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Jiang Y, Wei ZY, Wu YJ, Dou KF, Yang WX, Yang YJ, Zhao HJ, Ning Y, Li A, Chang Y, Li ZH, Qian HY. The impacts of percutaneous coronary intervention to treat chronic total occlusion of right coronary artery on the 5-year prognosis: A single-centered retrospective study. Int J Cardiol 2024:132384. [PMID: 39032578 DOI: 10.1016/j.ijcard.2024.132384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 05/08/2024] [Accepted: 07/17/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Chronic total occlusions (CTO) occur in about 20% of patients referred for coronary angiography, and right coronary artery (RCA) CTO has been reported in 38-50% of the entire CTO population. Limited data on angiographic and procedural characteristics of RCA-CTO and the risk of adverse cardiac events asks for a detailed study. METHODS From 2010 to 2013, patients with attempted revascularization of at least one CTO lesion were included and followed up to 5 years after PCI. Eligible patients are assigned to RCA-CTO and non-RCA-CTO groups based on their target vessels. The primary endpoint was major adverse cardiovascular events (MACEs; a composite of all-cause death, myocardial infarction (MI) or rehospitalization for heart failure), and secondary endpoints were cardiac death, target lesion revascularization (TLR) and target vessel revascularization (TVR). RESULTS The present study included 2659 eligible patients, among which 1285 patients were assigned to the RCA-CTO group, whereas 1374 patients were assigned to the non-RCA-CTO group. Lesions in RCA had longer lesion length, higher J-CTO score, higher rates of severe vessel tortuosity, a higher percentage of Rentrop grade 2-3, and more likely to be re-try lesion than those in LAD or LCX (all P < 0.01). CTO lesions in RCA reached less successful recanalization and post-procedural TIMI 3 flow (all <0.01). Multivariate Cox analysis revealed that RCA-CTO was not associated with primary outcome MACEs. Besides MACEs, RCA-CTO was also not associated with cardiac death, but was significantly associated with TLR and TVR (adjusted HR: 1.37 [95% CI:1.07-1.76], P = 0.01; adjusted HR: 1.43 [95% CI:1.13-1.82], P = 0.003). CONCLUSION RCA-CTO lesions, which had more complex angiographic features, independently contributed to TLR and TVR but not to MACEs or cardiac death in the 5 years of follow-up.
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Affiliation(s)
- Yu Jiang
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Yao Wei
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Jian Wu
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke-Fei Dou
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-Xian Yang
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Jin Yang
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han-Jun Zhao
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Ning
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ang Li
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue Chang
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Hao Li
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hai-Yan Qian
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Sahu AK, Kazmi DH, Kaushik A. Is it Worthy Enough to Revascularize Chronically Occluded Coronaries? Cardiol Rev 2024; 32:338-347. [PMID: 36912530 DOI: 10.1097/crd.0000000000000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Chronic total occlusions (CTOs) represent the "final frontier" of coronary interventions with the lowest procedural success rates and the most common reason for incomplete revascularization and referral to coronary artery bypass graft surgery (CABG). CTO lesions are not an infrequent finding during coronary angiography. They are often responsible for enhancing the complexity of the coronary disease burden thereby affecting the final interventional decision in the process. Notwithstanding the modest technical success of CTO-PCI, most of the earlier observational data demonstrated a clear survival benefit free of major cardiovascular events (MACE) in patients undergoing successful CTO revascularization. However, data from recent randomized trials fail to uphold the same survival advantage albeit, showing some trend toward improvement in left ventricular function, quality of life indicators and freedom from fatal ventricular arrythmia. Various guidance statements propose a well-defined role for CTO intervention in specific situations provided criterions for patient selection, appreciable inducible ischemia, myocardial viability and cost-risk-benefit analysis are met.
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Affiliation(s)
- Ankit Kumar Sahu
- From the Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
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Hailin D, Hongtu Q, Wenyong Z. Percutaneous coronary intervention for chronic total occlusion of the left circumflex branch in mirror dextrocardia: a case report. J Med Case Rep 2023; 17:486. [PMID: 37990278 PMCID: PMC10664485 DOI: 10.1186/s13256-023-04196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/02/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Mirror dextrocardia (MDC) is a condition in which the heart is located in a mirror-image position on the right side of the chest compared to the normal position in individuals with physiological variations. Patients with MDC and chronic total occlusion (CTO) of the left circumflex branch (LCX) are extremely rare in clinical practice. The treatment of MDC-CTO-LCX differs significantly from patients without mirror dextrocardia and the same condition in terms of instrument selection and procedural techniques. In this article, we report a successful case of interventional treatment in a patient with MDC-CTO-LCX. We summarize the anatomical and electrocardiographic variations in patients with MDC-CTO-LCX, and discuss the selection of interventional instruments and techniques that can be useful for interventionists as well as the diagnostic and therapeutic considerations that can be helpful for clinical physicians. CASE PRESENTATION A male Han Chinese patient, 51, was admitted, presenting recurrent chest pain for a year and recent onset of exertional fatigue over the past week.He reported episodes of chest pain following physical activities over the past year, lasting between 5 and 20 min.Despite these symptoms, the patient did not seek immediate medical attention, and the occurrence of his chest pain has progressively lessened within the year.A week prior, the patient developed exertional dyspnea after brief walks, though without any episodes of nocturnal paroxysmal dyspnea.Upon arrival at our hospital for evaluation, he was initially diagnosed with chronic coronary syndrome, previous inferior myocardial infarction, atrial arrhythmia, and classified under the New York Heart Association functional class III.Following his admission, a chest X-ray and coronary angiography were conducted.The results indicated mirror dextrocardia and total occlusion of the left circumflex branch. Percutaneous coronary intervention (PCI) was performed on the left circumflex branch. Subsequent angiography demonstrated optimal stent positioning without evidence of hematoma or dissection.Following the procedure, the patient's symptoms of chest pain and exertional dyspnea were resolved, which led to his subsequent discharge.A follow-up electrocardiogram, 10 months post-procedure, displayed a slow and regular atrial rhythm. CONCLUSIONS The incidence of dextrocardia is very low, and it may appear normal on an electrocardiogram; however, careful diagnosis is required when there is an abnormal direction of the P wave in limb leads. During the operation for chronic occlusive lesions of the right-sided coronary artery, the anomalous anatomical structure necessitates specific requirements for instrument selection and operative techniques. After revascularization of chronic occlusive vessels in dextrocardia, routine electrocardiographic examination may show false normalization, requiring caution in interpretation.
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Affiliation(s)
- Du Hailin
- Cardiovascular Department, Chengdu Qingbaijiang District People's Hospital, No.15, Fenghuang East 4th Road, Qingbaijiang District, Chengdu, 610399, Sichuan, China
| | - Qiao Hongtu
- Cardiovascular Department, Chengdu Qingbaijiang District People's Hospital, No.15, Fenghuang East 4th Road, Qingbaijiang District, Chengdu, 610399, Sichuan, China
| | - Zhang Wenyong
- Cardiovascular Department, Chengdu Qingbaijiang District People's Hospital, No.15, Fenghuang East 4th Road, Qingbaijiang District, Chengdu, 610399, Sichuan, China.
