To describe the contemporary approach of chronic total occlusion (CTO) treatment of patients at the Thoraxcenter, Rotterdam, The Netherlands. Additionally, to make a critical appraisal of the performance of state-of-the-art CTO dedicated guidewires and devices in a prospective registry of patients.During 20 months, a total of 160 consecutive patients (165 CTOs) were enrolled. The mean age was 61.5+/-11.1 years and 83.6% were male. In 91.5% of the patients this was the first attempt to open the CTO and 93.8% were de novo. The overall success rate was 60.6%. A median of 1 guiding catheter was used per case (Range: 1 to 9) and a median of 4 guidewires (Range: 1 to 11; 13 different types). 74.5% patients required more than one guidewire/device for the treatment of the CTO. The guidewires that most frequently crossed the CTO were the following: PT Graphix intermediate 33.0%, Miracle 3 g 27.4% and Crosswire NT 25.5%. The only device tested as a first option for the treatment of the CTOs was the CROSSER. Overall, the CROSSER system was used in 23 (13.9%) patients with a success rate of 60.9%. The Point 9(R) X-80 Laser catheter was used in 10 (6.1%) patients with a success rate of 60%. Another 3 patients were treated with the Point 7(R) laser catheter. Both were used either to facilitate the crossing of the balloon, or to treat primarily in-stent restenosis occlusions. The SafeCross(R) System was used in 15 (9.1%) patients and the success rate in these patients was 46.7%. The most common strategy used in this registry was the use of an over-the-wire balloon in 81.5% of the cases. The parallel wire technique was used in 27.3% of the cases and in 12.7% was converted into a "see-saw" technique. When a large false lumen was created, re-entry into the true lumen was attempted in 21.2% of the cases, by means of IVUS guided approach and/or the use of stiffer guidewires, such as a Confianza guidewire. Retrograde recanalisation was attempted in 10 cases (6.1%), in three cases a graft was used; the remaining cases were treated either via collaterals or the septal branches.The treatment of CTOs requires the use of a high number of guiding catheters and guidewires, as well as the use of sophisticated devices. The procedure must be carefully planned in advance as far as possible, as well as considering a prompt change in approach during the performance of the procedure to prevent complications derived from long procedures by using specific techniques such as parallel wire, see-saw, anchoring balloon, etc.
The level of sedation in mechanically ventilated patients is most often assessed with the Ramsay Scale. Its reliability, however, has never been evaluated in a large group of professionals using the Ramsay Scale in daily clinical practice, while differences in interpretations among professionals have been indicated. We developed a written stepwise instruction to optimize the inter-observer reliability of the Ramsay Scale within a large group of Intensive Care (IC) nurses.Reliability study.The Intensive Care Cardiology (ICC) and the Intensive Care Thoracic surgery (ICT) units of a university hospital.The study population comprises randomly selected mechanically ventilated patients and IC nurses with a bachelor's degree in Nursing and an IC certification. In total 2x105 Ramsay measures were performed in 45 patients by 24 nurses.Analysis of 105 paired Ramsay scores showed an almost perfect agreement between observers (weighted K (Kw)=0.90). In both ICC patients and ICT patients, agreement between Ramsay scores was high (Kw=0.95 and Kw=0.86, respectively).By using a written stepwise instruction with the Ramsay Scale, the inter-observer reliability of the level of sedation measurements, performed in daily clinical practice within a large team of IC nurses, proved to be almost perfect.
