This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Kimura, M. Articles by Suzuki, T. Search for Related Content PubMed Articles by Kimura, M. Articles by Suzuki, T.

The Efficacy of a Bilateral Approach for Treating Lesions With Chronic Total Occlusions

The CART (Controlled Antegrade and Retrograde subintimal Tracking) Registry

Masashi Kimura, MD^_*,_*, Osamu Katoh, MD^_*, Etsuo Tsuchikane, MD^_*, Kenya Nasu, MD^_*, Yoshihisa Kinoshita, MD^_*, Mariko Ehara, MD^_*, Mitsuyasu Terashima, MD^_*, Hitoshi Matsuo, MD^_*, Tetsuo Matsubara, MD^_*, Keiko Asakura, MD^_*, Yasushi Asakura, MD^_*, Shigeru Nakamura, MD, Akitsugu Oida, MD, Shinichi Takase, MD, Nicolaus Reifart, MD, Carlo Di Mario, MD^||, Takahiko Suzuki, MD^_*

^_* Toyohashi Heart Center, Aichi, Japan
Kyoto Katsura Hospital, Kyoto, Japan
Takase Clinic, Gunma, Japan
University of Frankfurt, Chief Department of Cardiology, Main Taunus Hospitals, Bad Soden, Germany
^|| Royal Brompton Hospital and Imperial College, London, United Kingdom

	Abstract

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
Objectives: The aim of this study was to evaluate the safety and feasibility of a new concept for chronic total occlusion (CTO) recanalization—using a bilateral approach that utilizes a Controlled Antegrade and Retrograde subintimal Tracking (CART) technique.

Background: Successful percutaneous recanalization of coronary CTOs results in improved long-term outcomes. The recanalization of CTOs in native coronary arteries no doubt represents one of the most technically challenging of interventional procedures.

Methods: A total of 224 consecutive patients (mean age 61 ± 9 years; 86.2% men) were enrolled in this prospective multicenter registry. This technique combines the simultaneous use of antegrade and retrograde approaches. A subintimal dissection is created in both antegrade and retrograde fashion, thereby limiting the extension of the subintimal dissection within the CTO portion.

Results: Of 224 CTO lesions (>3 months in duration) undergoing attempted recanalization using the CART technique, 145 cases (64.7%) had undergone previous CTO recanalization attempts. The success rates of crossing in a retrograde fashion with a wire and a balloon were 87.9% and 79.9%, respectively. The overall technical and procedural success rates achieved in this registry were 92.4% and 90.6%, respectively.

Conclusions: A bilateral approach for CTO lesions using the CART technique is feasible, safe, and has a higher success rate than previous approaches. These results indicate that a bilateral technique can solve a major dilemma that commonly affects CTO procedures.

Key Words: chronic total occlusions • bilateral approach • CART technique • revascularization

Abbreviations and Acronyms   CTO = chronic total occlusion   MACE = major adverse cardiac events   MI = myocardial infarction   PCI = percutaneous coronary intervention

Recently, we attempted to improve post-procedural outcomes using a bilateral approach for the treatment of complex CTO lesions. We have developed a new concept for CTO recanalization, the Controlled Antegrade and Retrograde subintimal Tracking (CART) technique (9,10), which allows limited subintimal tracking only in the area of the CTO lesion. Used in combination with a retrograde approach, this technique avoids the difficulty of re-entering the distal true lumen. Few previous studies have reported acute results with the introduction of this technique (11). The aim of this study was to evaluate the safety and feasibility of using a bilateral approach including the CART technique, a new concept for CTO recanalization.

	Methods

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
Patient population and protocol.   The CART registry is a prospective, nonrandomized, multicenter (43 centers) trial that enrolled 224 patients with CTO lesions from October 2005 to April 2008. Inclusion criteria were CTO lesions located in the left anterior descending artery, right coronary artery, left circumflex artery, or left main coronary artery with eligible collateral channels with greater than grade I fillings of the recipient artery assessed according to the Rentrop classification (12). In cases with eligible collateral channels (Rentrop class >1), after careful assessment by super-selective contrast injection with a microcatheter, the most suitable collateral with the best collateral connection grade (13) was assessed. Patients were excluded for any of the following: use of heparin, aspirin, or clopidogrel; severe renal failure (patients with hemodialysis were included); or severe heart failure or acute MI (within 2 weeks). In addition, cases without any collateral channel (Rentrop class 0) and cases with a collateral channel (often epicardial channel) serving as the only remaining feeding donor artery were contraindications for the retrograde approach. The protocol was approved by ethics committees in each participating center, and all participants gave written informed consent.