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Rha SW, Li H, Choi CU, Choi BG. Impact of complete revascularization on long-term clinical outcomes for patients with diabetes mellitus and coronary chronic total occlusion lesion. Heart Vessels 2022; 37:1679-1688. [PMID: 35525845 DOI: 10.1007/s00380-022-02079-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 04/15/2022] [Indexed: 11/24/2022]
Abstract
Diabetes mellitus (DM) is a substantial risk factor in developing coronary artery disease (CAD), coronary chronic total occlusion (CTO) lesions are discovering 10-35% in patients who underwent coronary angiography. This study compares the long-term clinical outcomes of two treatment strategies, percutaneous coronary intervention (PCI) with complete recanalization versus medication therapy (MT) with CTO lesion in DM patients with CTO. This study is a single-center, prospective, all-comer registry designed to reflect "real world" practice since 2004. Of a total of 4909 consecutive patients were diagnosed with significant CAD by coronary angiography (CAG). A total of 372 patients has DM and CTO lesions. Patients were divided into the PCI group (n = 184) and the MT group (n = 179). The primary endpoint, defined as the composite of death or myocardial infarction (MI), was compared between the two groups up to 5 years. In addition, inverse probability weighting (IPTW) analysis, derived from the logistic regression model, was performed to adjust for potential confounders. Compared to the MT group, the PCI group was associated with a significantly reduced incidence of the primary endpoint before [hazard ratio; HR 0.267, 95% confidence interval (CI) 0.116-0.614] and after (HR 0.142, 95% CI 0.032-0.629) adjusting confounding factors by IPTW. Complete revascularization by CTO-PCI with MT in DM patients should be the preferred treatment strategy compared with the MT alone strategy since it reduces the composite of death or MI up to 5 years.
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Affiliation(s)
- Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea.
| | - Hu Li
- Cardiovascular Department, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Byoung Geol Choi
- Cardiovascular Research Institute, Korea University, 198, Gamasan-ro, Guro-gu, Seoul, 08309, Republic of Korea.
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Aslan B, Özbek M, Aktan A, Boyraz B, Tenekecioğlu E. Factors associated with all-cause mortality in patients with coronary artery chronic total occlusions undergoing revascularization (percutaneous coronary intervention or surgery) or medical treatment. KARDIOLOGIIA 2022; 62:49-55. [PMID: 35414361 DOI: 10.18087/cardio.2022.3.n1948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/03/2022] [Indexed: 01/21/2023]
Abstract
Aim Chronic total occlusion of a coronary artery (CTO) is a predictor of early and late cardiovascular mortality and poor cardiovascular outcomes in patients with coronary artery disease. The purpose of this study was to identify predictors of all-cause mortality in CTO patients that underwent invasive treatment.Material and methods Patients between 2012 and 2018 with CTO in at least one vessel, as demonstrated by coronary angiography, were included retrospectively in the study. The patients were divided into two groups, an intervention group (percutaneous and surgical revascularization) and a medical group.Results A total of 543 patients were studied, 152 females (28%) and 391 males (72%). The median follow-up period was 49 (26-72) mos. A total of 186 (34.2%) patients in the medical group and 357 (65.8%) patients in the invasive therapy group were followed. The 5-yr death rate was observed in 50 (26.9%) patients in the medical group and 53 (14.8%) patients in the intervention group, and it was found to be statistically higher in the medical group (p=0.001). In multivariable analysis, heart failure (odds ratio (OR): 1.92, 95% CI: 1.18-3.14; p=0.01), higher glucose levels (OR: 1.05, 95% CI: 1,02-1.08; p=0.04), lower albumin levels (OR: 0.49, 95% Cl: 0.32-0.72; p=0.001), SYNTAX score (OR: 1.03, 95% CI: 1.01-1.05; p=0.001), and CTO (≥2 occluded artery) (OR: 0.42, 95% CI: 0.22-0.72; p=0.01) were independent factors for all-cause mortality.Conclusion In comparison to the revascularized group, there was an increase in mortality among CTO patients treated medically. Heart failure, SYNTAX score, albumin, glucose, and CTO (≥2 occluded arteries) were independent risk factors for all-cause mortality.
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Affiliation(s)
- B Aslan
- Health Science University, Gazi Yaşargil Training and Research Hospital
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6
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Scotti A, Godino C, Munafò A, Pivato CA, Chiarito M, Fiore G, Di Maio S, Vergara P, Della Bella P, Carlino M, Margonato A, Colombo A. Cardiac and sudden death after chronic total occlusion percutaneous coronary intervention: Prognostic role of the target vessel. Catheter Cardiovasc Interv 2021; 97:E789-E800. [PMID: 33332744 DOI: 10.1002/ccd.29425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/29/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The role of the target vessel in percutaneous revascularization of chronic total occlusion (CTO) is unclear. OBJECTIVE We sought to assess the long-term results of percutaneous coronary intervention (PCI) for CTO lesions in each coronary artery and to investigate the impact of successful revascularization and previous myocardial infarction (MI) in the territory of the target vessel. METHODS AND RESULTS Cohort observational study on 1,124 patients who have undergone CTO PCI attempt: 371 on left anterior descending artery (LAD), 485 right coronary artery, and 268 left circumflex. Patients were further stratified by successfully revascularized and not-revascularized CTO (CTO-NR). Vessels affected by a previous MI were defined as infarct-related artery (IRA). The primary endpoint was cardiac death; the secondary endpoint was the combined rate of sudden cardiac-death and sustained ventricular-arrhythmias (SCD/SVAs). Propensity score-matching was performed to evaluate LAD versus NON-LAD CTO. Up to 12-year follow-up, the clinical benefit associated with successful PCI was consistent across the three groups. CTO-NR had the greatest association with cardiac death and SCD/SVAs in each coronary artery and in IRA-CTO patients. CONCLUSIONS Unsuccessful percutaneous CTO revascularization was associated with lower cardiac survival and freedom from SCD/SVAs, irrespective of the vessel treated. This result was mainly driven by patients with an IRA CTO.
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Affiliation(s)
- Andrea Scotti
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy.,Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Cosmo Godino
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Munafò
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Carlo A Pivato
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.,Cardio Center, Humanitas Research Hospital, Milan, Italy
| | - Mauro Chiarito
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.,Cardio Center, Humanitas Research Hospital, Milan, Italy
| | - Giorgio Fiore
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Silvana Di Maio
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Vergara
- Arrhythmias and Cardiac Electrophysiology, Ospedale San Raffaele, Milan, Italy
| | - Paolo Della Bella
- Arrhythmias and Cardiac Electrophysiology, Ospedale San Raffaele, Milan, Italy
| | - Mauro Carlino
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Margonato
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.,Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
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Lin S, Chen S, Yan H, Dou K, Zhao Y, Liu J, Zheng Z. Clinical Outcomes in Chronic Total Occlusion Revascularization Versus No Chronic Total Occlusion Revascularization: Variability by Target Vessel. Angiology 2021; 72:565-574. [PMID: 33715476 DOI: 10.1177/0003319721991369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We aimed to investigate the impact of target vessel on clinical outcomes in chronic total occlusion (CTO) revascularization versus no CTO revascularization. This multicenter, retrospective, cohort study involves patients with ≥1 CTO. After classification based on different CTO target vessels or multiple CTOs, patients were further categorized as the CTO revascularization group and the no CTO revascularization group based on treatment received. The primary outcome was a composite of death, myocardial infarction, stroke, repeated revascularization, and hospital admission due to ischemic symptoms. From August 2016 to August 2017, 1712 eligible patients were consecutively enrolled. Chronic total occlusion revascularization was associated with lower risk of 1-year major adverse cardiovascular and cerebrovascular events (MACCEs; adjusted hazard ratio [HR]: 0.36; 95% CI: 0.20-0.67; P = .001) compared with no CTO revascularization in left anterior descending (LAD) CTO patients. The benefit of CTO revascularization was not evident among those with left circumflex (LCX; adjusted HR: 0.51; 95% CI: 0.23-1.10; P = .087), right coronary artery (RCA; adjusted HR: 1.17; 95% CI: 0.59-2.33; P = .648), and multiple CTOs (adjusted HR: 1.00; 95% CI: 0.41-2.44; P = .994). Revascularization for LAD CTO, but not LCX, RCA, or multiple CTOs, was associated with lower risk of 1-year MACCEs compared with no CTO revascularization.
