CORONARY ARTERY DISEASE
Application of the “Hybrid Approach” to Chronic Total Occlusion
Interventions: A Detailed Procedural Analysis
TESFALDET T. MICHAEL, M.D., M.P.H., OWEN MOGABGAB, M.D., ERIC FUH, M.D.,
VISHAL G. PATEL, M.D., ABDALLAH EL SABBAGH, M.D., MOHAMMED E. ALOMAR, M.D.,
BAVANAV. RANGAN, B.D.S., M.P.H., SHUAIB M. ABDULLAH, M.D.,
SUBHASH BANERJEE, M.D., and EMMANOUIL S. BRILAKIS, M.D., P H.D.
From the VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas
Objective: To assess the outcomes of the “hybrid” approach to chronic total occlusion (CTO) percutaneous
coronary interventions (PCIs).
Background: The “hybrid approach” to CTO PCI advocates appropriate and early change of crossing strategy to
maximize success, safety, and efficiency.
Methods: We prospectively recorded and analyzed detailed step‐by‐step procedural data in 73 consecutive CTO PCI
cases performed by a single operator between July 2011 and August 2012.
Results: Technical success was achieved in 66 of 73 cases (90.4%). Mean patient age was 65 7 years, and 30% had
prior coronary artery bypass surgery. Dual injection was used in 78%. The primary approach was retrograde in 9
cases (12.5%) and antegrade in 64 cases (87.5%), of whom 25 cases (39.1%) underwent retrograde attempt after
failed antegrade approach. The initial crossing approach was successful in 40 cases (54.8%), but 32 cases (44%)
required 3.6 1.4 approach changes (range 2–7). Antegrade wire escalation, antegrade dissection/reentry, and
retrograde crossing were utilized in 97.2%, 46.6%, and 46.6% of cases, respectively. Among successful cases, the
final CTO crossing technique was antegrade wire escalation in 50.0%, antegrade dissection/reentry in 24.2%, and
retrograde in 25.8%. The mean procedure time, fluoroscopy time, and air kerma radiation exposure until CTO
crossing or stopping the procedure were 66 55 minutes, 25 23 minutes, and 2.3 1.9Gray, respectively. Three
patients (4.1%) had a major complication.
Conclusion: In the “hybrid approach” to CTO PCI, changes in crossing strategy were needed in approximately half
the cases, resulting in high success and low complication rates. (J Interven Cardiol 2014;27:36–43)
Introduction
Percutaneous coronary intervention (PCI) of coro-
nary chronic total occlusions (CTOs) can be challeng-
ing with inability to cross the lesion with a guidewire
being the most common reason for failure.
1
In the past,
the CTO recanalization success rate ranged between
51% and 74%,
2–5
yet with the development and
application of advanced techniques and equipment
procedural success has significantly improved.
6–11
Three major categories of CTO crossing techniques
are currently in use: antegrade wire escalation,
antegrade dissection‐reentry,
12–14
and retrograde
approach.
11,15,16
Although there is ongoing controversy
on the relative merits of each strategy, experience with
all 3 is important to optimize crossing success rates.
We recently proposed a detailed, step‐by‐step
algorithm for selecting the initial and subsequent
CTO crossing strategies, called the “hybrid approach”
(Fig. 1).
17
The “hybrid approach” focuses on opening
an occluded vessel using all feasible techniques;
placing emphasis on procedural success, safety, and
efficiency; aiming to recanalize the CTO in the shortest
Address for reprints: Emmanouil S. Brilakis, Dallas VA Medical
Center (111A), 4500 South Lancaster Road, Dallas, TX 75216. Fax:
(214) 302‐1341; e‐mail: esbrilakis@gmail.com
© 2013, Wiley Periodicals, Inc.
DOI: 10.1111/joic.12083
36 Journal of Interventional Cardiology Vol. 27, No. 1, 2014