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Published online: 2021-07-07
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Subintimal shift as mechanism for side-branch occlusion in percutaneous treatment of chronic total occlusions with bifurcation lesions

Juan Luis Gutiérrez-Chico, Carlos Cortés, Mohamed Ayoub, Bernward Lauer, Sylvia Otto, Bernd Reisbeck, Manuela Reisbeck, Christian Schulze, Kambis Mashayekhi
DOI: 10.5603/CJ.a2021.0079
·
Pubmed: 34231874

open access

Ahead of print
Original articles
Published online: 2021-07-07

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 firstly described phenomenon is 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 firstly described phenomenon is 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.

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Keywords

percutaneous coronary intervention, coronary heart disease, chronic total occlusion, bifurcation lesion, complication

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About this article
Title

Subintimal shift as mechanism for side-branch occlusion in percutaneous treatment of chronic total occlusions with bifurcation lesions

Journal

Cardiology Journal

Issue

Ahead of print

Article type

Original Article

Published online

2021-07-07

DOI

10.5603/CJ.a2021.0079

Pubmed

34231874

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)
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