Definitions.   Coronary CTO is defined as a true total occlusion with complete interruption of antegrade blood flow as assessed by coronary arteriography (Thrombolysis In Myocardial Infarction [TIMI] flow grade 0, known as a "true" total occlusion) and with an estimated duration of occlusion >3 months. Technical success was defined as the ability to cross the occluded segment with both a wire and a balloon and successfully open the artery; the restoration of antegrade, TIMI flow grade 3; and a <40% final residual stenosis on all views. Procedural success was defined as technical success with no in-hospital major adverse cardiac events (MACE). In-hospital MACE included death, Q-wave MI, or recurrent angina that resulted in urgent revascularization (coronary artery bypass graft surgery/urgent repeat percutaneous transluminal coronary angioplasty). MI was diagnosed by an increase in the creatine kinase level to >2x the upper limit of normal.

Interventional technique.   Without attempting antegrade recanalization, the retrograde approach via collateral channels was attempted in all cases. During the retrograde approach, retrograde wire crossing, kissing wire technique (11), knuckle wire technique, CART technique, or reverse CART technique were attempted. First, a hydrophilic floppy wire was advanced in retrograde fashion through the intercoronary collateral using a microcatheter. After careful collateral channel assessment by super-selective contrast injection, the wire was advanced through the most suitable collateral. A small balloon (1.25 mm or 1.5 mm) or septal dilator (Asahi Intec, Aichi, Japan) was then advanced in the collateral channel.

With regard to the CART technique, as described previously (9,10), the retrograde wire is placed at the distal end of the CTO. The wire then penetrates in retrograde fashion from the distal true lumen into the CTO, and finally into the subintimal space at the CTO site. Simultaneously, another wire is advanced in antegrade fashion from the proximal true lumen into the CTO, then into the subintimal space at the CTO site. After advancing while inflating a small balloon (1.5 to 2.0 mm) over the retrograde wire into the subintima, the 2 dissections created by the antegrade wire and the retrograde balloon lie in the subintima at the CTO site, which allows them to be easily connected. Thereafter, the antegrade wire is advanced to the distal true lumen, after which balloon dilation and stent implantation are performed following successful recanalization. This technique allows limited subintimal tracking only in the portion of the CTO lesion. The reverse CART technique is a modified version of the CART technique in which a retrograde wire crosses the subintimal space after balloon dilation with an antegrade balloon. The knuckle wire technique is a procedure used to form the subintimal space, instead of using a balloon, with the rounded tip of the wire, which resembles a "knuckle" (Fig. 1). This technique is effective for CTO lesions characterized by heavy calcification or bending, in which only the wire crosses the lesion and the balloon is not able to enter. If we failed retrograde guidewire crossing, an antegrade approach was attempted. In this registry, patients were treated by a pair of highly skilled, experienced operators (O.K. and E.T.). Of 224 cases, 191 cases were treated by O.K. and 33 were treated by E.T. All patients were treated with a thienopyridine (ticlopidine or clopidogrel) and aspirin, and all patients received heparin at the time of the procedure to achieve an activated clotting time of 250 to 350 s.

View larger version (37K): [in this window] [in a new window] [Download PPT slide]   Figure 1 The Knuckle Wire Technique The technique is used to make the subintimal space, instead of using the balloon, with the rounded tip of the wire, which resembles the "knuckle." RCA = right coronary artery.

