open access
Subintimal shift as mechanism for side-branch occlusion in percutaneous treatment of chronic total occlusions with bifurcation lesions
, 34, 5, 6, 6, 7, 7, 6, 5
Affiliations- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- CardioCare Heart Center, Marbella, Spain
- Miguel Servet University Hospital, Zaragoza, Spain
- Hospital Clínico Universitario de Valladolid, Spain
- Division of Cardiology and Angiology II, University Heartcenter Freiburg – Bad Krozingen, Jena University Hospital, Jena, Germany
- Jena University Hospital, Jena, Germany
- CardioCare Heart Centre, Marbella, Spain
open access
Abstract
Background: The aim of this study was to describe the mechanism of subintimal shift (SIS), standardise diagnostic criteria and sensitise the interventional community to this phenomenon. The treatment of chronic total occlusions (CTO) by means of percutaneous coronary intervention (PCI) is complicated by bifurcation lesions involved in the CTO segment or adjacent to it. Extraplaque expansion of intracoronary devices during CTO PCI may extend the dissection plane over the bifurcation with the consequential side or main branch compression by an intimo-medial flap. This phenomenon is hereby described for the first time and named subintimal shift. Methods: Experienced CTO operators from 3 international high volume centers for CTO PCI retrospectively searched their personal records for paradigmatic cases of SIS, summarising key features and proposing diagnostic criteria. Results: The series comprised 7 demonstrative cases, illustrating SIS by intravascular imaging (2 cases) or indirect angiographic signs during CTO PCI (5 cases). Five cases were triggered by stent expansion, 1 by balloon inflation and 1 case was aborted after angiographic warning signs. In 4 cases, SIS resulted in total occlusion of a branch, refractory to ballooning whenever attempted. Four cases required bailout intervention and in 2 cases the branch was left occluded, resulting in a rise of cardiac markers. Conclusions: Subintimal shift is a noteworthy complication in CTO bifurcations, potentially resulting in occlusion of the relevant side or even the main branch. Intracoronary imaging prior to stenting is recommended to understand the tissue planes. Some counterintuitive peculiarities of this phenomenon, like its refractoriness to ballooning, must be known by CTO operators for its efficient resolution.
Abstract
Background: The aim of this study was to describe the mechanism of subintimal shift (SIS), standardise diagnostic criteria and sensitise the interventional community to this phenomenon. The treatment of chronic total occlusions (CTO) by means of percutaneous coronary intervention (PCI) is complicated by bifurcation lesions involved in the CTO segment or adjacent to it. Extraplaque expansion of intracoronary devices during CTO PCI may extend the dissection plane over the bifurcation with the consequential side or main branch compression by an intimo-medial flap. This phenomenon is hereby described for the first time and named subintimal shift. Methods: Experienced CTO operators from 3 international high volume centers for CTO PCI retrospectively searched their personal records for paradigmatic cases of SIS, summarising key features and proposing diagnostic criteria. Results: The series comprised 7 demonstrative cases, illustrating SIS by intravascular imaging (2 cases) or indirect angiographic signs during CTO PCI (5 cases). Five cases were triggered by stent expansion, 1 by balloon inflation and 1 case was aborted after angiographic warning signs. In 4 cases, SIS resulted in total occlusion of a branch, refractory to ballooning whenever attempted. Four cases required bailout intervention and in 2 cases the branch was left occluded, resulting in a rise of cardiac markers. Conclusions: Subintimal shift is a noteworthy complication in CTO bifurcations, potentially resulting in occlusion of the relevant side or even the main branch. Intracoronary imaging prior to stenting is recommended to understand the tissue planes. Some counterintuitive peculiarities of this phenomenon, like its refractoriness to ballooning, must be known by CTO operators for its efficient resolution.
Keywords
percutaneous coronary intervention, coronary heart disease, chronic total occlusion, bifurcation lesion, complication
About this articleTitle
Subintimal shift as mechanism for side-branch occlusion in percutaneous treatment of chronic total occlusions with bifurcation lesions
Journal
Issue
Article type
Original Article
Pages
24-35
Published online
2021-07-07
Page views
3909
Article views/downloads
784
DOI
Pubmed
Bibliographic record
Cardiol J 2023;30(1):24-35.
Keywords
percutaneous coronary intervention
coronary heart disease
chronic total occlusion
bifurcation lesion
complication
Authors
Juan Luis Gutiérrez-Chico
Carlos Cortés
Mohamed Ayoub
Bernward Lauer
Sylvia Otto
Bernd Reisbeck
Manuela Reisbeck
Christian Schulze
Kambis Mashayekhi
References (13)- Konstantinidis NV, Werner GS, Deftereos S, et al. Temporal trends in chronic total occlusion interventions in europe. Circ Cardiovasc Interv. 2018; 11(10): e006229.
- Galassi AR, Boukhris M, Tomasello SD, et al. Incidence, treatment, and in-hospital outcome of bifurcation lesions in patients undergoing percutaneous coronary interventions for chronic total occlusions. Coron Artery Dis. 2015; 26(2): 142–149.
- Chen Sl, Ye F, Zhang Jj, et al. Clinical outcomes after recanalization of a chronic total occluded vessel with bifurcation lesions: results from single-center, prospective, chronic total occlusion registry study. Chin Med J (Engl). 2012; 125(6): 1035–1040.
- Ojeda S, Pan M, Gutiérrez A, et al. Bifurcation lesions involved in the recanalization process of coronary chronic total occlusions: Incidence, treatment and clinical implications. Int J Cardiol. 2017; 230: 432–438.
- Baystrukov VI, Kretov EI, Boukhris M, et al. A randomized trial of bifurcation stenting technique in chronic total occlusions percutaneous coronary intervention. Coron Artery Dis. 2018; 29(1): 30–38.
- Guan C, Yang W, Song L, et al. Association of acute procedural results with long-term outcomes after CTO PCI. JACC Cardiovasc Interv. 2021; 14(3): 278–288.
- Louvard Y, Thomas M, Dzavik V, et al. Classification of coronary artery bifurcation lesions and treatments: time for a consensus! Catheter Cardiovasc Interv. 2008; 71(2): 175–183.
- Lassen JF, Holm NR, Banning A, et al. Percutaneous coronary intervention for coronary bifurcation disease: 11th consensus document from the European Bifurcation Club. EuroIntervention. 2016; 12(1): 38–46.
- Ybarra LF, Rinfret S, Brilakis ES, et al. Definitions and clinical trial design principles for coronary artery chronic total occlusion therapies: CTO-ARC consensus recommendations. Circulation. 2021; 143(5): 479–500.
- Galassi AR, Werner GS, Boukhris M. Percutaneous recanalisation of chronic total occlusions: 2019 consensus document from the EuroCTO Club. EuroIntervention. 2019; 15: 198–208.
- Mashayekhi K, Valuckiene Z, Neuser H, et al. Wire externalisation techniques for retrograde percutaneous coronary interventions of chronic total occlusions. EuroIntervention. 2017; 13(12): e1489–e1490.
- Song L, Maehara A, Finn MT, et al. Intravascular ultrasound analysis of intraplaque versus subintimal tracking in percutaneous intervention for coronary chronic total occlusions and association with procedural outcomes. JACC Cardiovasc Interv. 2017; 10(10): 1011–1021.
- Walsh SJ, Hanratty CG, McEntegart M, et al. Intravascular healing is not affected by approaches in contemporary CTO PCI: the CONSISTENT CTO study. JACC Cardiovasc Interv. 2020; 13(12): 1448–1457.