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Affiliation(s)
- Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sipeng Chen
- Department of Information Center, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Hongbing Yan
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736 Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Kefei Dou
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736 Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jian Liu
- Department of Cardiology, Peking University People's Hospital, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, 34736Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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Tian T, Guan C, Gao L, Yuan J, Cui J, Hu F, Tang Y, Dou K, Wu Y, Yang Y, Qiao S, Xu B, Yang W. Predictors for adverse outcomes of patients with recanalized chronic total occlusion lesion. Eur J Clin Invest 2021; 51:e13368. [PMID: 32748956 DOI: 10.1111/eci.13368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/27/2020] [Accepted: 07/26/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND It is ill-defined which factors affect the prognosis of patients with recanalized chronic total occlusion (CTO). This study sought to investigate predictors for adverse outcome in such a cohort with long-time follow-up. METHODS From 2010 to 2013, patients with successfully recanalized CTO were included. The primary endpoint was a composite of all-cause death, myocardial infarction or target vessel revascularization (TVR). The secondary endpoints were TVR and target lesion revascularization (TLR). RESULTS A total of 1987 patients were enrolled and 1806 (90.6%) subjects completed 5-year follow-up. Multivariate Cox analysis revealed that age ≥ 75 years (HR,1.70; 95% CI, 1.09-2.64; P = .02), left ventricular ejection fraction <40% (HR, 1.94; 95% CI, 1.02-3.69; P = .04) and residual SYNTAX score (HR, 1.02; 95% CI, 1.01-1.04; P = .01) were predictors for the primary endpoint. Non-LAD CTO (HR, 1.82; 95% CI, 1.23-2.70; P < .01), J-CTO score (HR, 1.31; 95% CI, 1.11-1.54; P < .01) and residual SYNTAX score (HR, 1.02; 95% CI, 1.00-1.04; P = .04) were independently related to TVR. Non-LAD CTO, high J-CTO score and residual SYNTAX score was also correlated with TLR. CONCLUSIONS Advanced age, left ventricular dysfunction and residual SYNTAX score were predictors for composite cardiovascular events in patients with CTO after revascularization. Those with non-LAD CTO, high J-CTO and residual SYNTAX score had higher risk for revascularization.
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Affiliation(s)
- Tao Tian
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Changdong Guan
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Lijian Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianson Yuan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingang Cui
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Fenghuan Hu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yida Tang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Kefei Dou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yongjian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yuejin Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Shubin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Bo Xu
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Weixian Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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9
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Khanra D, Mishra V, Jain B, Soni S, Bahurupi Y, Duggal B, Rathore S, Guha S, Agarwal S, Aggarwal P, Sinha S, Himanshu K. Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis. Indian Heart J 2020; 72:225-231. [PMID: 32861374 PMCID: PMC7474112 DOI: 10.1016/j.ihj.2020.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/21/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022] Open
Abstract
AIMS Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. METHODS AND RESULTS PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=<0.00001; I2 = 85%). All-cause mortality and cardiac death were significantly lower in the PCI+OMT group (P=<0.00001 in both). Myocardial infarction and stroke rates were lower in the PCI+OMT group, however they did not reach statistical significance (P = 0.24, P = 0.15 respectively). Unplanned revascularizations (of any vessel) were also similar in both the groups (P = 0.78, I2 = 88%). CONCLUSION PCI of CTO is rewarded with better long term outcome, in terms of MACE, all-cause mortality and cardiac death with similar rates of un-planned revascularization.
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Affiliation(s)
| | - Vikas Mishra
- Department of Cardiology, Super-Speciality Hospital, NSCB Medical College, Jabalpur, MP, India.
| | - Bhavna Jain
- All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Shishir Soni
- Department of Cardiology, All India Institution of Medical Sciences (AIIMS), Rishikesh, India.
| | - Yogesh Bahurupi
- All India Institute of Medical Sciences (AIIMS), Rishikesh, India.
| | - Bhanu Duggal
- All India Institute of Medical Sciences (AIIMS), Rishikesh, India.
| | - Sudhir Rathore
- Frimley Health NHS Foundation Trust, Camberley, Surrey, UK.
| | - Santanu Guha
- Cardiology, Medical College Kolkata, West Bengal, India.
| | | | - Puneet Aggarwal
- Department of Cardiology, ABVIMS and Dr. RML Hospital, New Delhi, India.
| | - SantoshKumar Sinha
- Department of Cardiology, LPS Institution of Cardiology, Kanpur, Uttar Pradesh, India.
| | - Kumar Himanshu
- Department of Cardiology, LPS Institution of Cardiology, Kanpur, Uttar Pradesh, India.
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10
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Yoon YH, Lee PH, Park TK, Lee JH, Cho YR, Suh J, Roh JH, Lee JH, Yoon CH, Hong YJ, Lee CH, Her SH, Chun KJ, Yoo SY, Lee JY, Lee SW. Technical Feasibility and Safety of Percutaneous Coronary Intervention for True Ostial Left Anterior Descending Artery-Chronic Total Occlusion. Can J Cardiol 2020; 37:458-466. [PMID: 32827638 DOI: 10.1016/j.cjca.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) for true ostial left anterior descending artery (LAD)-chronic total occlusion (CTO) lesions poses technical challenges owing to its inherent anatomic features. METHODS In total, 270 consecutive patients who underwent PCI for ostial LAD-CTO at 13 major cardiac centers in South Korea were included. Ostial LAD-CTO was strictly defined as a LAD-CTO lesion whose proximal cap was within 1 mm from the carina of the distal left main coronary artery (LMCA) bifurcation. RESULTS Ostial LAD-CTOs were frequently accompanied by stumpless lesion entry (43.4%), whereas significant bending within the occluded segment was less frequent (14.4%). The overall technical success rate was 85.9%, and serious in-hospital adverse events occurred in 5.6%. The retrograde approach tended to contribute more frequently to success in patients with concomitant LMCA disease, stumpless CTO, interventional collaterals, and higher Japanese-CTO scores. Apparent dissection or hematoma requiring rescue procedure at the LMCA or left circumflex artery occurred in 14 patients (5.2%), with a higher tendency in patients who had LMCA disease (12.1% vs 4.2%) and stumpless entry (9.4% vs 2.0%) than in those without. Among patients who were successfully treated, with an average of 1.7 stents, target-vessel failure occurred in 23 patients (9.9%) during a median 3.3 years of follow-up. CONCLUSIONS In this first large-scale analysis of true ostial LAD-CTO, PCI was feasible with a high technical success rate and favourable mid-term outcomes. Clinically relevant inflow vessel injury can occur during PCI and should be an important technical consideration regarding safety.