	Results

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
Baseline characteristics.   All 224 consecutive patients (224 lesions) who underwent PCI for a chronically occluded native coronary vessel were included in this registry. Baseline patient demographic and clinical data are shown in Table 1. The CTO vessel was located in the right coronary artery in 156 (69.6%) patients, the left anterior descending coronary artery in 54 (24.1%) patients, the left circumflex coronary artery in 9 (4.0%) patients, the left main coronary artery in 3 (1.3%) patients, and bypass graft segments in 2 (0.9%) patients. Target CTO lesions showed "no-stump" ends in 170 (75.9%) lesions, were located at the branching point in 139 (62.1%) lesions, and had fluoroscopically visible calcification in 130 (58.0%) lesions. After failure upon first attempt with the antegrade approach, reattempts were made in 64.7% of the patients in this registry.

View larger version (40K): [in this window] [in a new window] [Download PPT slide]   Figure 2 Flow Diagram of the Procedure In 197 of 224 patients, a retrograde guidewire was successfully crossed into the target artery distal to the chronic total occlusion lesion. In 189 patients, a retrograde balloon was successfully crossed into the target artery distal to the chronic total occlusion lesion. Successful recanalization was achieved in 207 patients. Solid arrows shows "success," and dashed arrows "failure." CART = Controlled Antegrade and Retrograde subintimal Tracking.

Clinical outcomes.   During the index hospitalization, in-hospital MACE occurred at a rate of 1.8%. The rates of Q-wave MI and non–Q-wave MI were 0.9% and 3.6%, respectively (Table 2). After including those cases in which an antegrade approach was attempted after a retrograde approach failed, the overall technical and procedural success rates were 92.4% (207 of 224 patients) and 90.6% (203 of 224 patients), respectively. Major in-hospital complications are shown in Table 3. In addition, hematoma/perforation in the septal branch, minor perforation/dissection in a distal vessel, and minor distal embolism at post-procedure were observed in 3 cases, 2 cases, and 1 case, respectively. Dissection in the ostium of a donor artery due to the guiding catheter occurred in 1 case. No major collateral sources were lost.

	Discussion

Top Abstract Methods Results Discussion Conclusions REFERENCES

Success rate.   Several large studies (2,5) have reported on the clinical impact of successful percutaneous CTO revascularization. In particular, studies have shown that successful PCI of a CTO lesion reduces the incidence of MI, cardiac death, and bypass surgery, resulting in enhanced 1-year survival. From this point of view, the influence of the immediate result of a CTO procedure on long-term outcomes is an important factor. In recent contemporary series, procedural success rates have ranged from 55% to 80%, with the variability reflecting differences in operator technique and experience, availability of advanced guidewires, CTO definitions, and case selection (2,15). Recent procedural outcomes after PCI for CTO lesions have increased significantly due to improved device technology, as well as technique and experience, such that successful recanalization of true CTOs may now be achieved in approximately 80% of attempted lesions (2,5,16). We reported that technical success was achieved in 207 (92.4%) of 224 attempted cases using a retrograde approach including the CART technique. In this registry, CTO lesions were most frequently located in the right coronary artery (69.6%), similar to previous reports of experience with a retrograde approach (11,17,18), although several studies (2,8) have demonstrated an equal distribution of CTO lesions in all 3 vessels. This discrepancy could be explained by the inclusion of cases with a retrograde approach and reattempted cases, which means that these cases included those with septal channels deemed suitable for approach as well as more complex cases. Additionally, in patients enrolled in this registry, there was a high incidence of diabetes, calcified lesions, previous attempts to open the occlusion, and longer CTO length. With such a complex patient population, it could be argued that CTO lesions attempted in this registry were more difficult to successfully treat than those of previous CTO studies. The high success rate in this registry was achieved despite the complex nature of the treated lesions (more repeat cases, diabetes, older CTO ages, and so on), which negatively affect the ability to successfully cross a CTO (3,5,19–23). Even with improvements in guidewire technology, guidewire crossing of a CTO is the most technically demanding phase of the procedure and the point at which success or failure is typically determined. The most common PCI failure mode for CTOs is the inability to successfully pass a guidewire across the lesion into the true lumen of the distal vessel when attempting to cross in an antegrade fashion (24). Jaffe et al. (25) analyzed the natural history of CTOs in an experimental model. In their histological analysis, anatomic evidence was shown of a "proximal fibrous cap," which was a thickened structure at the entrance of the CTO containing particularly densely packed collagen. Microcomputed tomographic imaging also demonstrated spatial differences in vascular geometry. Regression of the proximal recanalization channel and the blunt entrance appeared at 24 weeks (25). The histological composition of the proximal fibrous cap is thicker and harder than that of the distal fibrous cap (9,25). In addition, on angiography, the distal end of the CTO is typically tapered, although whether the proximal end of the CTO shows a tapered or abrupt occlusion depends on the individual case. Ozawa et al. (26) found that the CTO lesion could be crossed without difficulty even with a soft wire by following the retrograde approach. This was probably because the distal lesion was tapered and the fibrous cap at that end was either very thin or nonexistent (26). These 2 characteristics (thin, tapered) of the distal fibrous cap have been of paramount importance in spurring the development and successful application of the retrograde approach for percutaneous CTO recanalization (9). This anatomy and technique may account in large part for the ease of retrograde wiring and could be associated with the higher success rate achieved in this registry. We believe that the degree of difficulty in crossing a CTO lesion with a wire is, in part, different between the antegrade and retrograde approaches.

