International Journal of Cardiology 181 (2015) 344–346
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the editor
Coronary chronic total occlusion: Not only a therapeutic nihilism but also a lack of requisite expertise Gabriele L. Gasparini a,⁎, Jacopo A. Oreglia b, Patrizia Presbitero a a b
Department of Invasive Cardiology, Humanitas Research Hospital, Rozzano, Milan, Italy Department of Invasive Cardiology, Niguarda Hospital, Milan, Italy
a r t i c l e
i n f o
Article history: Received 16 December 2014 Accepted 21 December 2014 Available online 24 December 2014 Keywords: Coronary chronic total occlusion Percutaneous coronary intervention Previous CABG
Patients with prior coronary artery bypass graft (CABG) often develop recurrent symptoms and events due to saphenous vein graft disease or progression of native coronary atherosclerosis [1,2]. Percutaneous coronary intervention (PCI) of native coronary arteries is preferred as revascularization strategy among these patients given the increased risk of saphenous vein graft interventions [3] and the higher mortality rate of repeat CABG [4]. However patients with prior CABG surgery often have complex coronary anatomy, coexisting diffuse multivessel disease, severe coronary calcification, more co-morbidities and worse outcomes compared with patients without previous CABG [5] and are also more likely to have a coronary chronic total occlusion (CTO). Approximately half the patients with prior CABG undergoing coronary angiography have a CTO [5]; these findings may be explained by the acceleration of the atherosclerotic process in bypassed vessels [1,2]. Despite the fact that CTO has been associated with lower procedural success rates their treatment often represents the only chance of revascularization in patients with previous CABG suffering from refractory angina despite optimal medical therapy. However there is still a large amount of previous CABG patients that are classified as “nonrevascularizable” by conventional surgical or percutaneous means. This segment of the CAD population is growing and poses numerous challenges. When patients present with symptomatic multivessel coronary artery disease after CABG, the choice of revascularization method ⁎ Corresponding author at: Department of Invasive Cardiology, Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy. E-mail address: [email protected] (G.L. Gasparini).
http://dx.doi.org/10.1016/j.ijcard.2014.12.083 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
or lack of revascularization is dictated mostly by anatomical considerations: the presence of a CTO is one the main reasons to treat these patients medically or to refer for a surgery re-do [6]. This may be explained considering the lower procedural success achieved in these lesions in comparison with non-occluded lesions [7]. However the introduction of specific devices and improvement of operator's expertise has allowed the improvement of success rates of up to 80-90% [8]. We present a case of successful PCI of a 65-year-old male that was classified as “non-revascularizable” after a diagnostic coronary angiography performed in another hospital. The patient was symptomatic for severe minimal effort angina. Seven years before he underwent triple CABG [left internal mammary artery (LIMA) to left anterior descending artery (LAD), sequential saphenous vein graft (SVG) to first diagonal (D1) and obtuse marginal (OM) branches, and SVG to posterior descending artery (PDA)] and aortic valve replacement with biological prosthesis due to an ascending aorta dilatation associated with severe aortic regurgitation and three vessel diseases. Four years later the patient developed an aortic dissection from the valve plane to the aortic arch, so he underwent replacement of the ascending aorta with a Dacron vascular prosthesis and reimplantation of the sequential SVGs on the prolene prosthesis (Fig. 1A). Three years later, due to new onset minimal effort angina, the patient was admitted in another institute where a coronary angiography showed total occlusion of the proximal segments of all branches, with patency of LIMA to LAD (Fig. 1B) and complete SVGs proximal occlusion (Fig. 1C). Notably, sequential SVG segment from D1 to OM was already patent and was filled antegradely through native LAD (Fig. 1D), but there was a critical stenosis of proximal LAD just before diagonal branch (Fig. 1E); finally RCA was filled from distal LCX (Fig. 1F) Thus, the perfusion of the antero-lateral, lateral and infero-lateral walls was subtended by the critical stenosis of the LAD (Fig. 1E). Ejection fraction (EF) was 40% with diffuse hypokinesia and severe mitral regurgitation. The patient was classified as unamenable to any further revascularization and was discharged with optimal medical therapy. After few weeks the patient was admitted in our hospital for severe refractory minimal effort angina and dyspnea; after reviewing diagnostic coronary angiography we scheduled two different CTO PCI of the left circumflex artery (LCX) and of the right coronary artery (RCA). First, during hospitalization, we performed a successful LCX CTO PCI recanalization (Fig. 2A), then one month later we successfully treated RCA CTO achieving a complete revascularization (Fig. 2B), without any complications. Furthermore, an echocardiographic
G.L. Gasparini et al. / International Journal of Cardiology 181 (2015) 344–346
345
Fig. 1. Diagnostic angiography showed: A) severe ascending aorta distortion; B) LIMA to LAD patency; C) complete SVG proximal occlusion; D) sequential SVG segment from D1 to OM patency that was filled antegradely through native LAD; E) critical stenosis of proximal LAD just before diagonal branch, with perfusion of the antero-lateral, lateral and infero-lateral walls subtended by this stenosis; E) long and calcified RCA CTO that was filled retrogradely from distal LCX.
