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Yet another “Weapon” to conquer the last remaining challenge in PCI

Chronic total occlusion (CTO) remains one of the few remaining challenges in catheter-based treatment of coronary and peripheral vascular disease and is a major indication for surgical revascularization. CTO is associated with significant angina and left ventricular dysfunction, and poor long-term outcome and its treatment is often associated with a high failure rate (30–50%), a significant risk of complication, high reocclusion rates, and long procedure time and X-ray exposure [1–6]. With the advent of drug eluting stents, restenosis became a lesser concern and efforts have focused on improving the acute success rate while minimizing procedural complications and time. Everything has been tried with varying success including laser ablation, blunt dissection (Frontrunner catheter, Lumend, Redwood City, CA), proteolytic digestion, and as described in this issue of the journal near infrared optical coherence reflectometry with radiofrequency ablation (OCR-RF, Intraluminal Therapeutics, Carlsbad, CA) [4–10]. The latter two devices are the most commonly used for failure to cross with standard wires today. This, coupled with improved wire technology including tapered tips, hydrophylic coating, improved steerability, and improved visualization and X-ray equipment has improved the success rate to 60–70%, far below what is needed for a predictable and reliable procedure. However, the most significant variable has been a better understanding of CTO and improved operator skill set and a better understanding of the limitation of existing technologies, recognition of complications, and antithrombotic and antiplatelet therapy. Near Infrared light is less affected by tissue absorption and scatter and thus is an ideal tool for guiding wire progression. The “forward-looking” optical fiber emit Near Infrared light and uses algorithms to determine tissue types (plaque vs arterial wall) by measuring the intensity of light reflection. The second generation wire used in this study has the capability for radiofrequency ablation to enhance forward wire progression and has to promise to address the two limitations of existing technologies: forward progression and intraluminal localization. This paper illustrates the pitfalls of chronic occlusion treatment: long procedure times, excessive contrast use, unacceptable X-ray exposure time, and low success rate. The success rate of 51.7% in this paper, even in patients with failed standard recanalization strategies, remains unacceptably low, at least for the 48.3% of patients in whom the procedure failed. This may improve with third generation wires and improved steerability. The blunt dissection Frontrunner catheter in our experience gave similar results which improved with the second generation lower profile device. This raises several issues: