 mg/d), prasugrel (10 mg/d) or ticagrelor (90 mg

Abbreviations twice daily) for 6 to 12 months.

CTO: chronic total coronary occlusion

PCI: percutaneous coronary intervention Definitions

CTO was defined as an occlusive (100% stenosis) coronary lesion

INTRODUCTION with antegrade Thrombolysis In Myocardial Infarction (TIMI) flow
grade 0 for at least 3months.11 A CTO was considered to be aorto-
Although the development of dedicated devices and the ostial if the proximal cap was within 5 mm of the aortocoronary
growing experience of operators have significantly increased ostium.8 Flush aorto-ostial occlusion was defined as the complete
procedural success rates, chronic total coronary occlusions (CTO) absence of a stump at the aortocoronary junction (figure 1). The J-CTO
are still considered the most complex lesion subset for percutane-
ous coronary intervention (PCI).1,2 In this setting, special sub-
A B
groups confer additional challenges.3–5 Aorto-ostial CTOs are often
associated with unfavorable anatomic characteristics such as
proximal cap ambiguity and unclear vessel course.6,7 This type of
lesions hampers coronary engagement with the guide catheter,
limiting the success of antegrade crossing strategies.7 Consequent-
ly, the technical options to recanalize the occluded vessel are
usually limited, with a primary or secondary retrograde approach
often being required in these cases. There are limited published
data on PCI for aorto-ostial CTOs.8,9
The aim of this study was to analyze the technical aspects, as
well as the acute and long-term outcomes of aorto-ostial CTO PCI in
a large retrospective multicenter registry.

Figure 1. Types of aorto-ostial CTOs. A: flush aorto-ostial occlusion (total

METHODS absence of a stump at the aortocoronary junction). B: aorto-ostial CTO with a
minimal proximal cap. CTO: chronic total coronary occlusion.
Patients

Table 1
Patients undergoing attempted aorto-ostial CTO PCI at 4 high-
Baseline clinical characteristics
volume centers with specialized CTO PCI programs, between
February 2013 and December 2018, were included in this study. n = 103
Two centers only enrolled patients during part of the study period. Age, y 64  10
All procedures were indicated according to the presence of angina, Men 93 (90.3)
evidence of ischemia, or both, and were performed electively10 by Diabetes mellitus 38 (36.9)
experienced operators. Clinical, angiographic, procedural, hospi-
Dyslipidemia 75 (72.8)
talization and follow-up data were recorded. All participants gave
Hypertension 79 (76.7)
informed consent for the procedure and for data analysis and
publication. Current smoker 29 (28.1)
Prior myocardial infarction 54 (52.4)
Prior PCI 77 (74.7)

Procedure Prior coronary artery bypass graft surgery 27 (26.2)

Chronic kidney disease 16 (15.5)
CTO PCI was performed in all patients using the femoral or Prior TIA/Stroke 7 (6.8)
radial approach, at the operator’s discretion, using simultaneous Peripheral arterial disease 15 (14.6)
double injection, with the exception of patients with only Ejection fraction, % 51.6  13.2
ipsilateral collateral filling.
Ejection fraction < 45% 30 (29.1)
The patients were pretreated with dual antiplatelet therapy. In
Indication of PCI
the cardiac catheterization laboratory, weight-adjusted heparin
Stable coronary artery disease 67 (65.0)
was administered to maintain an activated clotting time for >
300 seconds and was monitored every 30 minutes to determine Silent ischemia/low ejection fraction 27 (26.2)

whether an additional bolus of unfractionated heparin was Acute coronary syndrome 9 (8.7)
necessary. After the procedure, all patients received 81 to PCI, percutaneous coronary intervention; TIA: transient ischemic attack.
100 mg of aspirin daily indefinitely and a maintenance dose of Data are expressed as No. (%) or mean  standard deviation.
 S. Ojeda et al. / Rev Esp Cardiol. 2020;73(12):1011–1017 1013

Table 2 defined as a composite of cardiac death, myocardial infarction,

Angiographic characteristics and clinically-driven target lesion revascularization.
n = 103