follow-up performed three months later showed regression of antero-lateral, lateral and infero-lateral walls' hypokinesia with EF normalization and improvement of mitral regurgitation which became moderate. This illustrative case emphasizes the importance to reconsider the definition of “non-revascularizable” patient. In a recent review [9], Strauss et al. underline how indications to CTO recanalization should be reconsidered, in light of new evidence of current rates of procedural success and clinical effectiveness. They conclude that “therapeutic nihilism” often associated with their treatment may be fueled by persistent misconceptions on the actual degree of ischemia or symptoms caused
by the CTO, and the potential benefit of revascularization. It is our opinion, according to Carlino et al. [10], that an important role was also played by the inability to treat this subset of lesions by many operators. This, however, cannot and should not be one of the criteria used to define a patient as “non-revascularizable”. In fact, referral to dedicated CTO operators should be considered before a patient is deemed unsuitable for any further percutaneous revascularization. We are optimistic that the growing attention to CTO lesions can raise awareness about the feasibility, efficacy and safety of these procedures, assisting clinicians to more judiciously determine indications of CTOs' revascularization.
Fig. 2. A) Final result after successful LCX CTO recanalization; B) final result after successful RCA CTO recanalization.
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G.L. Gasparini et al. / International Journal of Cardiology 181 (2015) 344–346
Conflict of interest All the authors have no relevant relationship with industry and financial associations that might pose a conflict of interest.
References [1] M.S. Lee, S.J. Park, D.E. Kandzari, et al., Saphenous vein graft intervention, JACC Cardiovasc Interv 4 (2011) 831–843. [2] E.S. Brilakis, S.V. Rao, S. Banerjee, et al., Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients: a report from the National Cardiovascular Data Registry, JACC Cardiovasc Interv 4 (2011) 844–850. [3] A.R. Abdel-Karim, S. Banerjee, E.S. Brilakis, Percutaneous intervention of acutely occluded saphenous vein grafts: contemporary techniques and outcomes, J. Invasive Cardiol. 22 (2010) 253–257.
[4] G.M. Fitzgibbon, H.P. Kafka, A.J. Leach, et al., Coronary bypass graft fate and patient outcome: angiographic follow-up of 5065 grafts related to survival and reoperation in 1388 patients during 25 years, J. Am. Coll. Cardiol. 28 (1996) 616–626. [5] P. Fefer, M.L. Knudtson, A.N. Cheema, et al., Current perspectives on coronary chronic total occlusions; the Canadian Multicenter Chronic Total Occlusion Registry, J. Am. Coll. Cardiol. 59 (2012) 991–997. [6] G.W. Stone, D.E. Kandzary, R. Mehran, et al., Percutaneous recanalization of chronically occluded coronary artery: a consensus document: part I, Circulation 112 (2005) 2364–2372. [7] G.W. Stone, B.D. Rutherford, D.R. Mc-Conahay, et al., Procedure outcome of angioplasty for total coronary occlusion: an analysis of 971 lesions in 905 patients, J. Am. Coll. Cardiol. 15 (1990) 849–856. [8] G1. Sianos, G.S. Werner, A.R. Galassi, et al., Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club, EuroIntervention 8 (1) (2012 May 15) 139–145. [9] B.H. Strauss, M. Shuvy, H.C. Wijeysundera, Revascularization of chronic total occlusions: time to reconsider? J. Am. Coll. Cardiol. 64 (12) (2014 Sep 23) 1281–1289. [10] M. Carlino, C.J. Magri, B.F. Uretsky, et al., Treatment of the chronic total occlusion: a call to action for the interventional community, Catheter. Cardiovasc. Interv. 10 (2014 Nov).
