Contrast modulation in chronic total occlusion percutaneous coronary intervention.
Lorenzo AzzaliniBarry F UretskyEmmanouil S BrilakisAntonio ColomboMauro CarlinoPublished in: Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions (2018)
The intraplaque injection of contrast media in the recanalization of coronary chronic total occlusions (CTO) has witnessed a dynamic journey since its initial formulation. Contrast-guided subintimal tracking and re-entry (STAR) was the first contrast modulation technique for CTO percutaneous coronary intervention (PCI). With this technique, a forceful injection of a large volume of contrast (3-4 mL) was performed in order to achieve hydraulic recanalization of the vessel. This approach was associated with extensive vessel injury and unpredictable true lumen re-entry, which were in turn linked to high rates of restenosis on follow-up. In the subsequent iteration, called the "microchannel technique", a smaller amount of contrast media (1 mL) was gently injected inside the plaque to modify its compliance by softening and recruiting loose tissue, which facilitated subsequent true-to-true lumen crossing with a polymer-jacketed wire along paths of least resistance. The microchannel technique has later evolved into what is currently known as the "Carlino technique", where a minimal volume of contrast media (<0.5 mL) is gently injected inside the occlusion, with the goal of modifying plaque compliance to facilitate guidewire and microcatheter advancement through a fibrocalcific plaque. The Carlino technique is now widely utilized to allow negotiation of difficult-to-cross occlusions, particularly by the "hybrid operators", with high success rates and low incidence of complications. The purpose of this article is to provide a historical perspective on the use of contrast modulation in CTO PCI, its pathophysiological basis, as well as technical recommendations on how and when to perform these maneuvers.
Keyphrases
- percutaneous coronary intervention
- coronary artery disease
- magnetic resonance
- contrast enhanced
- acute myocardial infarction
- acute coronary syndrome
- st segment elevation myocardial infarction
- st elevation myocardial infarction
- antiplatelet therapy
- atrial fibrillation
- heart failure
- coronary artery bypass grafting
- ultrasound guided
- risk factors
- computed tomography
- coronary artery
- drug delivery
- stress induced