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Affiliation(s)
- Yong-Hoon Yoon
- Division of Cardiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jang Hoon Lee
- Division of Cardiology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Young-Rak Cho
- Department of Cardiology, Dong-A University Hospital, Busan, Korea
| | - Jon Suh
- Department of Cardiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jae-Hyung Roh
- Division of Cardiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae-Hwan Lee
- Division of Cardiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chang-Hwan Yoon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Joon Hong
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Cheol Hyun Lee
- Division of Cardiology, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Sung-Ho Her
- Department of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Kook-Jin Chun
- Division of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang-Yong Yoo
- Cardiovascular Center, Gangneung Asan Hospital, Gangneung, Korea
| | - Jong-Young Lee
- Division of Cardiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Seung-Whan Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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11
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Scoring System for Identification of "Survival Advantage" after Successful Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion. J Clin Med 2020; 9:jcm9051319. [PMID: 32370276 PMCID: PMC7291306 DOI: 10.3390/jcm9051319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Percutaneous coronary intervention (PCI) is widely used in patients with chronic total occlusion (CTO), but its benefit in improving long-term outcomes is controversial. We aimed to develop a prediction score for grading “survival advantage” conferred by successful results of CTO-PCI and a scoring system for prediction of the influence of CTO-PCI results on major adverse cardiac and cerebrovascular events (MACCEs). Methods: Follow-up data of 2625 patients who underwent CTO-PCI at 65 Japanese centers were analyzed. An integer scoring system was developed by including statistical effect modifiers on the association between successful CTO-PCI and one-year mortality. Results: Follow-up at 12 months was completed in 2034 patients. During follow-up, 76 deaths (3.7%) occurred. Patients with successful CTO-PCI had a better one-year survival than patients with failed CTO-PCI (log rank P = 0.016). Effect modifiers for the association between successful procedure and one-year mortality included diabetes (P interaction = 0.043), multivessel disease (P interaction = 0.175), Canadian Cardiovascular Society class ≥2 (P interaction = 0.088), and prior myocardial infarction (MI) (P interaction = 0.117). Each component was assigned a single point and summed to develop the scoring system. The patients were then categorized to specify the prediction of survival advantage by successful PCI: ≤2 (normal) and ≥3 (distinct). The differences in one-year mortality between patients with successful and failed treatment were −0.7% and 11.3% for normal and distinct score categories, respectively. In the scoring system for MACCE, score components were prior MI (P interaction = 0.19), left anterior descending artery (LAD)-CTO (P interaction = 0.079), and reattempt of CTO-PCI (P interaction = 0.18). The differences in one-year MACCEs between successful and failed patients for each score category (0, 1, and ≥2) were −1.7%, 7.5%, and 15.1%, respectively. Conclusions: The novel scoring system assessing the advantage of successful PCI can be easily applied in patients with CTO. It is a valid instrument for clinical decision-making while assessing the survival advantage of CTO-PCI and the influence of procedural results on MACCEs.
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12
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Left Main Coronary Artery Disease and Outcomes after Percutaneous Coronary Intervention for Chronic Total Occlusions. J Clin Med 2020; 9:jcm9040938. [PMID: 32235416 PMCID: PMC7231249 DOI: 10.3390/jcm9040938] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/13/2020] [Accepted: 03/21/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Concomitant left main coronary artery (LMCA) disease in patients with chronic total occlusions (CTO) commonly results in referral for coronary artery bypass grafting, although the impact of LMCA in CTO patients remains largely unknown. Nevertheless, patient selection for percutaneous coronary intervention of CTOs (CTO-PCI) or alternative revascularization strategies should be based on precise evaluation of the coronary anatomy to anticipate those patients that most likely benefit from a procedure and not on strict adherence to perpetual clinical practice. Therefore, the aim of this study was to assess the impact of LMCA disease on long-term outcomes in patients undergoing percutaneous coronary intervention for CTO. Methods: We enrolled 3860 consecutive patients undergoing PCI for at least one CTO lesion and investigated the predictive value of concomitant LMCA disease. All-cause mortality was defined as the primary study endpoint. Results: We observed that LMCA disease is significantly associated with mortality. In the Cox regression analysis, we observed a crude hazard ratio (HR) 1.59 (95% confidence interval (CI) 1.23–2.04, p < 0.001) for patients with LMCA disease as compared to patients without. Results remained unchanged after bootstrap- or clinical confounder-based adjustment. Conclusion: LMCA disease is associated with excess mortality in CTO patients. Specifically, anatomical features such as CTO of the circumflex artery represent a high risk patient population.
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13
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Aktürk E, Aşkın L, Taşolar H, Kurtoğlu E, Türkmen S, Tanrıverdi O, Uzel KE. Evaluation of contrast nephropathy in percutaneous treatment of chronic total occlusions. Interv Med Appl Sci 2020; 11:95-100. [PMID: 32148912 PMCID: PMC7044539 DOI: 10.1556/1646.11.2019.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Contrast-induced nephropathy (CIN) is a leading cause of morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI). Chronic total occlusions (CTO) are frequently observed among patients undergoing coronary angiography. Methods A total of 128 CTO patients were included. Mehran score, lesion characteristics, interventional procedure, serological specimens and devices were recorded. The first group was administered with 1 ml · kg-1 · h-1 saline (0.9% NaCl) infusion that started 12 h before the procedure and continued 12 h post procedure as recommended by the guidelines. The second group was administered with saline infusion of 12 ml · kg-1 · h-1 only during CTO-PCI procedure, which is called as intensive infusion. Results CIN development was similar in two groups (four patients in standard hydration group and five patients in intensive hydration group). The amount of saline was significantly higher in the standard group (1,767 ± 192.2 vs. 1,043.6 ± 375; p < 0.001). Patients with higher creatinine levels prior to PCI had a higher rate of CIN development after procedure. Interestingly, age, left ventricular ejection fraction, and diabetes mellitus independently predicted CIN. Conclusion Intensive hydration administration appears to be an effective and cost-effective method in CTO-PCI patients, especially in patients without left ventricular function failure.
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Affiliation(s)
- Erdal Aktürk
- Faculty of Medicine, Department of Cardiology, Adiyaman University, Adiyaman, Turkey
| | - Lütfü Aşkın
- Faculty of Medicine, Department of Cardiology, Adiyaman University, Adiyaman, Turkey
| | - Hakan Taşolar
- Faculty of Medicine, Department of Cardiology, Inönü University, Malatya, Turkey
| | - Ertuğrul Kurtoğlu
- Department of Cardiology, Malatya Training and Research Hospital, Malatya, Turkey
| | - Serdar Türkmen
- Faculty of Medicine, Department of Cardiology, Adiyaman University, Adiyaman, Turkey
| | - Okan Tanrıverdi
- Faculty of Medicine, Department of Cardiology, Adiyaman University, Adiyaman, Turkey
| | - Kader Eliz Uzel
- Faculty of Medicine, Department of Cardiology, Adiyaman University, Adiyaman, Turkey
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Iannaccone G, Scarparo P, Wilschut J, Daemen J, Den Dekker W, De Jaegere P, Zijlstra F, Van Mieghem NM, Diletti R. Current approaches for treatment of coronary chronic occlusions. Expert Rev Med Devices 2019; 16:941-954. [PMID: 31594416 DOI: 10.1080/17434440.2019.1676729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Coronary chronic total occlusions (CTO) represent a challenging subset in interventional cardiology.Areas covered: During the last decade, improvements in materials, techniques, and meticulous pre-procedural lesion assessment have increased the success rate in CTO lesions. Several scores have been developed to address overall lesion evaluation and help select the most appropriate treatment strategy. In addition, specific algorithms such as the hybrid algorithm have been introduced to provide a framework for CTO operators and a rapid management of the various challenging aspects of the procedure. The hybrid approach requires operator's ability to switch from one treatment strategy to another when the first one appears to be unsuccessful. Adequate training and operators' experience remain crucial to improve the likelihood of success.Expert opinion: The aim of this review is to provide insights and guidance for operators on current approaches for treatment of CTO and complication management.