Number of diseased vessels 2.3  0.4 Follow-up study

Target vessel
Right coronary artery 96 (93.2) Clinical follow-up was performed with scheduled visits and
Left main 6 (5.8) telephone calls. Patients with symptom recurrence or with
Circumflex artery (independent ostium) 1 (1.0) inducible ischemia were recommended to undergo angiographic
Occlusion length 51.7  34.1
evaluation.
Moderate-severe calcification 63 (61.2)
Blunt stump/proximal cap ambiguity 76 (73.8) Statistical analysis
Moderate-severe tortuosity 57 (55.3)
Flush ostial CTO 34 (33.0) Continuous variables are expressed as the mean  standard
Presence of a proximal side branch 21 (20.4)
deviation or median [IQ25-75]. Categorical variables are presented as
counts and percentages. Independent predictors of recanalization
J-CTO score 3.1  1.1
failure were studied using a backward stepwise logistic regression
J-CTO score  2 94 (91.3)
model. Variables with a P-value of  .1 in univariate analyses and
Progress-CTO score 1.5  0.7
those previously linked with technical failure were introduced into
In-stent CTO 23 (22.3) the model. The final model included the following variables: flush
CTO, chronic total coronary occlusion. ostial CTO, blunt stump/proximal cap ambiguity, moderate-severe
Data are expressed as No. (%) or mean  standard deviation. calcification, moderate-severe tortuosity, occlusion length > 20 mm,
in-stent CTO and the absence of interventional collaterals. A P value of
< .05 was considered statistically significant. Model fit was evaluated
(Japanese-Chronic Total Occlusion) score12 and the PROGRESS-CTO with the Hosmer-Lemeshow goodness-of-fit test. Statistical analyses
score13 were calculated for each lesion. were performed using SPSS, version 20 (IBM Corp., United States).
Technical success was defined as residual stenosis < 30% with
TIMI 3 flow in the CTO vessel.10 Procedural success was defined
as technical success plus the absence of in-hospital adverse RESULTS
events (all-cause death, Q-wave myocardial infarction, stroke,
recurrent angina requiring target vessel revascularization with Clinical characteristics
PCI or coronary artery bypass graft, tamponade requiring
pericardiocentesis or surgery). 10 Procedural complications and During the study period, 1371 patients underwent CTO PCI at
in-hospital adverse events included death, stroke, periproce- the 4 participating centers. Of these, 103 (7.5%) patients had an
dural type 4a myocardial infarction,14 need for urgent revascu- aorto-ostial CTO and were included in this registry. Clinical
larization, major bleeding (bleeding requiring transfusion, characteristics of the study population are shown in table 1. Mean
vasopressors, surgery, or percutaneous intervention), vascular age was 64  10 years and 90.3% of the patients were men. The
complications, coronary perforation requiring intervention (coil prevalence of cardiovascular risk factors was high: half of the study
embolization, covered stent implantation, pericardiocentesis, population had prior myocardial infarction, three quarters prior PCI,
and/or surgery), and contrast-induced nephropathy (increase in and one quarter prior coronary artery bypass grafting. The most
serum creatinine > 25% or > 0.5 mg/dL at 48 hours postproce- frequent indication for CTO PCI was angina despite optimal medical
dure). Major adverse cardiac events (MACE) on follow-up were treatment.

A B C

G
D E F

Figure 2. Left main CTO after Jatene surgery. Ostial left main CTO after Jatene surgery. Contralateral filling from the RCA and LCx (anomalous origin of the LCx from
the RCA) (arrows) (A, B). A retrograde approach was chosen (C). A Sion guidewire (Asahi Intecc, Japan) was advanced through a microcatheter from the RCA to the
diagonal branch, reaching the distal cap of the occlusion (arrow) (D). A Pilot 200 (Abbott, United States) passed into the aorta (arrows) (ER). The externalization
guidewire was snared to create the circuit (F). Final result after drug-eluting stent implantation (G). CTO, chronic total coronary occlusion; LCx, left circumflex
coronary artery; RCA, right coronary artery.
1014 S. Ojeda et al. / Rev Esp Cardiol. 2020;73(12):1011–1017

Angiographic characteristics Table 3

Procedural data
The angiographic features of the target lesions are presented in n = 103
table 2. The most frequent target CTO vessel was the right coronary Contralateral injection 91 (88.3)
artery (n = 96, 93.2%). Six patients (5.8%) underwent PCI of an
Access site
occluded left main coronary (figure 2) and 1 patient (1%) had a CTO
Bifemoral 57 (55.3)
of a circumflex artery with a separate ostium. The mean J-CTO
score was 3.1  1.1. Most CTOs had moderate or severe calcification Femoral – Radial 32 (31.1)

