Main Article Content

Muhammad Wajahat Jan
Asmara Ali
Muhammad Shahjehan Mirza
Soban Abu Khifs
Muhammad Hamid
Retaj Alawadhi


Complex chronic total occlusions, IVUS-guided wiring re-entry technique, percutaneous coronary intervention


Background and Aim: Chronic total occlusions (CTOs) encountered in coronary angiography procedures pose a considerable contemporary challenge. Intravascular ultrasound (IVUS) emerges as a valuable asset in CTO, assisting in the attainment of successful outcomes. The utilization of intravascular ultrasound (IVUS) can prove beneficial in directing the subintimal guidewire back into the true lumen. This current study assessed the IVUS guidance wiring re-entry technique in managing complex chronic total occlusion (CTO) lesions.

Patients and Methods: This study encompassed 18 CTOs patients who underwent the IVUS-guided wiring re-entry technique in the department of cardiology, Lady Reading Hospital, Peshawar from February 2021 to February 2022. All the patients had a minimum of one chronic total occlusion (CTO) lesion and met the criteria for CTO lesion recanalization. A complete occlusion for >3 months within the blocked segment was considered as CTO. It guided the positioning of an additional inflexible wire to return to the genuine inner vessel channel, relying on either the neighboring side branch or the initial wire as points of reference, or utilizing the IVUS-guided parallel wire method.

Results: The overall mean age of the patients was 67.6 ± 10.7 years. Of the total 18 patients, there were 17 (94.4%) male and 1 (5.6%) female. A total of two patients, constituting 11.1% of the study cohort, had experienced prior unsuccessful attempts at vascularizing their chronic total occlusions (CTOs). The left ventricular ejection fraction and mean length of the occluded segment was 50.6 ± 11.4 and 62.8 ± 24.3 mm respectively. Among the patients studied, the morphology of the CTO stump was characterized as blunt in 16 individuals, making up 88.9% of the cases. Additionally, 12 patients (66.7%) exhibited moderate to severe calcification, while 10 patients (55.6%) had bridging collaterals. The IVUS guided wiring re-entry success rate was 88.9% (n=16 cases). The procedure did not result in any complications.

Conclusion: The present study found that the use of the IVUS-guided wire re-entry technique can assist the effective reopening of these CTO lesions while minimizing the occurrence of significant complications. Furthermore, this approach could potentially be related to favorable long-term clinical outcomes.