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Affiliation(s)
- Giulia Iannaccone
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Paola Scarparo
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Jeroen Wilschut
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Wijnand Den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Peter De Jaegere
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
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15
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Allahwala UK, Ward MR, Brieger D, Weaver JC, Bhindi R. Indications for Percutaneous Coronary Intervention (PCI) in Chronic Total Occlusion (CTO): Have We Reached a DECISION or Do We Continue to EXPLORE After EURO-CTO? Heart Lung Circ 2019; 28:1484-1489. [DOI: 10.1016/j.hlc.2019.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/06/2019] [Accepted: 03/19/2019] [Indexed: 01/09/2023]
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16
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Yan Y, Zhang M, Yuan F, Liu H, Wu D, Fan Y, Guo X, Xu F, Zhang M, Zhao Q, Lyu S. Successful revascularization versus medical therapy in diabetic patients with stable right coronary artery chronic total occlusion: a retrospective cohort study. Cardiovasc Diabetol 2019; 18:108. [PMID: 31434572 PMCID: PMC6702731 DOI: 10.1186/s12933-019-0911-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/12/2019] [Indexed: 12/28/2022] Open
Abstract
Background The territory of the right coronary artery (RCA) is smaller than that of the left anterior descending artery. Previous studies have reported conflicting results when considering whether stable RCA-chronic total occlusion (CTO) should be reopened. The coexistence of diabetic and coronary artery diseases represents a severe situation. Therefore, we aimed to determine if stable RCA-CTO in diabetic patients was necessary to be reopened. To our knowledge, no studies have focused on this topic to date. Methods We enrolled diabetic patients with RCA-CTO who had clinical presentations of symptomatic stable angina or silent ischemia. RCA-CTO was treated with either successful revascularization (the CTO-SR group) or medical therapy (the CTO-MT group). The primary endpoint was all-cause death. Both Cox regression and propensity score matching analyses were used. Sensitivity analysis was performed based on subgroup populations and relevant baseline variables. Results A total of 943 patients were included: 443 (46.98%) patients in the CTO-MT group and 500 (53.02%) patients in the CTO-SR group. After a mid-term follow-up (CTO-SR: 48 months; CTO-MT: 42 months), we found that CTO-SR was superior to CTO-MT in terms of all-cause death (adjusted hazard ratio [HR] [model 1]: 0.429, 95% conference interval [CI] 0.269–0.682; adjusted HR [model 2]: 0.445, 95% CI 0.278–0.714). The superiority of CTO-SR was consistent for cardiac death, possible/definite cardiac death, repeat revascularization, target vessel revascularization (TVR) and repeat nonfatal myocardial infarction. Subgroup analysis confirmed the mortality benefit of CTO-SR by percutaneous coronary intervention (the successful CTO-PCI subgroup, 309 patients in total). While CTO-SR by coronary artery bypass grafting (the CTO-CABG subgroup, 191 patients in total) offered patients more benefit from repeat revascularization and TVR than that offered by successful CTO-PCI. Conclusions For stable RCA-CTO patients with diabetes, successful revascularization offered patients more clinical benefits than medical therapy. CTO-CABG might be a more recommended way to accomplish revascularization. Trial registration This study was not registered in an open access database Electronic supplementary material The online version of this article (10.1186/s12933-019-0911-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yunfeng Yan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Mingduo Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Fei Yuan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Hong Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Di Wu
- Department of Cardiology, Emergency General Hospital, 29 Xibahe Nanli, Chaoyang District, Beijing, China
| | - Yudong Fan
- Department of Cardiology, Emergency General Hospital, 29 Xibahe Nanli, Chaoyang District, Beijing, China
| | - Xinjing Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Feng Xu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Min Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Quanming Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Shuzheng Lyu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.
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Marechal P, Davin L, Gach O, Martinez C, Lempereur M, Lhoest N, Lancellotti P. Coronary chronic total occlusion intervention: utility or futility. Expert Rev Cardiovasc Ther 2018; 16:361-367. [PMID: 29589974 DOI: 10.1080/14779072.2018.1459187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Despite an incidence of about 18-52% of the patients undergoing coronary angiography, chronic total occlusions (CTO) are rarely revascularised by percutaneous angioplasty (PCI). Nevertheless, current evidence suggests that successful CTO angioplasty improves symptoms, quality of life and long-term survival. During the last decade, the improvement of specific tools and techniques for these complex procedures, and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO angioplasty. Areas covered: This review focuses on the clinical benefits of CTO revascularization and on appropriate patient selection. Expert commentary: Current evidence suggests that successful CTO-PCI improves symptoms, quality of life and long-term survival. During the last years, the improvement of specific techniques for these complex procedures and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO lesion angioplasty.
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Affiliation(s)
- Patrick Marechal
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | - Laurent Davin
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | - Olivier Gach
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | - Christophe Martinez
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | - Mathieu Lempereur
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | | | - Patrizio Lancellotti
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium.,c Gruppo Villa Maria Care and Research , Anthea Hospital , Bari , Italy
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18
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Wang N, Fulcher J, Abeysuriya N, Adams M, Lal S. Predictors of successful chronic total occlusion percutaneous coronary interventions: a systematic review and meta-analysis. Heart 2018; 104:517-524. [PMID: 28986404 DOI: 10.1136/heartjnl-2017-311986] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/30/2017] [Accepted: 09/04/2017] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE The aim of this study was to identify positive and negative predictors of technical and clinical success for percutaneous coronary intervention (PCI) of chronic total occlusions (CTO). METHODS We conducted a systematic review and meta-analysis of studies published between 2000 and 2016 analysing rates of CTO PCI success with respect to demographic and angiographic characteristics. Crude ORs and 95% CIs for each predictor were calculated using a random effects model. Predictors of technical and clinical success were assessed among 28 demographic and 31 angiographic variables. Clinical success was defined as technical success without major adverse cardiac events. RESULTS A total of 61 studies, totalling 69 886 patients were included in this analysis. The major demographic characteristics associated with a 20% or greater reduction in the odds of technical and clinical success were a history of myocardial infarction, PCI, coronary artery bypass grafting, stroke/transient ischaemic attack and peripheral vascular disease. Angiographic factors were generally stronger predictors of reduced technical and clinical success. Those associated with >20% odds reduction included non-left anterior descending CTOs, multivessel disease, presence of bridging collaterals, moderate-to-severe calcification, >45 degree vessel bending, tortuous vessel, blunt stump and ostial lesions. Of these, novel predictors included prior PCI, prior stroke, peripheral vascular disease, presence of multivessel disease and bridging collaterals. CONCLUSION The present study has identified strong negative predictors for clinical success for CTO PCI, which will aid in patient selection for this procedure.
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Affiliation(s)
- Nelson Wang
- University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jordan Fulcher
- University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | - Mark Adams
- University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sean Lal
- University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Hasun M, Weidinger F. Culprit Vessel Only Versus Complete Revascularisation in Patients with ST-Segment Elevation Myocardial Infarction – Should we Stay or Stage? Interv Cardiol 2018; 13:129-134. [DOI: 10.15420/icr.2018.13.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Multivessel coronary artery disease (MVCAD) is common in patients with ST-elevation myocardial infarction (STEMI), thereby negatively affecting mortality and outcome. Currently there is increasing evidence that complete revascularisation should be considered in haemodynamically stable patients. There are few larger randomised controlled trials available showing a lower risk of major adverse cardiac events after complete revascularisation, mainly driven by a reduction of repeat revascularisation. However, these trials are not adequately powered to show a mortality benefit or reduced risk of myocardial infarction. As there are several possible strategies, the presence of MVCAD often poses a therapeutic dilemma for interventional cardiologists and there is still ongoing debate on when and how to perform complete revascularisation. Pending further trials that may clarify which strategy is best, an individualised approach should be adopted.