(n = 63; 61.2%) and proximal cap ambiguity (n = 76; 73.8%). Biradial 2 (1.9)
Additionally, flush ostial CTOs were present in 34 (33.0%) of the Single femoral 9 (8.7)
patients. Single radial 3 (2.9)
Crossing strategies attempted
AWE 42 (40.1)
Procedural data
ADR 19 (18.4)
Retrograde approach 81 (78.6)
The procedural data of this cohort are shown in table 3. The
Initial crossing strategy attempt
access site was bifemoral or radial-femoral in most of the patients
(n = 89; 86.4%). A single guide catheter was used in 12 (11.6%) AWE 33 (32.0)
patients. The retrograde approach was the initial crossing strategy ADR 8 (7.8)
in most patients (n = 62; 60.2%), as well as the final successful Retrograde approach 62 (60.2)
strategy: retrograde wire escalation in 17 (21.5%) patients and Final successful crossing technique
reverse controlled antegrade and retrograde tracking in 32 (40.5%). AWE 20 (25.3)
In flush ostial CTOs, retrograde strategies were the successful
ADR 10 (12.6)
crossing techniques in an even higher proportion of cases (n = 19/
RWE 17 (21.5)
23, 82.6% vs n = 30/56, 53.6%, in flush vs no flush ostial CTO;
RDR 32 (40.5)
P = .02). However, in patients with in-stent CTO, antegrade
techniques were the most common successful recanalization None 24 (23.3)

strategies (n = 12/18, 66.7% vs n = 18/61, 29.5%; P = .01). Externalization technique

Guidewire externalization after retrograde crossing was Externalization wire into guiding catheter 30 (61.2)
commonly performed using the conventional technique using a Snaring in aorta 8 (16.3)
long externalization wire (n = 30/49, 61.2%). Tip-in 10 (20.4)
Technical and procedural success were achieved in 79 (76.7%) Rendez-vous 1 (2.1)
and 78 (75.7%) of the patients, respectively. In our series, the
Type of stent:
success rate of nonaorto-ostial CTOs was significantly higher
Second generation DES 97 (94.2)
(89.8% vs 76.7%, P < .001). Moreover, there was a trend toward a
lower technical success rate in the flush ostial CTOs in comparison Bioresorbable scaffolds 6 (5.8)

with no flush CTOs (23/34, 67.6% vs 56/69, 81.2%; P = .13). The Diameter of largest stent, mm 3.34  0.49
reasons for failed recanalization were the following: absence of Stent length, mm 72  31
interventional collaterals in 14/24 patients (58.3%), presence of an IVUS 42 (40.7)
impenetrable proximal cap in 7 (29.2%), and inability to advance Contrast volume, mL 307  246
the microcatheter through the collaterals after successful wiring in Fluoroscopy time, min 70  32
the remaining 3 patients (12.5%).
Radiation dose, Gy/cm2 312  246

ADR, antegrade dissection reentry; AWE, antegrade wire escalation; DES, drug-
eluting stents; IVUS, intravascular ultrasound; RDR, retrograde dissection and
In-hospital and follow-up outcomes
reentry; RWE, retrograde wire escalation.
Data are expressed as No. (%) or mean  standard deviation.
In-hospital complications are presented in table 4. Periproce-
dural MI was diagnosed in 6 (5.8%) patients, and was associated
with a coronary perforation requiring intervention in 2 of them. In
the remaining patients, this was an asymptomatic event with no
Table 4
clinical consequences. We observed 4 coronary perforations (3.9%), In-hospital adverse events
which were all successfully treated with covered stent implanta-
tion, without subsequent cardiac tamponade. Vascular complica- n = 103

tions were observed in 6 (5.8%) patients, mainly minor Overall complications 8 (7.8)
complications consisting of local hematoma (n = 4, 3.9%). Two Periprocedural myocardial infarction 6 (5.8)
patients had a major bleeding at the puncture site (1.9%). Other Coronary perforation 4 (3.9)
complications included contrast-induced nephropathy (n = 4; Cardiac tamponade 0
3.9%) without the need for dialysis, transient ischemic attack
Major bleedinga 2 (1.9)
(n = 1; 0.9%) and stroke (n = 1; 0.9%).
Contrast-induced nephropathyb 4 (3.9)
During a median follow-up of 31 months [16.5-44], the MACE
rate was 15.5%. Five (4.8%) patients died, 3 of them (2.9%) from Stroke 1 (0.9)