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the editor
Coronary chronic total occlusion: Not only a therapeutic nihilism but also a lack of requisite expertise Gabriele L. Gasparini a,⁎, Jacopo A. Oreglia b, Patrizia Presbitero a a b
Department of Invasive Cardiology, Humanitas Research Hospital, Rozzano, Milan, Italy Department of Invasive Cardiology, Niguarda Hospital, Milan, Italy
a r t i c l e
i n f o
Article history: Received 16 December 2014 Accepted 21 December 2014 Available online 24 December 2014 Keywords: Coronary chronic total occlusion Percutaneous coronary intervention Previous CABG
Patients with prior coronary artery bypass graft (CABG) often develop recurrent symptoms and events due to saphenous vein graft disease or progression of native coronary atherosclerosis [1,2]. Percutaneous coronary intervention (PCI) of native coronary arteries is preferred as revascularization strategy among these patients given the increased risk of saphenous vein graft interventions [3] and the higher mortality rate of repeat CABG [4]. However patients with prior CABG surgery often have complex coronary anatomy, coexisting diffuse multivessel disease, severe coronary calcification, more co-morbidities and worse outcomes compared with patients without previous CABG [5] and are also more likely to have a coronary chronic total occlusion (CTO). Approximately half the patients with prior CABG undergoing coronary angiography have a CTO [5]; these findings may be explained by the acceleration of the atherosclerotic process in bypassed vessels [1,2]. Despite the fact that CTO has been associated with lower procedural success rates their treatment often represents the only chance of revascularization in patients with previous CABG suffering from refractory angina despite optimal medical therapy. However there is still a large amount of previous CABG patients that are classified as “nonrevascularizable” by conventional surgical or percutaneous means. This segment of the CAD population is growing and poses numerous challenges. When patients present with symptomatic multivessel coronary artery disease after CABG, the choice of revascularization method ⁎ Corresponding author at: Department of Invasive Cardiology, Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy. E-mail address: [email protected] (G.L. Gasparini).
http://dx.doi.org/10.1016/j.ijcard.2014.12.083 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
or lack of revascularization is dictated mostly by anatomical considerations: the presence of a CTO is one the main reasons to treat these patients medically or to refer for a surgery re-do [6]. This may be explained considering the lower procedural success achieved in these lesions in comparison with non-occluded lesions [7]. However the introduction of specific devices and improvement of operator's expertise has allowed the improvement of success rates of up to 80-90% [8]. We present a case of successful PCI of a 65-year-old male that was classified as “non-revascularizable” after a diagnostic coronary angiography performed in another hospital. The patient was symptomatic for severe minimal effort angina. Seven years before he underwent triple CABG [left internal mammary artery (LIMA) to left anterior descending artery (LAD), sequential saphenous vein graft (SVG) to first diagonal (D1) and obtuse marginal (OM) branches, and SVG to posterior descending artery (PDA)] and aortic valve replacement with biological prosthesis due to an ascending aorta dilatation associated with severe aortic regurgitation and three vessel diseases. Four years later the patient developed an aortic dissection from the valve plane to the aortic arch, so he underwent replacement of the ascending aorta with a Dacron vascular prosthesis and reimplantation of the sequential SVGs on the prolene prosthesis (Fig. 1A). Three years later, due to new onset minimal effort angina, the patient was admitted in another institute where a coronary angiography showed total occlusion of the proximal segments of all branches, with patency of LIMA to LAD (Fig. 1B) and complete SVGs proximal occlusion (Fig. 1C). Notably, sequential SVG segment from D1 to OM was already patent and was filled antegradely through native LAD (Fig. 1D), but there was a critical stenosis of proximal LAD just before diagonal branch (Fig. 1E); finally RCA was filled from distal LCX (Fig. 1F) Thus, the perfusion of the antero-lateral, lateral and infero-lateral walls was subtended by the critical stenosis of the LAD (Fig. 1E). Ejection fraction (EF) was 40% with diffuse hypokinesia and severe mitral regurgitation. The patient was classified as unamenable to any further revascularization and was discharged with optimal medical therapy. After few weeks the patient was admitted in our hospital for severe refractory minimal effort angina and dyspnea; after reviewing diagnostic coronary angiography we scheduled two different CTO PCI of the left circumflex artery (LCX) and of the right coronary artery (RCA). First, during hospitalization, we performed a successful LCX CTO PCI recanalization (Fig. 2A), then one month later we successfully treated RCA CTO achieving a complete revascularization (Fig. 2B), without any complications. Furthermore, an echocardiographic
G.L. Gasparini et al. / International Journal of Cardiology 181 (2015) 344–346
345
Fig. 1. Diagnostic angiography showed: A) severe ascending aorta distortion; B) LIMA to LAD patency; C) complete SVG proximal occlusion; D) sequential SVG segment from D1 to OM patency that was filled antegradely through native LAD; E) critical stenosis of proximal LAD just before diagonal branch, with perfusion of the antero-lateral, lateral and infero-lateral walls subtended by this stenosis; E) long and calcified RCA CTO that was filled retrogradely from distal LCX.
