Recanalization of chronic total occlusion using a new device: the real-time intravascular ultrasound double-lumen microcatheter.
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ABSTRACT:
SUBMITTER: Ma YZ
PROVIDER: S-EPMC7909382 | biostudies-literature | 2020 Nov
REPOSITORIES: biostudies-literature
Publications
Recanalization of chronic total occlusion using a new device: the real-time intravascular ultrasound double-lumen microcatheter.
Ma Yan-Zhuo YZ Hou Guang-Dao GD Li Zhi-Wen ZW Zhang Xiao-Jiang XJ Wang Xiao-Ye XY Wang Gang G Peng Yu-Hong YH Ru Lei-Sheng LS
Chinese medical journal 20201107 4
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Project description:Intravascular ultrasound (IVUS)-guided guidewire manipulation technique is often useful to cross the lesion of chronic total occlusion (CTO) antegradely and solve retrograde CTO failure cases. However, this technique is usually complex because we need many devices and it requires many steps. Some steps usually take time and/or sometimes create a large dissection space which cause the procedure to fail. To overcome a weakness in this technique, we introduce the new IVUS-guided wiring technique with double lumen catheter named "Slipstream technique" here. This technique is simple, easy, and associated with less injury. It will be helpful for penetrating into the true lumen from the subintimal space with a guidewire correctly and safely. <Learning objective: IVUS-guided wiring technique in the treatment of chronic total occlusion is usually complex. The key point of new IVUS-guided wiring technique is to put both the IVUS catheter and double lumen catheter on the same wire. This manner is simple. Moreover, it will increase the stability of double lumen catheter and be helpful to manipulate the second guidewire effectively.>.
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Project description:Despite the benefits of successful percutaneous coronary interventions (PCIs) for chronic total occlusion (CTO) lesions, PCIs of CTO lesions still carry a high rate of adverse events, including in-stent restenosis (ISR). Because previous reports have not specifically investigated the intravascular ultrasound (IVUS) predictors of ISR in CTO lesions, we focused on these predictors. We included 126 patients who underwent successful PCIs, using drug-eluting stents, and post-PCI IVUS of CTO lesions. Patient and lesion characteristics were analyzed to elucidate the ISR predictors. In each lesion, an average of 1.7 ± 0.7 (mean length, 46.4 ± 20.3 mm) stents were used. At 9 months follow-up, 14 (11%) patients demonstrated ISR, and 8 (6.3%) underwent target lesion revascularization. Multivariate logistic regression analysis showed that the independent predictors of ISR were the post-PCI minimal luminal diameter (MLD) and the stent expansion ratio (SER; minimal stent cross-sectional area (CSA) over the nominal CSA of the implanted stent), measured using quantitative coronary angiography (QCA) and IVUS, respectively. A receiver operating characteristic analysis indicated that the best post-PCI MLD and SER cut-off values for predicting ISR were 2.4 mm (area under the curve [AUC], 0.762; 95% confidence interval (CI), 0.639-0.885) and 70% (AUC, 0.714; 95% CI, 0.577-0.852), respectively. Lesions with post-PCI MLD and SER values less than these threshold values were at a higher risk of ISR, with an odds ratio of 23.3 (95% CI, 2.74-198.08), compared with lesions having larger MLD and SER values. Thus, the potential predictors of ISR, after PCI of CTO lesions, are the post-PCI MLD and SER values. The ISR rate was highest in lesions with a post-PCI MLD ≤2.4 mm and an SER ≤70%.
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Project description:BackgroundFew studies have evaluated intravascular ultrasound (IVUS) use in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).AimsIn CTO-PCI, we aimed to (1) evaluate the clinical benefits of performing post-stent IVUS in preventing adverse clinical events, and (2) identify IVUS parameters and cut-off values for prediction of target lesion revascularisation (TLR)/reocclusion.MethodsA total of 1,077 patients with 1,077 CTO lesions treated with drug-eluting stents (DES) were included. Clinical outcomes during a median follow-up of 6.3 years were compared between subjects with and those without post-stent IVUS using the inverse probability weighting method.ResultsOf 1,077 patients, post-stent IVUS was performed in 838 (77.8%) cases while in the remaining 239 (22.2%) cases it was not. In the weighted population, the risk of TLR/reocclusion was significantly lower in subjects with post-stent IVUS (9.6% vs 18.9%, hazard ratio [HR] 0.54, 95% confidence interval [CI]: 0.34-0.86, p=0.01), compared with those without post-stent IVUS. Cox regression analysis showed that minimal stent area (MSA) measured by IVUS was the only parameter independently associated with TLR/reocclusion (HR 0.78, 95% CI: 0.64-0.95; p=0.01) and the optimal MSA cut-off value was 4.9 mm2 for prediction of TLR/reocclusion (area under the curve=0.632, p=0.001).ConclusionsIn CTO-PCI with DES, post-stent IVUS evaluation was associated with a lower risk of TLR/reocclusion. The final MSA was independently associated with TLR/reocclusion with a cut-off value of 4.9 mm2.