cardiovascular causes and 2 (1.9%) due to noncardiac causes (end Transient ischemic attack 1 (0.9)
stage chronic kidney disease and pulmonary disease). Thirteen In-hospital mortality 0
patients (12.6%) required repeat target vessel revascularization Data are expressed as No. (%).
due to focal restenosis in 4 patients (30.8%), diffuse in 6 (46.1%) and a
Puncture site.
reocclusion in the remaining 3 patients (23.1%). Twelve patients b
None required dialysis.
 S. Ojeda et al. / Rev Esp Cardiol. 2020;73(12):1011–1017 1015

Table 5
Predictors of technical failure

Variable Univariate Multivariate

OR 95%CI P OR 95%CI P

Flush ostial CTO 1.58 0.64-3.94 .32 -

Blunt stump/proximal cap ambiguity 2.45 0.92-7.02 .07 -
Moderate-severe calcification 1.11 0.45-2.74 .82 -
Moderate-severe tortuosity 4.33 1.70-11.04 .002 -
Occlusion length > 20 mm 3.49 0.42-28.95 .25 -
In-stent CTO 0.7 0.24-2.21 .58 -
Absence of interventional collaterals 10.28 3.08-31.89 < .001 12.38 4.02-38.15 < .001

95%CI, 95% confidence interval; CTO, chronic total coronary occlusion; OR: odds ratio.

had been previously treated with second generation drug-eluting reasonably low incidence of complications; d) as a retrograde
stents and 1 patient with a bioresorbable scaffold. approach is usually required to cross the occluded segment, the
With regard to the patients with successfully treated in-stent presence of interventional collaterals seems to be key for achieving
CTO, only 1 of them needed repeat target vessel revascularization procedure success; d) the incidence of MACE on follow-up was
because of a new reocclusion. reasonably low and similar to that of other contemporary series.
To the best of our knowledge, this is the first study exclusively
focused on aorto-ostial CTO PCI. In line with previous studies
Factors associated with technical failure including side branch ostial and aorto-ostial CTOs,8,9 these
occlusions were found in patients with an extensive comorbidity
Factors associated with technical failure are presented in table burden, with a high prevalence of cardiovascular risk factors and
5. The absence of interventional collaterals was the only factor comorbidities. Likewise, the angiographic characteristics were also
associated with a higher risk of technical failure (OR, 12.38; 95% fairly unfavorable, as reflected by a mean J-CTO score of
confidence interval, 4.02-38.15; P < .001). approximately 3. Among them, a blunt/ambiguous stump (argu-
ably the most adverse feature in a CTO) was observed in most of the
patients (n = 76, 73.8%) and a flush ostial occlusion in about one
DISCUSSION third of our series.15 Additionally, only 20% of the patients had a
proximal side branch allowing an anchoring technique or the use
This study sought to analyze the clinical and angiographic of intravascular ultrasound to guide the proximal cap puncture.16
characteristics, procedural aspects, and outcomes of a particularly An aorto-ostial occlusion hampers coronary engagement with the
challenging CTO PCI subset, aorto-ostial occlusions. The main guide catheter (figure 3). Moreover, guide support is often poor. As a
findings of our registry are as follows: a) aorto-ostial CTOs have high consequence, a primary retrograde approach can be the most
complexity, often requiring the use of the retrograde approach; b) effective alternative to cross the occluded segment. In fact, in our
the PCI success rate of aorto-ostial CTOs was lower than those study, a retrograde approach was attempted in most patients (n = 81,
reported in the literature in all-comers with CTOs, although with a 78.6%) and was the most common final successful crossing technique

A B C

D E F
G

Figure 3. Flush ostial occlusion of the right coronary artery (RCA) recanalized with a retrograde approach. Flush ostial RCA occlusion (dotted line) with distal filling
by contralateral collaterals (A). The total absence of stump hampered coronary engagement with the guide catheter. As a consequence, a retrograde approach was
planned as the first option through a septal channel (arrows) (B). The retrograde wire crossed the occluded segment in what was thought to be the aorta. However,
this possibility was ruled out by a contralateral projection (C). Finally, and after several attempts, a Confianza Pro 12 (Asahi Intecc, Japan) crossed through the
ostium retrogradely and passed into the aorta (D). After confirmation of the correct position of the wire in the aorta lumen, the retrograde microcatheter was
advanced. Then, the externalization guidewire was introduced into an antegrade multipurpose catheter (arrows) creating a circuit (E). Final result after
2 overlapping drug-eluting stents (F). Small contained perforation (arrows) caused by the exit of the retrograde guidewire (G).
1016 S. Ojeda et al. / Rev Esp Cardiol. 2020;73(12):1011–1017

