Percutaneous recanalization of chronic total occlusions: wherein lies the body of proof?

Therapeutic strategies aiming at the reduction of the antiplatelet intensity should not overlook the ischemic risk in patients with coronary syndromes

De-escalation of dual antiplatelet therapy (DAPT) is gaining traction as a strategy to reduce bleeding risks while ensuring ischemic outcomes. Undiscriminating de-escalation, notably in patients with high ischemic risk, might expose them to major adverse cardiac events. Platelet function and genetic tests are emerging tools to guide de-escalation, but both present specific drawbacks. Recent meta-analyses have aimed to consolidate the findings of individual trials to provide clearer insights. Yet, limitations remain for patients with concomitant high bleeding and ischemic risks. These high-risk patients are frequently underrepresented in clinical trials, and, therefore, currently available guidelines lack evidence-based recommendations for this subset. While DAPT de-escalation strategies hold promise, the choice of approach, whether clinically or assay-guided, remains complex and should be individualized.

The Association between Serum Total Bile Acid Level and Long-Term Prognosis in Patients with Coronary Chronic Total Occlusion Undergoing Percutaneous Coronary Intervention

Background and Aims

Bile acids, the key products for elimination of cholesterol, play an important role in coronary artery disease (CAD). However, few studies focused on the roles of more accessible serum total bile acids (TBA) in the prediction of adverse cardiovascular events for coronary chronic artery occlusion (CTO). The aim of this study was to explore the potential relationship between serum TBA and long-term prognosis in patients with CTO undergoing percutaneous coronary intervention (PCI).

Methods

Baseline TBA was determined in 613 patients with CTO after PCI in the present study. All patients were divided into 3 groups according to the median (3.5 μmol/l) and the normal upper limit of the TBA (10 μmol/l). The primary endpoint was all-cause mortality, and the secondary endpoint was major adverse cardiovascular events (MACE).

Results

Average age in this study was 65.44 ± 9.94 years old. The median of TBA was 3.5 (2.1-6.1) μmol/l. Over a median follow-up of 33.5 months, compared to those with below 3.5 μmol/l TBA, 3.5 ~ 10 μmol/l TBA was associated with significantly reduced risk for the MACE (hazard ratio (HR): 0.59, 95% confidence interval (CI): 0.40 to 0.88; p = 0.009) even after adjustment for baseline variables. However, TBA did not predict all-cause mortality and cardiovascular death. Spline analyses showed an L-shaped relationship of the serum TBA with the incidence of MACE.

Conclusions

Moderate fasting serum TBA level has a predictive value for MACE even after adjusting for lifestyle and clinical risk factors in CTO patients undergoing PCI.

Ticagrelor versus clopidogrel in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention

OBJECTIVES

To evaluate the effectiveness and safety of ticagrelor versus clopidogrel in patients with acute coronary syndromes (ACS) undergoing complex percutaneous coronary intervention (PCI).

BACKGROUND

It remains inconclusive whether ticagrelor is superior to clopidogrel in ACS patients undergoing complex PCI in real-world practice.

METHODS

Based on an all-comers PCI registry, we compared the long-term effectiveness and safety between ticagrelor and clopidogrel in ACS patients undergoing complex PCI, defined as PCI procedures for complex lesions including bifurcation, chronic total occlusion, ostial, tortuous, calcific, diffused, thrombus-containing, and restenotic lesions. The primary ischemic outcome was a composite of cardiac death, myocardial infarction, or stroke. The safety outcome comprised Bleeding Academic Research Consortium (BARC) types 2, 3, and 5 bleeding. Propensity score matching (PSM) was performed to reduce bias.

RESULTS

Among ACS patients who underwent complex PCI, 4373 (35.2%) and 8065 (64.8%) received dual antiplatelet therapy based on ticagrelor and clopidogrel, respectively. The incidences of composite ischemic events (before PSM: 1.74% vs. 2.84%; after PSM: 1.50% vs. 2.65%; p < 0.01 for both) and all-cause death (before PSM: 1.23% vs. 2.12%, p < 0.01; after PSM: 1.09% vs. 1.81%, p = 0.02) were significantly lower in the ticagrelor-treated than in the clopidogrel-treated group. There was no significant difference in BARC types 2, 3, and 5 bleeding between groups.

CONCLUSIONS

Whilst the risk of major bleeding was comparable between the two drugs, ticagrelor was associated with a significantly lower risk of ischemic events than clopidogrel in ACS patients undergoing complex PCI.

Prognostic value of malnutrition using geriatric nutritional risk index in patients with coronary chronic total occlusion after percutaneous coronary intervention

BACKGROUND

Malnutrition is associated with poor prognosis in a wide range of chronic illnesses, however, the impact of malnutrition on long-term outcomes of patients at advanced stages of atherosclerosis, coronary chronic artery occlusion (CTO), is not known.