follow-up performed three months later showed regression of antero-lateral, lateral and infero-lateral walls' hypokinesia with EF normalization and improvement of mitral regurgitation which became moderate. This illustrative case emphasizes the importance to reconsider the definition of “non-revascularizable” patient. In a recent review [9], Strauss et al. underline how indications to CTO recanalization should be reconsidered, in light of new evidence of current rates of procedural success and clinical effectiveness. They conclude that “therapeutic nihilism” often associated with their treatment may be fueled by persistent misconceptions on the actual degree of ischemia or symptoms caused
by the CTO, and the potential benefit of revascularization. It is our opinion, according to Carlino et al. [10], that an important role was also played by the inability to treat this subset of lesions by many operators. This, however, cannot and should not be one of the criteria used to define a patient as “non-revascularizable”. In fact, referral to dedicated CTO operators should be considered before a patient is deemed unsuitable for any further percutaneous revascularization. We are optimistic that the growing attention to CTO lesions can raise awareness about the feasibility, efficacy and safety of these procedures, assisting clinicians to more judiciously determine indications of CTOs' revascularization.
Fig. 2. A) Final result after successful LCX CTO recanalization; B) final result after successful RCA CTO recanalization.
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G.L. Gasparini et al. / International Journal of Cardiology 181 (2015) 344–346
Conflict of interest All the authors have no relevant relationship with industry and financial associations that might pose a conflict of interest.
References [1] M.S. Lee, S.J. Park, D.E. Kandzari, et al., Saphenous vein graft intervention, JACC Cardiovasc Interv 4 (2011) 831–843. [2] E.S. Brilakis, S.V. Rao, S. Banerjee, et al., Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients: a report from the National Cardiovascular Data Registry, JACC Cardiovasc Interv 4 (2011) 844–850. [3] A.R. Abdel-Karim, S. Banerjee, E.S. Brilakis, Percutaneous intervention of acutely occluded saphenous vein grafts: contemporary techniques and outcomes, J. Invasive Cardiol. 22 (2010) 253–257.
[4] G.M. Fitzgibbon, H.P. Kafka, A.J. Leach, et al., Coronary bypass graft fate and patient outcome: angiographic follow-up of 5065 grafts related to survival and reoperation in 1388 patients during 25 years, J. Am. Coll. Cardiol. 28 (1996) 616–626. [5] P. Fefer, M.L. Knudtson, A.N. Cheema, et al., Current perspectives on coronary chronic total occlusions; the Canadian Multicenter Chronic Total Occlusion Registry, J. Am. Coll. Cardiol. 59 (2012) 991–997. [6] G.W. Stone, D.E. Kandzary, R. Mehran, et al., Percutaneous recanalization of chronically occluded coronary artery: a consensus document: part I, Circulation 112 (2005) 2364–2372. [7] G.W. Stone, B.D. Rutherford, D.R. Mc-Conahay, et al., Procedure outcome of angioplasty for total coronary occlusion: an analysis of 971 lesions in 905 patients, J. Am. Coll. Cardiol. 15 (1990) 849–856. [8] G1. Sianos, G.S. Werner, A.R. Galassi, et al., Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club, EuroIntervention 8 (1) (2012 May 15) 139–145. [9] B.H. Strauss, M. Shuvy, H.C. Wijeysundera, Revascularization of chronic total occlusions: time to reconsider? J. Am. Coll. Cardiol. 64 (12) (2014 Sep 23) 1281–1289. [10] M. Carlino, C.J. Magri, B.F. Uretsky, et al., Treatment of the chronic total occlusion: a call to action for the interventional community, Catheter. Cardiovasc. Interv. 10 (2014 Nov).