Complications of CTO angioplasty.   Typical complications with an antegrade approach are often induced by excessive challenges to cross with stiffer guidewires. During CTO angioplasty, death and MI may occur from shearing off the collateral circulation, damaging the proximal epicardial coronary artery or proximal side branches, thrombus formation, arrhythmia, air embolism, or perforation (27,28). A bilateral approach allows us to avoid such excessive challenges because it is possible to change the approach side if either side proves too difficult to cross with a wire. The complications that accompany the retrograde approach are similar to those encountered with the antegrade approach, except for device-induced thrombosis in the donor artery, collateral perforations, subendocardial hematoma, and collateral channel rupture. The rate of in-hospital MACE in this registry was 1.8%. This was lower than previously reported (2,5), although the strategy was more complicated and required a steeper learning curve than the conventional approach. A total of 3 in-hospital major complications occurred in the early phase (within 8 months of the beginning of this registry). These results may suggest that the retrograde approach with the CART technique is safe and secure, but requires a learning period. A possible reason for the low rate of in-hospital MACE could be the participation of experienced, highly skilled operators in this registry. Minor complications such as hematoma/perforation/dissection/embolism in septal branches and distal vessels were also observed. These minor complications did not induce residual ischemia or loss of the major collateral source.

Study limitations.   Although this was a multicenter registry, the study was performed in a nonrandomized manner. We included CTO lesions for a retrograde approach with eligible collateral channels with greater than grade I fillings of the recipient artery assessed according to Rentrop classification. The success of CTO angioplasty is highly dependent on the operator's experience. In this registry, patients were treated by a pair of highly skilled, experienced operators (O.K. and E.T.). There were other CTO cases in each institute that were unsuitable for a retrograde approach during this registry that were difficult to investigate. In this registry, as we examined the feasibility of the retrograde approach, all procedures were initiated in a retrograde manner, unlike the general strategy for CTO lesions. Appropriately powered randomized trials using the latest technology are required to definitively prove their safety and efficacy for this application.

	Conclusions

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
The use of a combination of antegrade and retrograde approaches including the CART technique for CTO lesions is feasible and safe. This approach can provide a higher rate of successful CTO recanalization than the previous approach. These results indicate that this technique can solve a major dilemma with current CTO procedures.

	Acknowledgments

 
The authors thank Ryuichi Sakai, MD, Masakazu Aroga, MD, Kazuyoshi Ohata, MD, Yuji Ikari, MD, Keiichi Igarashi, MD, Tsutomu Fujita, MD, Kazushi Urasawa, MD, Noriyuki Miyamoto, MD, Mikihiro Kijima, MD, Tomohiro Kawasaki, MD, Mitsugu Hirokami, MD, Yuko Onishi, MD, Yasumi Igarashi, MD, Eiji Nozaki, MD, Satoru Otsuji, MD, Takatoshi Hayashi, MD, Norio Komatsu, MD, Taro Saito, MD, Kenichiro Ito, MD, Yoichi Nozaki, MD, Eijiro Hattori, MD, Yoshinori Yasaka, MD, Shigeihro Tanaka, MD, Hideo Tamai, MD, Yuichi Matsuda, MD, Hideo Nishikawa, MD, Makoto Muto, MD, Yasuhiro Taniguchi, MD, Jun Tanigawam, MD, Eulogio Garcia, MD, Barry D. Rutherford, MD, and Thierry Lefevre, MD, for patient recruitment.

