How to recanalize in-stent chronic total occlusions

Abstract

In-stent chronic total occlusions (IS CTOs) remain one of the most difficult and challenging subset of lesions in the field of CTO interventions. In a modern practice, this is not a rare situation and the prevalence has been reported between 5 and 25 % of all CTOs. Given that patients with CTOs caused by in-stent restenosis (ISR) are usually excluded from clinical trials, little published data exists to guide coronary intervention in this setting. The clinical impact of IS CTO is fairly significant and most patients will present with recurrent stable angina at the time of repeat angiography (60 %), while a minority of these patients present with unstable syndrome. These procedures have traditionally been associated with low success rate mainly due to wire crossing difficulties. The pathophysiology of these specific occlusions is perceived by CTO operators to play a role in the behavior of wires and subsequent success. In this chapter, we will discuss the specificities that makes in-stent occlusions challenging to re-open. Then, we will discuss how angiographic appearance can guide our strategies and how the hybrid algorithm apply to this specific entity. Finally, we will discuss different bailout techniques to avoid failing the intervention.