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Project description:BackgroundEndovascular therapy is an effective method for revascularization in lower extremity artery disease, but treating chronic total occlusion (CTO) remains challenging. This is particularly true for patients with severe calcification, poor run-off in below-the-knee arteries, or limited access sites, where even guidewire (GW) passage can be difficult and bidirectional approaches are often not feasible. The tip-detection (TD) method has been reported as a useful technique in coronary artery CTO interventions, allowing real-time visualization of the GW tip direction. Here, we applied the TD technique for peripheral CTO intervention.Case presentationCase 1 involved a 71-year-old man with a right toe ulcer. Angiography revealed total occlusion from the right anterior tibial artery (ATA) to the proximal dorsalis pedis artery. While attempting IVUS-guided parallel wiring, the GW could not advance through the intraplaque route because of severe calcification. We intentionally advanced the GW and IVUS into the subintimal space of the ATA to bypass the calcified lesion and performed IVUS-guided reentry using the TD technique in the distal ATA, where calcification was less severe. The second GW successfully passed through the intraplaque of the distal ATA and into the true lumen of the dorsalis pedis artery. Case 2 involved a 60-year-old man with bilateral intermittent claudication. Angiography revealed severe stenosis of the right common iliac artery (CIA) and CTO of the left CIA. Because of anatomical limitations and access site challenges, the antegrade approach for the left CIA was unsuccessful, and retrograde intraluminal wiring was difficult because of flexion and calcification. We advanced the GW and IVUS into the subintimal space and performed IVUS-guided reentry using the TD technique to access the true lumen of the proximal CIA. Finally, bilateral VBX stent grafts were implanted using the kissing stent technique.ConclusionsIVUS-guided reentry wiring with the TD technique may offer a useful solution for passing complex peripheral CTO lesions in cases where only a uni-directional approach is feasible.
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Project description:BackgroundIt has been considered impossible to perform antegrade dissection and reentry (ADR) by simply puncturing with a guidewire using the intravascular ultrasound (IVUS) observation without the support of the Stingray system.Case summaryA 78-year-old man suffered from effort angina pectoris due to a chronic total occlusion (CTO) lesion in the left circumflex coronary artery. A retry percutaneous coronary intervention for the CTO lesion was attempted at our hospital. The J-CTO score was 3. The first guidewire entered the subintimal space. We moved onto Stingray-ADR using the angiographic observation, but the guidewire could not be led into the true lumen. AnteOwl WR-IVUS (AO-IVUS) observation revealed a distal true lumen in which the inner lumen was maintained 5 mm beyond the CTO exit. We decided to perform the tip detection-ADR using the AO-IVUS observation. The tip detection method allowed the tip of the penetration wire to puncture the wall between the subintima and the true lumen in an exactly vertical direction, resulting in the successful creation of a reentry point. The CTO lesion was dilated with one drug-eluting stent, and normal antegrade blood flow was achieved.DiscussionSince the tip detection method enables accurate punctures, it may allow for ADR by simply puncturing using a guidewire. Due to this method being performed using the IVUS observation, it is likely more reliable than Stingray-ADR using the angiographic observation.
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Project description:This case describes percutaneous coronary intervention of a chronic total occlusion of the right coronary artery at the RV marginal bifurcation that was wire-uncrossable until plaque modification with side branch intravascular lithotripsy into the right ventricular marginal allowed crossing.
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Project description:Urinary obstruction secondary to benign prostatic hyperplasia is a late manifestation of the disease, and a poor prognostic sign for responding to conservative therapies. Prostatic artery embolization - when performed successfully - can be an effective treatment for reducing obstructive urinary symptoms. Outlined in this report is the successful recanalization of a prostatic artery chronic total occlusion prior to embolization in an 89-year-old man with benign prostatic hyperplasia, who initially presented with urinary obstruction. Prostatic artery recanalization was possible using a specialized crossing technique from peripheral arterial disease interventions, and allowed for more distal embolization of the prostate gland. This technique may be useful when advanced atherosclerotic disease limits the feasibility and clinical success of prostatic artery embolization.
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Project description:AimsAssessment of minimum lumen areas in intravascular ultrasound (IVUS) pullbacks is time-consuming and demands adequately trained personnel. In this work, we introduce a novel and fully automated pipeline to segment the lumen boundary in IVUS datasets.Methods and resultsFirst, an automated gating is applied to select end-diastolic frames and bypass saw-tooth artefacts. Second, within a machine learning (ML) environment, we automatically segment the lumen boundary using a multi-frame (MF) convolutional neural network (MFCNN). Finally, we use the theory of Gaussian processes (GPs) to regress the final lumen boundary. The dataset consisted of 85 IVUS pullbacks (52 patients). The dataset was partitioned at the pullback-level using 73 pullbacks for training (20 586 frames), 6 pullbacks for validation (1692 frames), and 6 for testing (1692 frames). The degree of overlapping, between the ground truth and ML contours, median (interquartile range, IQR) systematically increased from 0.896 (0.874-0.933) for MF1 to 0.925 (0.911-0.948) for MF11. The median (IQR) of the distance error was also reduced from 3.83 (2.94-4.98)% for MF1 to 3.02 (2.25-3.95)% for MF11-GP. The corresponding median (IQR) in the lumen area error remained between 5.49 (2.50-10.50)% for MF1 and 5.12 (2.15-9.00)% for MF11-GP. The dispersion in the relative distance and area errors consistently decreased as we increased the number of frames, and also when the GP regressor was coupled to the MFCNN output.ConclusionThese results demonstrate that the proposed ML approach is suitable to effectively segment the lumen boundary in IVUS scans, reducing the burden of costly and time-consuming manual delineation.
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