^_* Reprint requests and correspondence: Dr. Masashi Kimura, Toyohashi Heart Center 21-1, Gobudori, Oyama-cho, Toyohashi 4418530, Japan (Email: kimura.masashi{at}gmail.com).

Manuscript received June 15, 2009; revised manuscript received September 8, 2009, accepted September 18, 2009.

	REFERENCES

Top Abstract Methods Results Discussion Conclusions REFERENCES

 

1. Melchior JP, Doriot PA, Chatelain P, et al. Improvement of left ventricular contraction and relaxation synchronism after recanalization of chronic total coronary occlusion by angioplasty J Am Coll Cardiol 1987;9:763-768.[Abstract]
2. Suero JA, Marso SP, Jones PG, et al. Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience J Am Coll Cardiol 2001;38:409-414.[Abstract/Free Full Text]
3. Noguchi T, Miyazaki MS, Morii I, Daikoku S, Goto Y, Nonogi H. Percutaneous transluminal coronary angioplasty of chronic total occlusions. Determinants of primary success and long-term clinical outcome. Catheter Cardiovasc Interv 2000;49:258-264.[CrossRef][Web of Science][Medline]
4. Ivanhoe RJ, Weintraub WS, Douglas Jr. JS, et al. Percutaneous transluminal coronary angioplasty of chronic total occlusions. Primary success, restenosis, and long-term clinical follow-up. Circulation 1992;85:106-115.[Abstract/Free Full Text]
5. Olivari Z, Rubartelli P, Piscione F, et al. Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE) J Am Coll Cardiol 2003;41:1672-1678.[Abstract/Free Full Text]
6. Angioi M, Danchin N, Juilliere Y, et al. [Is percutaneous transluminal coronary angioplasty in chronic total coronary occlusion justified? Long term results in a series of 201 patients] Arch Mal Coeur Vaiss 1995;88:1383-1389.[Web of Science][Medline]
7. Dzavik V, Buller CE, Lamas GA, et al. Randomized trial of percutaneous coronary intervention for subacute infarct-related coronary artery occlusion to achieve long-term patency and improve ventricular function: the Total Occlusion Study of Canada (TOSCA)-2 trial Circulation 2006;114:2449-2457.[Abstract/Free Full Text]
8. Prasad A, Rihal CS, Lennon RJ, Wiste HJ, Singh M, Holmes Jr DR. Trends in outcomes after percutaneous coronary intervention for chronic total occlusions: a 25-year experience from the Mayo Clinic J Am Coll Cardiol 2007;49:1611-1618.[Abstract/Free Full Text]
9. Surmely JF, Katoh O, Tsuchikane E, Nasu K, Suzuki T. Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions Catheter Cardiovasc Interv 2007;69:826-832.[CrossRef][Web of Science][Medline]
10. Surmely JF, Tsuchikane E, Katoh O, et al. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique J Invasive Cardiol 2006;18:334-338.[Medline]
11. Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion Catheter Cardiovasc Interv 2008;71:8-19.[CrossRef][Web of Science][Medline]
12. Rentrop KP, Cohen M, Blanke H, Phillips RA. Changes in collateral channel filling immediately after controlled coronary artery occlusion by an angioplasty balloon in human subjects J Am Coll Cardiol 1985;5:587-592.[Abstract]
13. Werner GS, Ferrari M, Heinke S, et al. Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions Circulation 2003;107:1972-1977.[Abstract/Free Full Text]
14. Barlis P, Mario CD. Retrograde approach to recanalising coronary chronic total occlusions immediately following a failed conventional attempt Int J Cardiol 2009;133:e14-e17.[CrossRef][Web of Science][Medline]
15. Safian RD, McCabe CH, Sipperly ME, McKay RG, Baim DS. Initial success and long-term follow-up of percutaneous transluminal coronary angioplasty in chronic total occlusions versus conventional stenoses Am J Cardiol 1988;61:23G-28G.[CrossRef][Medline]