AIMS

This study aims to investigate the relationship between malnutrition and adverse cardiovascular events in patients with CTO after percutaneous coronary intervention (PCI).

METHODS

Baseline malnutrition risk was determined in 669 patients with CTO after PCI in this study. All patients were divided into 3 groups according to 3 categories of the geriatric nutritional risk index (GNRI): moderate to severe, GNRI of <92 (n = 70); low, GNRI of 92-98 (n = 197); and absence of risk, GNRI of ≥98 (n = 402). The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiovascular events (MACE).

RESULTS

Average age in this study was 65.32 ± 9.97 years old. More than one-third of patients were at risk of malnutrition (moderate to severe: 10.5%; low: 29.4%; and absence of risk: 60.1%). Over a median follow-up of 33 months, compared to those with absent risk for malnutrition, moderate to severe risk was associated with significantly increased risk for the all-cause death, cardiovascular death and MACE (hazard ratio [HR]: 2.90, 95% confidence interval [CI]: 1.43 to 5.87, P for trend = 0.002; HR: 3.72, 95% CI: 1.42 to 9.77, P for trend = 0.010; HR: 1.76, 95% CI: 1.02 to 3.03, P for trend = 0.040; respectively) after adjustment for baseline variables. Moreover, addition of the GNRI score significantly raised the predictive value for the all-cause death (0.383, p = 0.004 and 0.022, p = 0.011, NRI and IDI respectively), cardiovascular death (0.488, p < 0.001 and 0.013, p = 0.014, NRI and IDI respectively) and MACE (0.368, p = 0.004 and 0.014, p = 0.008, NRI and IDI respectively) as compared to traditional factors.

CONCLUSIONS

Malnutrition assessed by the GNRI score on admission was an independent predictor for adverse cardiovascular events in CTO patients after PCI. Addition of the GNRI score to the existing risk prediction model significantly increased the predictive ability for cardiovascular events in CTO patients after PCI.

Tailoring Dual Antiplatelet Therapy for the Complex PCI Patient: Current Status and Perspectives

Dual antiplatelet therapy (DAPT) duration in patients undergoing percutaneous coronary intervention (PCI) has long been considered a matter of controversy. Complex-PCI (C-PCI) is considered to be associated with an increased ischemic risk that tends to be greater with progressively higher procedural complexity. Thus, with a view to balance ischemic versus bleeding risks, high complexity of PCI intuitively represents an advocate of prolonged DAPT duration. However, the optimal DAPT strategy in this high ischemic risk subset of patients remains unclear, a fact that is exacerbated by the absence of a universal definition of C-PCI, resulting in a significant between-study heterogeneity. The aim of this review is to highlight the increased risks associated with C-PCI, compare long- versus short-term DAPT regimens regarding safety and efficacy endpoints as well as investigate outcomes in special C-PCI cohorts, such as patients with bifurcation, left main or chronic total occlusion lesions. Furthermore, controversial issues, such as antithrombotic regimens in C-PCI patients with atrial fibrillation, and future perspectives are addressed.

Temporal Trends in Chronic Total Occlusion Interventions in Europe

BACKGROUND

The study focuses on the evolution of practice, procedural outcomes, and in-hospital complications of chronic total occlusion percutaneous coronary intervention in Europe.

METHODS AND RESULTS

Data from 17 626 procedures enrolled in European Registry of Chronic Total Occlusion between January 2008 and June 2015 were assessed. The mean patient age was 63.9±10.9 years; 85% were men. Procedural success increased from 79.7% to 89.3% through the study period. Patients enrolled during the years had increasing comorbidities and lesion complexity (J-CTO score [Multicenter CTO Registry of Japan] increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015; P for trend, <0.001). Retrograde approach utilization steadily increased from 10.1% in 2008 to 29.9% in 2015 ( P for trend, <0.001). Antegrade dissection reentry adoption was low, not exceeding 5.5%. In-hospital mortality decreased during the study period from 0.4% to 0.1% ( P for trend, <0.001), whereas in-hospital complication rates remained essentially unchanged, in the range 4.4% to 5.2% ( P for trend, 0.390).

CONCLUSIONS

Chronic total occlusion percutaneous coronary intervention has shown a steady increase in procedural success rate over time, with unchanged complication rates, despite the increasing complexity of the lesions attempted. The J-CTO score predictive value for procedural success was low for the entire registry and had no predictive ability for the retrograde approach.