(n = 49, 62%). Additionally, in flush aorto-ostial CTOs, retrograde only option for recanalization is frequently a retrograde approach,
techniques were required in an even higher proportion of the the existence of interventional collaterals, as well as mastering the
patients. These percentages are well above the figures provided by retrograde, approach seems to be key in procedural success. During
large contemporary registries,1,17–21 in which antegrade techniques long-term follow-up, the incidence of adverse events is reasonably
were predominant. In fact, the specific angiographic complexity low and should not discourage recanalization attempts.
features of this subset of CTOs often induce the operator to choose a
retrograde approach, which is sometimes the only feasible revascu-
larization strategy (particularly in stumpless aorto-ostial occlu- CONFLICTS OF INTEREST
sions).1,17–19 In this regard, we found that the absence of
‘‘interventional’’ collaterals was the only factor independently S. Ojeda received horaria from Terumo and Philips. M. Pan
associated with recanalization failure, underlining the importance received horaria from Terumo, Abbott Vascular, and Philips. E.S.
of a retrograde access to improve the success rate. Although Brilakis received consulting/speaker honoraria from Abbott
‘‘interventional collaterals’’ are usually defined as collaterals that Vascular, American Heart Association (associate editor Circula-
appear suitable for being crossed with a guidewire and a tion), Boston Scientific, Cardiovascular Innovations Foundation
microcatheter according to the operator’s judgemen,13 that criterion (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, and
is subjective and highly dependent on operator skills and experience: Medtronic; research support from Regeneron and Siemens; is a
collaterals initially considered to be interventional, later prove to be shareholder of MHI Ventures; and is on the Board of Trustees of the
uncrossable. Additionally, ‘‘invisible’’ (CC0)22 collaterals can often be Society of Cardiovascular Angiography and Interventions. L.
successfully crossed using the ‘‘surfing’’ technique.23 Azzalini received honoraria from Abbott Vascular, Guerbet,
The adoption of the hybrid algorithm along with the develop- Terumo, and Sahajanand Medical Technologies; and research
ment of new specialized wires and microcatheters have allowed support from ACIST Medical Systems, Guerbet, and Terumo. The
high success rates to be achieved in CTO PCI.24,25 In the present other authors have no disclosures.
study, these rates were acceptable, but slightly lower than those
reported in large contemporary all-comers CTO PCI registries.1,17– WHAT IS KNOWN ABOUT THE TOPIC?
19
That finding could be explained by the anatomic complexity of
these occlusions, a factor clearly associated with the probability of - The anatomic characteristics of aorto-ostial CTOs can
recanalization, together with the limited technical options confer additional challenges for PCI and the technical
available in some cases. Accordingly, we observed a trend toward options to recanalize the occluded vessel are usually
a lower technical success rate in the most complex subgroup,
limited.
represented by flush ostial CTOs.
- There are scarce data on experience with percutaneous
Although the risk for complications is related to the use of
revascularization of this lesion subset.
advanced crossing techniques, commonly required in more
complex occlusions,1 the overall complication rate was relatively
low in our series, which is likely related to the experience of the WHAT DOES THIS STUDY ADD?
operators involved in the study. Indeed, a stiff guidewire can be
required to cross through the ostium retrogradely to pass into the - This multicenter registry shows that, in these complex
aorta. In such setting, the risk of a subintimal pathway is CTOs, an acceptable success rate can be achieved with a
nonnegligible and this could be associated with aortic root injury low incidence of complications.
(dissection). To avoid these complications, the operator should not
- As a retrograde approach is usually required, the
advance the retrograde microcatheter until the correct position of
existence of interventional collaterals seems to be key
the wire in the aorta lumen is confirmed (figure 3).
Moreover, the retrograde approach is associated with a risk of in procedural success.
perforation, donor vessel injury, ischemia, and equipment - On long-term follow-up, the incidence of adverse events
entrapment. Proximal cap ambiguity is also associated with a risk is reasonably low.
of perforation when an antegrade approach is undertaken.26–28

Limitations

REFERENCES
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