16. Stone GW, Colombo A, Teirstein PS, et al. Percutaneous recanalization of chronically occluded coronary arteries: procedural techniques, devices, and results Catheter Cardiovasc Interv 2005;66:217-236.[CrossRef][Web of Science][Medline]
17. Di Mario C, Barlisi P, Tanigawa J, et al. Retrograde approach to coronary chronic total occlusions: preliminary single European center experience EuroIntervention 2007;3:181-187.[Medline]
18. Rathore S, Matsuo H, Terashima M, et al. Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008: impact of novel guidewire techniques J Am Coll Cardiol Intv 2009;2:489-497.[Abstract/Free Full Text]
19. Lamas GA, Flaker GC, Mitchell G, et al. Effect of infarct artery patency on prognosis after acute myocardial infarction. The Survival and Ventricular Enlargement Investigators. Circulation 1995;92:1101-1109.[Abstract/Free Full Text]
20. Giokoglu K, Preusler W, Storger H, et al. [The recanalization of chronic coronary artery occlusions: what factors influence success?] Dtsch Med Wochenschr 1994;119:1766-1770.[Medline]
21. Suzuki T, Hosokawa H, Yokoya K, et al. Time-dependent morphologic characteristics in angiographic chronic total coronary occlusions Am J Cardiol 2001;88:167-169.[CrossRef][Web of Science][Medline]
22. Melchior JP, Meier B, Urban P, et al. Percutaneous transluminal coronary angioplasty for chronic total coronary arterial occlusion Am J Cardiol 1987;59:535-538.[CrossRef][Web of Science][Medline]
23. Tan KH, Sulke N, Taub NA, Watts E, Karani S, Sowton E. Determinants of success of coronary angioplasty in patients with a chronic total occlusion: a multiple logistic regression model to improve selection of patients Br Heart J 1993;70:126-131.[Abstract/Free Full Text]
24. Kinoshita I, Katoh O, Nariyama J, et al. Coronary angioplasty of chronic total occlusions with bridging collateral vessels: immediate and follow-up outcome from a large single-center experience J Am Coll Cardiol 1995;26:409-415.[Abstract]
25. Jaffe R, Leung G, Munce NR, et al. Natural history of experimental arterial chronic total occlusions J Am Coll Cardiol 2009;53:1148-1158.[Abstract/Free Full Text]
26. Ozawa N. A new understanding of chronic total occlusion from a novel PCI technique that involves a retrograde approach to the right coronary artery via a septal branch and passing of the guidewire to a guiding catheter on the other side of the lesion Catheter Cardiovasc Interv 2006;68:907-913.[CrossRef][Web of Science][Medline]
27. Stewart JT, Denne L, Bowker TJ, et al. Percutaneous transluminal coronary angioplasty in chronic coronary artery occlusion J Am Coll Cardiol 1993;21:1371-1376.[Abstract]
28. Orford JL, Fasseas P, Denktas AE, Garratt KN. Anterior ischemia secondary to embolization of the posterior descending artery in a patient with a chronic total occlusion of the left anterior descending artery J Invasive Cardiol 2002;14:527-530.[Medline]

This article has been cited by other articles:

				Y. Morino, M. Abe, T. Morimoto, T. Kimura, Y. Hayashi, T. Muramatsu, M. Ochiai, Y. Noguchi, K. Kato, Y. Shibata, et al. Predicting Successful Guidewire Crossing Through Chronic Total Occlusion of Native Coronary Lesions Within 30 Minutes: The J-CTO (Multicenter CTO Registry in Japan) Score as a Difficulty Grading and Time Assessment Tool J. Am. Coll. Cardiol. Intv., February 1, 2011; 4(2): 213 - 221. [Abstract] [Full Text] [PDF]

This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Kimura, M. Articles by Suzuki, T. Search for Related Content PubMed Articles by Kimura, M. Articles by Suzuki, T.