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20
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Tanabe M, Kodama K, Asada K, Kunitomo T. Lesion characteristics and procedural outcomes of re-attempted percutaneous coronary interventions for chronic total occlusion. Heart Vessels 2017; 33:573-582. [PMID: 29224054 DOI: 10.1007/s00380-017-1091-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/01/2017] [Indexed: 12/31/2022]
Abstract
This study was performed to investigate lesion characteristics and procedural outcomes of re-attempted percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Prior failure of percutaneous revascularization of CTO has been identified as an independent predictor of failure at subsequent attempts. However, procedural outcomes of re-attempted PCI for CTO have not been elucidated. We evaluated lesion characteristics and procedural outcomes in 310 consecutive patients undergoing CTO-PCI, and compared the results between re-attempted (n = 59) and initial procedures (n = 251). Overall, 266 CTO lesions (85.8%) were treated successfully. In addition, the technical success rate in the re-attempted CTO lesions was 69.5% (41 of 59), although this was lower than for initially attempted lesions (89.6%, 225 of 251; P = 0.0021). In the details of reasons of previous failures, treatment devices failed to cross even after guidewire cross and procedure discontinuation due to management of complications achieved higher rates of technical success compared to those with the inability of guidewire crossing in re-attempted CTO-PCI (87.5 and 85.7 vs. 65.9%, respectively). CTO lesions in which PCI was re-attempted had more complex features, including calcification, tortuous morphology, and long lesion length, whereas patient demographics were similar. Re-attempted CTO lesions required complex procedures, including the retrograde approach (55.9 vs. 13.9%, P < 0.001), longer fluoroscopic time, and larger radiation dose. Meanwhile, rates of complications and in-hospital MACCE were similarly low in both groups. The technical success rates of re-attempted CTO-PCI lesions were acceptable. Furthermore, CTO-PCIs in re-attempted lesions were as safe as initially attempted CTO-PCI. However, re-attempted CTO-PCI lesions showed features of high anatomical complexity that required more complex and longer procedures, including the retrograde approach, for successful interventional revascularization. Re-attempted CTO-PCI due to treatment devices failed to cross even after guidewire cross and procedure discontinuation due to management of complications in previous attempt had higher success rates that those with the inability of guidewire crossing.
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Affiliation(s)
- Masaki Tanabe
- Department of Cardiology, Kyoto Okamoto Memorial Hospital, 58 Sayama Nishinokuchi, Kumiyama, Kyoto, 611-0034, Japan.
| | - Kenji Kodama
- Department of Cardiology, Nagahama Red Cross Hospital, Nagahama, Shiga, Japan
| | - Kohei Asada
- Division of Cardiology, Okamura Memorial Hospital, Shizuoka, Japan
| | - Takeo Kunitomo
- Department of Cardiology, Nagahama City Hospital, Nagahama, Shiga, Japan
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Angiographic predictors of success in antegrade approach of Chronic Total Occlusion interventions in a South Indian population in the contemporary era. Indian Heart J 2017; 70:15-19. [PMID: 29455771 PMCID: PMC5902916 DOI: 10.1016/j.ihj.2017.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/24/2017] [Accepted: 09/08/2017] [Indexed: 11/23/2022] Open
Abstract
Chronic Total Occlusion (CTO) intervention is a challenging area in interventional cardiology. Presently about 70% of CTO interventions are successful. MATERIALS AND METHODS This was a single center prospective study of a cohort of all patients undergoing percutaneous coronary intervention (PCI) as elective or adhoc procedure for CTO from August 2014 to June 2015. Only antegrade CTO interventions were included. In all patients the following data were recorded. RESULTS A total of 210 (8.9% of total PCI (2353) during the study period) CTO patients were followed up. The mean age was 56.54±8.9. In the study sixty nine patients (32.9%) presented with chronic stable angina and rest of the patients had history of acute coronary syndrome of which 22.9% (n=48) had unstable angina (UA) or non ST elevation myocardial infarction (NSTEMI) and 44.2% (n=93) had ST Elevation Myocardial Infarction (STEMI). In those with history of ACS, 64.78% (n=92) had ACS during the previous year and remaining 35.22% (n=49) had ACS prior to that. Single vessel CTO was seen in 89.5% (n=188) and two vessel CTO in 10.5% (n=22). LAD was involved in 36.7% (n=77), RCA in 48.1% (n=101), and LCX in 15.2% (n=32). Procedural success in the first attempt was 68.1% (n=143), which increased to 71.42% (n=150) after the second attempt. CTO interventions were more frequently successful when the calcium was absent or minimal (p-0.05), CTO length was <10mm (p<0.01) and good distal reformation (p<0.01).
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Impact of target vessel on long-term cardiac mortality after successful chronic total occlusion percutaneous coronary intervention: Insights from a Japanese multicenter registry. Int J Cardiol 2017; 245:77-82. [PMID: 28789842 DOI: 10.1016/j.ijcard.2017.07.098] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 07/06/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The impact of successful chronic total occlusion (S-CTO) percutaneous coronary intervention (PCI) on cardiac mortality may differ depending on target CTO vessel; however, to date this has not yet been adequately evaluated. The aim of this study was to investigate the impact of target vessel on cardiac mortality after S-CTO PCI. METHODS From January 2004 to December 2011, 1517 CTO PCIs were performed in 4 Japanese centers and enrolled in a multicenter registry. Cases were retrospectively analyzed and divided per target vessel treated. The primary endpoint was cardiac mortality during the follow-up period. RESULTS During the study period, 1424 CTOs with 1 main vessel CTO per patient were analyzed (left anterior descending artery [LAD]: 487, right coronary artery [RCA]: 599, left circumflex [LCx]: 338). 92.3% (n=1314) of cases were S-CTO PCIs. The median follow-up period was 1677 (interquartile range; 811-2463) days. In LAD and RCA CTOs, S-CTO PCI was associated with a lower cardiac mortality rate at 5-year follow-up when compared with unsuccessful CTO (U-CTO) (2.6% vs 9.7%, p=0.01, 2.6% vs 27.3%, p<0.01, respectively). This finding was not present with LCx CTO PCI (2.2% vs 0.0%, p=0.53). Cox regression analysis demonstrated that LAD and RCA S-CTO PCI were independent predictors of a lower cardiac mortality rate (LAD; HR: 0.18, 95% CI: 0.06-0.56; p<0.01; RCA; HR: 0.24, 95% CI: 0.09-0.65; p<0.01). CONCLUSIONS S-CTO LAD and RCA PCI were associated with a lower long-term cardiac mortality after CTO PCI. This finding was not observed with LCx CTO PCI.
