Editorial Comment

Across the Great Divide

Richard R. Heuser,† MD

Phillip A. Morales, MD

Phoenix Heart Center at St. Luke’s Medical CenterPhoenix, AZ

While one could argue that divides of any sort are madeto be crossed, percutaneous treatment of chronic totalcoronary occlusions (CTOs) has been severely limited byprocedural complications such as vessel injury or perfo-ration [1–3]. Despite recent advances in equipment de-sign and the introduction of new pharmacologic plateletinhibitors, the odds of successfully navigating a CTOusing a conventional wire may be less than 50% [4].Thus, these lesions have remained the Achilles’ heel ofendovascular intervention, representing a divide many ofus have been reluctant to take on.

But it appears that’s all about to change. As Yamashitaet al. report in their article, the use of an optical coher-ence reflectometry (OCR) guidance system is making theCTO divide considerably more navigable. The OCRcatheter measures the reflectivity of a scanned beam ofnear-infrared light and accurately differentiates tissuetypes, such as plaque, thrombus, and intima, and a real-time tracing relays a picture of what the forward-lookingtip sees. Resolution of up to 15 microns is possible and,when the tip of the wire comes too close to the vesselwall, improper position is reflected in the tracing and anaudible signal alerts the operator. The catheter tip maythen be repositioned and maintained in the vessel, reduc-ing the risk of perforation or extensive dissection.

Sounds great in theory, but does it really work? Theresults presented here indicate OCR’s sensitivity and

specificity for determining plaque versus the media oradventia boundary were 79% and 89%, respectively,suggesting the technology does allow differentiation thatmay prevent iatrogenic vessel injury or perforation. Ourown results [5] now include 26 patients treated for CTOsusing the OCR catheter and a technical success rate of85% without a single perforation. While outcomes withmore traditional percutaneous intervention suggest thatprocedural success is more likely in occlusions, 3months of age [2], our group has successfully used OCRto negotiate lesions. 15 years old.

These early results indicate OCR technology has thepotential to optimize treatment of CTOs, but the proce-dure is not without risk. Complications may ultimatelyprove similar to that of angioplasty in nonocclusive ste-nosis, and at present, the primary indication for recana-lization of a CTO is symptomatic angina pectoris. Theadvisability of treating asymptomatic patients is lessclear, and additional study is needed to assess the safetyand utility of OCR technology in crossing this particulardivide.

REFERENCES

1. Puma JA, Sketch MH Jr, Tcheng JE, Harrington RA, Phillips HR,Stack RS, Califf RM. Percutaneous revascularization of chroniccoronary occlusions: an overview. J Am Coll Cardiol 1995;26:1–11.

2. Danchin N, Angioi M, Rodriguez RM. Angioplasty in chroniccoronary occlusion. Arch Mal Coeur Vaiss 1999;92(Suppl 11):1657–1660.

3. Laarman GJ, Plante S, de Feyter PJ. PTCA of chronically occludedcoronary arteries. Am Heart J 1990;119:1153–1160.

4. Serruys PW, Hamburger JN, Fajadet J, Haude M, Kues H, et al.Total occlusion trial with angioplasty by using laser guidewire: theTOTAL trial. Eur Heart J 2000;21:1797–1805.

5. Heuser RR, Cordero H, Schroeder W, Weirick BA, Hatler CW,Underwood P. Fiberoptic guidance for the treatment of chronictotal occlusions: a single-center experience. J Am Coll Cardiol2001;37(Suppl A):45A.

†In accordance with the policy of the Journal, the designated authordiscloses a financial or other interest in the subject discussed in thisarticle.

Catheterization and Cardiovascular Interventions 54:264 (2001)

© 2001 Wiley-Liss, Inc.