Editor’s 2024 Top 10: Update on Chronic Total Occlusion Percutaneous Coronary Intervention
Dr Deepak L. Bhatt, editor-in-chief of the Journal of Invasive Cardiology, catches up with Dr Emmanouil S. Brilakis about his Editor’s 2024 Top 10 article, “Update on Chronic Total Occlusion Percutaneous Coronary Intervention”.
Transcript:
Dr Bhatt: Hello, I'm Dr. Deepak Bhatt, the editor-in-chief of the Journal of Invasive Cardiology, and it's really a pleasure to have with me today Dr. Manos Brilakis from the Minneapolis Heart Institute. He's been a leader in complex coronary intervention for a long time. In particular, he’s contributed immensely to the field of chronic total occlusion, or CTO, intervention. He's published a lot of great articles through the years in the Journal of Invasive Cardiology on that and other topics. And it's great to have you here today, Manos.
Dr Brilakis: My pleasure. Thank you so much, Deepak.
Dr Bhatt: So, we're going through the top 10 articles from the Journal of Invasive Cardiology for 2024, and one of your articles made the list. I thought it was a really great review on chronic total occlusions, an update on the latest data, techniques, etc. Did you just want to recap to the audience the real highlights from that piece?
Dr Brilakis: Yeah, absolutely. And again, thanks again for the opportunity to publish in the Journal of Invasive Cardiology. I think it brings a lot of very practical content to the interventionalist; that's why many people use it as a reference for techniques and what to do next.
But, in this article, what we did is we reviewed the latest information, both on the indications in terms of when to do CTO intervention, the impact of place and characteristics, such as previous coronary bypass graft surgery, or having poor distal vessel quality, and we looked at what happens with the different techniques. As you know, now we do have more evolving equipment; there are new techniques. There is change in the most commonly used techniques with, for example, the limited, antegrade subintimal tracking and the ADR technique gaining a lot of ground, and also we discussed a little bit about the complications that, despite the improvements, there's still room to make the complications better as well. And also we do have now newer equipment such as the Ringer balloon, some other equipment that can be used to address the complications in an effective way.
Dr Bhatt: That's really terrific. I mean, there were all sorts of insights here. For example, you've reviewed a meta-analysis that showed that the MACE rate was actually higher for CTOs involving stents vs de novo lesions, which I think many people might find counterintuitive. So really all sorts of pearls in terms of just what the latest data and implications for practice are on CTOs. Any specific pearls that were mentioned in this article that you want to share with the audience?
Dr Brilakis: Yes, there are some techniques that are not widely known, but they were published recently and they can help a lot. One of them is to use IVUS for what's called three-dimensional wiring. And that's a very rapidly developing area in CTO. It originated in Japan, and it's reviewed in this paper as well. But essentially what is done is if the wire goes into the subintimal or extra-plaque space, then the operator advances an IVUS catheter and admittedly the ones they have in Japan are a little lower profile than here, but we can still do it with the ones available in the US. And then use this intravascular ultrasound going back and forth to detect the tip of the guide wire and be able to direct this tip of the guidewire into the true lumen. So, this is called 3D wiring. It does require some practice, but this is a very rapidly evolving area and that can help things to succeed, especially when other techniques don't work as well.
Another technique is one for retrieving lost guide wires. So, for example, sometimes we'll have a tip of a wire get lost. And sometimes it's not a big deal; we leave it in the distal coronary vessel, it's not a big deal. But if it's in a bigger vessel, and that can create a nidus for stent thrombosis, and this is a technique called the knuckle twister. So from Gregor Leibundgut from Switzerland, where he takes a polymer-jacket wire, he puts a large bend on the distal tip about 3 centimeters from the tip and then instead of having multiple wires he puts this knuckled wire down next to the lost wire fragment, he rotates it several times and this can cause entanglement of the wire fragment with our new knuckled wire and then allow the wire fragment to be retrieved. Again, the knuckle-twister can be really useful when there is a lost broken guide wire in the distal coronary tree.
Dr Bhatt: Those are really practical sorts of points. You know, with the intravascular ultrasound, some operators might be worried about perforation risk from that maneuver, what has been the risk of perforation in your opinion and what can you do to minimize it?
Dr Brilakis: That's a great point and that's a common concern when we work on the extra-plaque space in general. It turns out the extra-plaque space is fairly pliable. Of course, if the wire is out, then advancing anything over it, including an IVUS catheter, will create a big exit hole and cause tamponade that's obviously not desirable. But as long as we have confirmed and are pretty confident that the guide wire is in the extra-plaque space, that space actually is fairly dilatable and can accommodate the IVUS catheter. The concern is less that of perforation, the concern is that with manipulations, hematoma can form in the extra plaque space, compressing the distal true lumen. And when that happens, then there's more difficulty in getting the blood back into the lumen because everything is compressed for the extra plaque hematoma. So, less concern for perforation but yes, there is some concern that advancing a lot of equipment into the extra-plaque space will create a larger hematoma.
Dr Bhatt: Really useful advice from someone that's been doing very complex CTO work for a while. Are any other final pearls that you want to bring up before we conclude?
Dr Brilakis: I think another thing we're seeing is that now we do have dedicated scores not only for the success of the procedure, but also for the risk. So there is the PROGRESS and JCTO and many scores for success. There is the PROGRESS MACE, there is a score specific for complications. And I think many operators and patients find it useful because it's one thing to tell the patient, yes, you have 90% chance of being successful, but also if they know that the risk is, let's say, 2%, that's and a risk of 10% that can help the patient and the operator make informed decisions about whether to proceed or not with recanalizing this CTO.
Dr Bhatt: Really good point. Just one last thing I'll ask because it brings together 2 hot topics, but one that many interventionists may not necessarily couple together in their minds and that is urgent mechanical circulatory support and CTO PCI. Many people think, oh, CTO PCI, those are folks with bad but stable symptoms usually. Why would you end up needing mechanical support there? And in this article, you review a score that can predict the need for urgent MCS. But do you want to say anything about MCS in the context of CTO PCI, either put in ahead of the attempt or as a bailout for complications?
Dr Brilakis: Absolutely. So, I think people are right that circulatory support is not very common. I think it's about 4% in the PROGRESS-CTO registry. So, it's not very common, but there are some patients who need it, especially those who have the low ejection fraction, poor hemodynamics to start with, and they're also doing a complex procedure such as going through the last remaining vessel. The elective one is one thing, but I think being able to understand what is the likelihood of hemodynamic deterioration during the procedure, that can be very useful, that was actually one of the papers we reviewed which showed that if you have a low ejection fraction, which is self -explanatory, long lesions, and especially if you go to the retrograde approach the risk of needing an urgent circulatory support goes up and taking this into account may help convert some of those emergent needs for support, which sometimes have much worse outcomes, to an elective potentially or even postponing the procedure deciding that maybe the risk is not worth the potential benefits of opening that lesion.
Dr Bhatt: Well, terrific. This has been extremely valuable information. I'm sure the audience has learned a lot, I certainly did from discussing your paper with you. Thanks so much for this contribution to the Journal of Invasive Cardiology and all your contributions to the field over the years.
Dr Brilakis: Thank you so much.
© 2025 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.