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Leibundgut G, Kaspar M. Chronic Total Occlusions. Interv Cardiol 2017. [DOI: 10.5772/68067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Karjalainen PP, Nammas W. Percutaneous revascularization of coronary chronic total occlusion: Toward a reappraisal of the available evidence. J Cardiol 2017; 69:799-807. [DOI: 10.1016/j.jjcc.2016.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 11/29/2016] [Accepted: 12/08/2016] [Indexed: 12/19/2022]
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Fang HY, Wu CJ, Fang CY, Lee WC. Influence about the flow of distal branch after intervention of the right coronary artery chronic total occlusion. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:411-417. [PMID: 28366607 DOI: 10.1016/j.carrev.2017.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 03/16/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Limited data are available for the clinical outcomes after the recanalization of right coronary artery (RCA) chronic total occlusion (CTO). The study aims to assess the clinical outcomes in the antegrade flow of the distal branch after successful RCA CTO percutaneous coronary intervention (PCI). METHODS Between January 2002 and December 2012, 538 patients who underwent RCA CTO PCI were enrolled. The clinical outcomes as myocardial infarction (MI), target vessel revascularization, cardiac death, major adverse cardiac events, and all-cause mortality, were compared to the antegrade flow of distal branch after successful RCA CTO PCI. RESULTS The CTOs were located in proximal segments (57.6%), mid segments (27.5%) and distal segments (14.9%). The average Syntax score was 18.4±9.6 and 47.8% patients had a Syntax score greater than 27.5. A total of 62.8% patients had final thrombolysis of myocardial infarction (TIMI)-3 flow of distal branch, 16.9% patients had final TIMI-3 flow of only one major branch, 11.3% patients had TIMI-1-2 flow, and 8.9% patients had no antegrade flow. The incidence of periprocedural MI was lower in both side branches were preserved (13.9% vs. 23.0% and 18.8%, p=0.01). The clinical outcomes were similar between the groups with and without good antegrade flow of distal side branch. End stage renal disease (ESRD) and left ventricular ejection fraction (LVEF) <40% predicted three-year cardiac death. CONCLUSIONS There is no significant difference of clinical outcomes when distal side branches of RCA are recanalized successfully. ESRD and LVEF <40% were the predictors for three-year cardiac death.
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Affiliation(s)
- Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI. J Am Coll Cardiol 2016; 68:1622-1632. [DOI: 10.1016/j.jacc.2016.07.744] [Citation(s) in RCA: 236] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/05/2016] [Accepted: 07/13/2016] [Indexed: 12/25/2022]
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Benedetto U, Caputo M, Zakkar M, Bryan A, Angelini GD. Are three arteries better than two? Impact of using the radial artery in addition to bilateral internal thoracic artery grafting on long-term survival. J Thorac Cardiovasc Surg 2016; 152:862-869.e2. [DOI: 10.1016/j.jtcvs.2016.04.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/11/2016] [Accepted: 04/19/2016] [Indexed: 11/26/2022]
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Hoebers LP, Elias J, van Dongen IM, Ouweneel DM, Claessen BE, Piek JJ, Henriques JP. The impact of the location of a chronic total occlusion in a non-infarct-related artery on long-term mortality in ST-elevation myocardial infarction patients. EUROINTERVENTION 2016; 12:423-30. [DOI: 10.4244/eijv12i4a75] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hari P, Kirtane AJ, Bangalore S. Retrograde approach to an ostial left anterior descending chronic total occlusion through a left internal mammary artery graft. Catheter Cardiovasc Interv 2016; 87:E224-8. [PMID: 27145744 DOI: 10.1002/ccd.26136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 04/20/2015] [Accepted: 07/11/2015] [Indexed: 01/28/2023]
Abstract
Retrograde approach to chronic total occlusions (CTO) has been described via saphenous vein grafts, septal and epicardial collaterals. We report for the first time a successful retrograde approach to an ostial left anterior descending (LAD) artery CTO through a failed left internal mammary artery (LIMA) to LAD anastamosis. This case demonstrates the technical aspects of using a LIMA conduit as a retrograde approach to CTO. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Pawan Hari
- Division of Cardiology, New York University Langone Medical Center, New York, New York, USA
| | - Ajay J Kirtane
- Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York, USA
| | - Sripal Bangalore
- Division of Cardiology, New York University Langone Medical Center, New York, New York, USA
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Galassi AR, Boukhris M, Azzarelli S, Castaing M, Marzà F, Tomasello SD. Percutaneous Coronary Revascularization for Chronic Total Occlusions: A Novel Predictive Score of Technical Failure Using Advanced Technologies. JACC Cardiovasc Interv 2016; 9:911-22. [PMID: 27085580 DOI: 10.1016/j.jcin.2016.01.036] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/13/2016] [Accepted: 01/28/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aims of this study were to describe the 10-year experience of a single operator dedicated to chronic total occlusion (CTO) and to establish a model for predicting technical failure. BACKGROUND During the last decade, the interest in percutaneous coronary interventions (PCIs) of chronic total occlusions (CTOs) has increased, allowing the improvement of success rate. METHODS One thousand nineteen patients with CTO underwent 1,073 CTO procedures performed by a single CTO-dedicated operator. The study population was subdivided into 2 groups by time period: period 1 (January 2005 to December 2009, n = 378) and period 2 (January 2010 to December 2014, n = 641). Observations were randomly assigned to a derivation set and a validation set (in a 2:1 ratio). A prediction score was established by assigning points for each independent predictor of technical failure in the derivation set according to the beta coefficient and summing all points accrued. RESULTS Lesions attempted in period 2 were more complex in comparison with those in period 1. Compared with period 1, both technical and clinical success rates significantly improved (from 87.8% to 94.4% [p = 0.001] and from 77.6% to 89.9% [p < 0.001], respectively). A prediction score for technical failure including age ≥75 years (1 point), ostial location (1 point), and collateral filling Rentrop grade <2 (2 points) was established, stratifying procedures into 4 difficulty groups: easy (0), intermediate (1), difficult (2), and very difficult (3 or 4), with decreasing technical success rates. In derivation and validation sets, areas under the curve were comparable (0.728 and 0.772, respectively). CONCLUSIONS With growing expertise, the success rate has increased despite increasing complexity of attempted lesions. The established model predicted the probability of technical failure and thus might be applied to grading the difficulty of CTO procedures.
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Affiliation(s)
- Alfredo R Galassi
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Cannizzaro Hospital, University of Catania, Catania, Italy.
| | - Marouane Boukhris
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Cannizzaro Hospital, University of Catania, Catania, Italy; Faculty of Medicine of Tunis, University of Tunis El Manar, El Manar, Tunisia
| | - Salvatore Azzarelli
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Marine Castaing
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Francesco Marzà
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Salvatore D Tomasello
- Department of Clinical and Experimental Medicine, Catheterization Laboratory and Cardiovascular Interventional Unit, Cannizzaro Hospital, University of Catania, Catania, Italy
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Sianos G, Konstantinidis NV, Di Mario C, Karvounis H. Theory and practical based approach to chronic total occlusions. BMC Cardiovasc Disord 2016; 16:33. [PMID: 26860695 PMCID: PMC4746803 DOI: 10.1186/s12872-016-0209-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 12/21/2022] Open
Abstract
Coronary chronic total occlusions (CTOs) represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. The complexity of these procedures and the suboptimal success rates over a long period of time, along with the perception that CTOs are lesions with limited scope for recanalization, account for the underutilization of CTO Percutaneous Coronary Intervention (PCI). During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardization of modern CTO recanalization techniques, achieving success rates far beyond 90%, while coping with lesions of increasing complexity. Numerous studies support the rationale of CTO revascularization following documentation of viability and ischemia in the territory distal to the CTO. Successful CTO PCI provide better tolerance in case of future acute coronary syndromes and can significantly improve angina and left ventricular function. Randomized trials are on the way to further explore the prognostic benefit of CTO revascularization. The following review reports on the theory and the most recent advances in the field of CTO recanalization, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries.