Abstract 232 | PDF Downloads 69


1. Huang W-C, Teng H-I, Hsueh C-H, Lin S-J, Chan W-L, Lu T-M. Intravascular ultrasound guided wiring re-entry technique for complex chronic total occlusions. J Interven Cardiol. 2018;1–8.
2. Azzalini L, Dautov R, Brilakis ES, et al. Procedural and longer-term outcomes of wire-versus device-based antegrade dissection and reentry techniques for the percutaneous revascularization of coronary chronic total occlusions. Int J Cardiol. 2017;231:78–83.
3. Hasegawa K, Tsuchikane E, Okamura A, et al. Incidence and impact on midterm outcome of intimal versus subintimal tracking with both antegrade and retrograde approaches in patients with successful recanalization of chronic total occlusions: j-PROCTOR 2 study. EuroIntervention. 2017;12:e1868–e1873.
4. Lee, J.M.; Choi, K.H.; Bin Song, Y.; Lee, J.-Y.; Lee, S.-J.; Lee, S.Y.; Kim, S.M.; Yun, K.H.; Cho, J.Y.; Kim, C.J.; et al. Intravascular Imaging-Guided or Angiography-Guided Complex PCI. N. Engl. J. Med. 2023, 388, 1668–1679.
5. Vemmou, E.; Khatri, J.; Doing, A.H.; Dattilo, P.; Toma, C.; Sheikh, A.; Alaswad, K.; Jefferson, B.K.; Patel, T.N.; Chandwaney, R.H.; et al. Impact of Intravascular Ultrasound Utilization for Stent Optimization on 1-Year Outcomes After Chronic Total Occlusion Percutaneous Coronary Intervention. J. Invasive Cardiol. 2020, 32, 392–399.
6. Kalogeropoulos, A.S.; Alsanjari, O.; Davies, J.R.; Keeble, T.R.; Tang, K.H.; Konstantinou, K.; Vardas, P.; Werner, G.S.; Kelly, P.A.; Karamasis, G.V. Impact of Intravascular Ultrasound on Chronic Total Occlusion Percutaneous Revascularization. Cardiovasc. Revascularization Med. 2021, 33, 32–40.
7. Räber, L.; Mintz, G.S.; Koskinas, K.C.; Johnson, T.W.; Holm, N.R.; Onuma, Y.; Radu, M.D.; Joner, M.; Yu, B.; Jia, H.; et al. Clinical use of intracoronary imaging. Part 1: Guidance and optimization of coronary interventions. An. expert consensus document of the European Association of Percutaneous Cardiovascular Interventions. Eur. Heart J. 2018, 39, 3281–3300.
8. Panuccio, G.; Abdelwahed, Y.S.; Carabetta, N.; Salerno, N.; Leistner, D.M.; Landmesser, U.; De Rosa, S.; Torella, D.; Werner, G.S. Clinical and Procedural Outcomes of IVUS-Guided vs. Angiography Guided CTO-PCI: A Systematic Review and Meta-Analysis. J. Clin. Med. 2023, 12, 4947.
9. Råmunddal, T.; Hoebers, L.P.; Henriques, J.P.; Dworeck, C.; Angerås, O.; Odenstedt, J.; Ioanes, D.; Olivecrona, G.; Harnek, J.; Jensen, U.; et al. Prognostic Impact of Chronic Total Occlusions: A Report From SCAAR (Swedish Coronary Angiography and Angioplasty Registry). JACC Cardiovasc. Interv. 2016, 9, 1535–1544.
10. Werner, G.S.; Martin-Yuste, V.; Hildick-Smith, D.; Boudou, N.; Sianos, G.; Gelev, V.; Rumoroso, J.R.; Erglis, A.; Christiansen, E.H.; Escaned, J.; et al. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur. Heart J. 2018, 39, 2484–2493.
11. Nikolakopoulos, I.; Choi, J.W.; Khatri, J.J.; Alaswad, K.; Doing, A.H.; Dattilo, P.; Rafeh, N.A.; Maalouf, A.; Jaoudeh, F.A.; Tamez, H.; et al. Follow-up Outcomes After Chronic Total Occlusion Percutaneous Coronary Intervention in Patients With and Without Prior Coronary Artery Bypass Graft Surgery: Insights From the PROGRESS-CTO Registry. J. Invasive Cardiol. 2020, 32, 315–320.
12. Barbato, E.; Gallinoro, E.; Abdel-Wahab, M.; Andreini, D.; Carrié, D.; Di Mario, C.; Dudek, D.; Escaned, J.; Fajadet, J.; Guagliumi, G.; et al. Management strategies for heavily calcified coronary stenoses: An EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group. Eur. Heart J. 2023, ehad342.
13. Blessing, R.; Buono, A.; Ahoopai, M.; Geyer, M.; Knorr, M.; Brandt, M.; Steven, S.; Drosos, I.; Muenzel, T.; Wenzel, P.; et al. Use of intravascular ultrasound for optimal vessel sizing in chronic total occlusion percutaneous coronary intervention. Front. Cardiovasc. Med. 2022, 9, 922366.
14. Zhong, Z.; Zhao, L.; Chen, K.; Xia, S. The Clinical Effects of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion: A Meta-Analysis. Cardiol. Res. Pract. 2022, 2022, 4170060.