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Affiliation(s)
- Georgios Sianos
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Nikolaos V Konstantinidis
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Carlo Di Mario
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
| | - Haralambos Karvounis
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
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Galassi AR, Brilakis ES, Boukhris M, Tomasello SD, Sianos G, Karmpaliotis D, Di Mario C, Strauss BH, Rinfret S, Yamane M, Katoh O, Werner GS, Reifart N. Appropriateness of percutaneous revascularization of coronary chronic total occlusions: an overview. Eur Heart J 2015; 37:2692-700. [DOI: 10.1093/eurheartj/ehv391] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/26/2015] [Indexed: 01/24/2023] Open
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Touma G, Ramsay D, Weaver J. Chronic total occlusions - Current techniques and future directions. IJC HEART & VASCULATURE 2015; 7:28-39. [PMID: 28785642 PMCID: PMC5497190 DOI: 10.1016/j.ijcha.2015.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 09/28/2014] [Accepted: 02/01/2015] [Indexed: 11/24/2022]
Abstract
Chronic total occlusions (CTOs) of coronary arteries represent a common and significant challenge to interventional cardiology. Medical therapy is often regarded as an adequate long term strategy in the management of these lesions with surgical intervention for refractory symptoms. Extensive collateralisation is used as a marker of distal coronary perfusion, further reinforcing non-invasive strategies. This together with relatively low percutaneous success rates outside of specialised centres has meant that rates of percutaneous intervention have remained low. Increasing evidence suggests that CTOs are not a benign entity. Further, symptom control and quality of life improve significantly with successful percutaneous revascularisation. Both factors have reignited interest in percutaneous modalities. The Japanese have been pioneers in the field of CTO intervention although their success rates have been difficult to replicate. New techniques and equipment developed in North America offer an alternative to the Japanese approach. These techniques focus on time, radiation and contrast minimisation. This review will assess the histopathology of CTO and shifting paradigms in CTO treatment strategies. Chronic total occlusions are common and prognostically important. Strategies for chronic occlusions are pioneered by Japanese, adapted by North American operators. Japanese and North American strategies appear divergent, both add considerable expertise.
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Affiliation(s)
- George Touma
- Department of Cardiology, The St George Hospital, Kogarah, Sydney, Australia
| | - David Ramsay
- Department of Cardiology, The St George Hospital, Kogarah, Sydney, Australia
| | - James Weaver
- Department of Cardiology, The St George Hospital, Kogarah, Sydney, Australia
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Carlino M, Magri CJ, Uretsky BF, Brilakis ES, Walsh S, Spratt JC, Hanratty C, Grantham JA, Rinfret S, Thompson CA, Lombardi WL, Galassi AR, Sianos G, Latib A, Garbo R, Karmpaliotis D, Kandzari DE, Colombo A. Treatment of the chronic total occlusion: A call to action for the interventional community. Catheter Cardiovasc Interv 2014; 85:771-8. [DOI: 10.1002/ccd.25736] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 11/07/2014] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Barry F. Uretsky
- University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Emmanouil S. Brilakis
- VA North Texas Health Care System, and University of Texas Southwestern Medical Center; Dallas Texas
| | - Simon Walsh
- Department of Cardiology; Belfast Health and Social Care Trust; Belfast United Kingdom
| | | | - Colm Hanratty
- Department of Cardiology; Belfast Health and Social Care Trust; Belfast United Kingdom
| | | | - Stéphane Rinfret
- Quebec Heart and Lung Institute, Laval University; Quebec City Canada
| | | | | | - Alfredo R. Galassi
- Department of Medical Sciences and Pediatrics; Clinical Division of Cardiology, Cannizzaro Hospital, University of Catania; Italy
| | - George Sianos
- Department of Cardiology; AHEPA University Hospital; Thessaloniki Greece
| | - Azeem Latib
- San Raffaele Scientific Institute; Milan Italy
| | | | | | | | - Antonio Colombo
- San Raffaele Scientific Institute; Milan Italy
- EMO-GVM Centro Cuore Columbus; Milan Italy
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Kelbæk H, Holmvang L, Richardt G, Eberli FR, Stella P, Buszman PE, Neumann FJ, Serruys PW, Windecker S, Widimský P, Belardi JA, Silber S. Clinical results with the Resolute zotarolimus-eluting stent in total coronary occlusions. EUROINTERVENTION 2014; 11:650-7. [PMID: 25033102 DOI: 10.4244/eijy14m07_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS We conducted a pooled post hoc analysis (RESOLUTE All Comers and RESOLUTE International) of patients who had the Resolute® zotarolimus-eluting stent (R-ZES) implanted in revascularised total occlusions (TO) compared with patients treated with R-ZES for non-occluded lesions. METHODS AND RESULTS Patients were divided into three groups: chronic TO (CTO; n=256), non-chronic TO (n=292), and no occlusion (n=2,941). Clinical and safety outcomes assessed through two years included target lesion failure (TLF: cardiac death, target vessel myocardial infarction, and clinically driven target lesion revascularisation) and Academic Research Consortium definite or probable stent thrombosis. The rate of TLF at two years was not significantly different among patients in the CTO (9.1%), TO (9.8%), and no occlusion (10.4%) groups (log-rank p=0.800); neither were the components of TLF. Definite or probable stent thrombosis occurred more frequently in the TO group (2.8% vs. 1.2% in the CTO and 1.1% in the group with no occlusion, p=0.027). There were 10 late and six very late stent thrombosis events. CONCLUSIONS Apart from a higher rate of stent thrombosis in patients with TO, patients with totally occluded coronary arteries who receive revascularisation with an R-ZES have clinical outcomes comparable to those who receive a similar stent in non-occluded lesions.
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Affiliation(s)
- Henning Kelbæk
- Cardiac Catheterisation Laboratory, Rigshospitalet, Copenhagen, Denmark
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Abstract
Chronic total occlusions (CTOs) are often detected on diagnostic coronary angiograms, but percutaneous coronary intervention (PCI) for CTO is currently infrequently performed owing to high technical difficulty, perceived risk of complications, and a lack of randomized data. However, successful CTO-PCI can significantly increase a patient's quality of life, improve left ventricular function, reduce the need for subsequent CABG surgery, and possibly improve long-term survival. A number of factors must be taken into account for the selection of patients for CTO-PCI, including the extent of ischaemia surrounding the occlusion, the level of myocardial viability, coronary location of the CTO, and probability of procedural success. Moreover, in patients with ST-segment elevation myocardial infarction, a CTO in a noninfarct-related artery might lead to an increase in infarct area, increased end-diastolic left ventricular pressure, and decreased left ventricular function, which are all associated with poor clinical outcomes. In this Review, we provide an overview of the anatomy and histopathology of CTOs, perceived benefits of CTO-PCI, considerations for patient selection for this procedure, and a summary of emerging techniques for CTO-PCI.
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Lv A, Tao L, Cao F, Li Y, Guo W, Wang H. The key features of percutaneous coronary intervention with chronic total obstruction lesion of right coronary artery. Ther Adv Cardiovasc Dis 2014; 8:22-7. [PMID: 24441174 DOI: 10.1177/1753944713517022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We summarize recent research on percutaneous coronary intervention of chronic total occlusion of the right coronary artery. We then explain the method and technology of forward and backward revascularization in chronic total occlusion of the right coronary artery. Finally, we emphasize the monitoring methods and key treating measures for better prognosis of the patients.
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Affiliation(s)
- Anlin Lv
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shanxi, China
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Golemati S, Sanidas EA, Dangas GD. Long-term clinical outcomes after percutaneous coronary intervention for chronic total occlusions. Curr Cardiol Rep 2014; 16:450. [PMID: 24430013 DOI: 10.1007/s11886-013-0450-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Optimal treatment of chronic total occlusions (CTOs) remains one of the major challenges in interventional cardiology. A number of factors, including both patient clinical conditions and technical procedural considerations, have been identified to affect percutaneous coronary intervention (PCI) success and long-term outcomes, in large multicenter cohorts as well as smaller patient groups. As opposed to patient-centered factors, technical factors can be managed and as a result, a lot of research aims at improving stent technology and imaging guidance, toward enhancing PCI efficiency, in regards to patient safety.
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Affiliation(s)
- Spyretta Golemati
- Columbia University Medical Center and New York Presbyterian Hospital, New York, NY, USA,
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