15. Chugh, Y.; Buttar, R.; Kwan, T.; Vemmou, E.; Karacsonyi, J.; Nikolakopoulos, I.; Garcia, S.; Goessl, M.; Wang, Y.; Chavez, I.; et al. Outcomes of Intravascular Ultrasound-Guided Versus Angiography-Guided Percutaneous Coronary Interventions in Chronic Total Occlusions: A Systematic Review and Meta-Analysis. J. Invasive Cardiol. 2022, 34, E310–E318.
16. Garbo R, Iannaccone M. Why IVUS When Approaching a CTO?. In-Percutaneous Coronary Intervention for Chronic Total Occlusion: The Hybrid Approach 2022 Nov 24 (pp. 255-268). Cham: Springer International Publishing.
17. Galassi AR, Werner GS, Boukhris M, Azzalini L, Mashayekhi K, Carlino M, et al. Percutaneous recanalisation of chronic total occlusions: 2019 consensus document from the EuroCTO Club. EuroIntervention. (2019) 15:198–208. doi: 10.4244/EIJ-D-18-00826
18. Azzalini L, Carlino M, Bellini B, Marini C, Pazzanese V, Toscano E, et al. Long-term outcomes of chronic total occlusion recanalization versus percutaneous coronary intervention for complex non-occlusive coronary artery disease. Am J Cardiol. (2020) 125:182–8. doi: 10.1016/j.amjcard.2019.10.034
19. Hirai T, Nicholson WJ, Sapontis J, Salisbury AC, Marso SP, Lombardi W, et al. A detailed analysis of perforations during chronic total occlusion angioplasty. JACC Cardiovasc Interv. (2019) 12:1902–12. doi: 10.1016/j.jcin.2019.05.024.
20. Galassi AR, Sumitsuji S, Boukhris M, Brilakis ES, Di Mario C, Garbo R, et al. Utility of intravascular ultrasound in percutaneous revascularization of chronic total occlusions: an overview. JACC Cardiovasc Interv. (2016) 9:1979–91. doi: 10.1016/j.jcin.2016.06.057
21. Finn MT, Doshi D, Cleman J, Song L, Maehara A, Hatem R, et al. Intravascular ultrasound analysis of intraplaque versus subintimal tracking in percutaneous intervention for coronary chronic total occlusions: one year outcomes. Catheter Cardiovasc Interv. (2019) 93:1048–56. doi: 10.1002/ccd.27958
22. Harding SA, Wu EB, Lo S, Lim ST, Ge L, Chen J-Y, et al. A new algorithm for crossing chronic total occlusions from the Asia Pacific chronic total occlusion club. JACC Cardiovasc Interv. (2017) 10:2135–43. doi: 10.1016/j.jcin.2017.06.071
23. Wu EB, Brilakis ES, Mashayekhi K, Tsuchikane E, Alaswad K, Araya M, et al. Global chronic total occlusion crossing algorithm: JACC state-of-the-art review. J Am Coll Cardiol. (2021) 78:840–53.
24. Malaiapan Y, Leung M, White AJ. The role of intravascular ultrasound in percutaneous coronary intervention of complex coronary lesions. Cardiovasc Diagn Ther. (2020) 10:1371–88. doi: 10.21037/cdt-20-189
25. Tian N-L, Gami S-K, Ye F, Zhang J-J, Liu Z-Z, Lin S, et al. Angiographic and clinical comparisons of intravascular ultrasound- versus angiography-guided drug-eluting stent implantation for patients with chronic total occlusion lesions: two-year results from a randomised AIR-CTO study. EuroIntervention. (2015) 10:1409–17. doi: 10.4244/EIJV10I12A245.
26. Mohandes M, Vinhas H, Fernández F, Moreno C, Torres M, Guarinos J. When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion. Cardiovasc Revasc Med. (2018) 19(3 Pt A):292–7.
doi: 10.1016/j.carrev.2017.10.004
27. Allahwala UK, Brilakis ES, Byrne J, Davies JE, Ward MR, Weaver JC, et al. Applicability and interpretation of coronary physiology in the setting of a chronic total occlusion. Circ Cardiovasc Interv. (2019) 12:e007813. doi: 10.1161/CIRCINTERVENTIONS.119.007813
28. Allahwala UK, Ward MR, Bhindi R. Change in the distal vessel luminal diameter following chronic total occlusion revascularization. Cardiovasc Interv Ther. (2018) 33:345–9. doi: 10.1007/s12928-017-0491-8
29. Brilakis ES, Mashayekhi K, Tsuchikane E, Abi Rafeh N, Alaswad K, Araya M, et al. Guiding principles for chronic total occlusion percutaneous coronary intervention. Circulation. (2019) 140:420–33.
30. Kalogeropoulos AS, Alsanjari O, Davies JR, Keeble TR, Tang KH, Konstantinou K, et al. Impact of intravascular ultrasound on chronic total occlusion percutaneous revascularization. Cardiovasc Revasc Med. (2021) 33:32–40. doi: 10.1016/j.carrev.2021.01.008.

Most read articles by the same author(s)