Coronary chronic total occlusions: How to dilate the tough ones

Several chronic total occlusions (CTOs) may be undilatable despite successful wire passage; several techniques can be used for lesion preparation, such as high-pressure balloon inflations, rotational atherectomy laser, cutting balloon, and scoring balloons. Presence of moderate to severe calcification and lesion length over 40 mm in association with comorbidities, such as diabetes mellitus and reduced ejection fraction, may contribute to making a CTO lesion undilatable. Still, appropriate therapy selection for a patient with CTO should be individualized and procedure safety attended to.

Contemporary Evidence, Treatment Strategies, and Indications for Chronic Total Occlusion-Percutaneous Coronary Intervention

Chronic total occlusions (CTOs) are detected incidentally in ˜20% of patients undergoing coronary angiography and are often associated with significant morbidity and mortality. CTOs can manifest with worsening symptoms, reduced left ventricular function, and increased incidence of ventricular arrhythmias. Despite this, according to USA, Italian, and Japanese national registry data, only ~5–22% of CTO lesions are treated by percutaneous coronary intervention (PCI). CTO-PCI is a particularly challenging technique for this subset of lesions and has traditionally been associated with increased risks and complications compared to conventional PCI. However, increased experience, the development of novel techniques, and dedicated equipment have revolutionised CTO-PCI. USA, Italian, and Japanese registry data have shown success rates of between 85% and 90%, with diminishing complication rates when performed by experienced operators. Moreover, observational studies have suggested that there are significant benefits of using CTO-PCI, including fewer symptoms, improved quality of life, reduced need for coronary artery bypass surgery, and reduction in ischaemic burden and mortality. In addition, when there is demonstrable ischaemia and viable myocardium in the CTO territory, there is further potential prognostic benefit from complete revascularisation. However, there has so far been a relative lack of randomised trial data to support the routine use of CTO-PCI. This paper reviews the current evidence surrounding this subject and discusses the arguments for and against CTO-PCI. It includes an exploration of the interventionalist’s ‘toolbox’ and the techniques used in CTO-PCI, including a section on ‘tips and tricks’ for the most challenging cases. Finally, there is a discussion on the future of CTO-PCI including promising ongoing clinical trials and novel equipment that may improve outcomes and help to establish a more widespread adoption of CTO-PCI.

Duration of dual antiplatelet therapy in patients treated with percutaneous coronary intervention for coronary chronic total occlusion

Background

The duration of dual antiplatelet therapy (DAPT) after drug-eluting stent implantation in coronary chronic total occlusion (CTO) remains unclear.

Methods

We retrospectively analyzed a total of 512 patients treated with percutaneous coronary intervention (PCI) in the Samsung Medical Center CTO registry. Patients were separated into ≤ 12-month (199, 38.9%) vs. > 12 month (313, 61.1%) based on DAPT duration with aspirin and clopidogrel. The primary outcome was major adverse cardiac and cerebrovascular event (MACCE) during follow-up.

Results

Median follow-up duration was 67 (interquartile range: 51–84) months. MACCE occurred in 43 patients (21.6%) in the ≤ 12-month and 55 patients (17.6%) in the > 12-month groups. In the propensity-matched population, the rate of MACCE did not differ significantly between the ≤ 12-month and > 12-month group (19.4% vs. 18.8%; hazard ratio [HR], 0.95; 95% confidential interval [CI], 0.52–1.76, p = 0.88). Moreover, moderate or severe bleeding according to BARC criteria (type 2, 3 or 5) was also similar between the ≤ 12-month and > 12-month group (2.5% vs. 1.9%; HR, 1.00; 95% CI, 0.20–4.96, p = 0.99).

Conclusion

Among patients treated with PCI for CTO, DAPT with durations of ≤ 12-month showed similar long-term clinical outcomes compared to > 12-month DAPT.

Is Complete Revascularisation Mandated for all Patients with Multivessel Coronary Artery Disease?

In multivessel coronary artery disease (MVCAD), myocardial revascularisation can be achieved by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), with complete revascularisation on all diseased coronary segments or with incomplete revascularisation on selectively targeted lesions. Complete revascularisation confers a long-term prognostic benefit, but is associated with a higher rate of periprocedural events compared with incomplete revascularisation. In most patients with MVCAD, the main advantage of CABG over PCI is conferred by the achievement of more extensive revascularisation. According to current international guidelines, PCI is generally preferred in single-vessel disease, low-risk MVCAD or isolated left main disease; whereas CABG is usually recommended in patients with complex two-vessel disease, most patients with three-vessel disease and/or non-isolated left main disease. In patients with MVCAD, the choice on revascularisation modality should depend on a multifactorial evaluation, taking into account not only coronary anatomy, the ischaemic burden, myocardial function, age and the presence of comorbidities, but also the adequacy of myocardial revascularisation.

Everolimus-eluting bioresorbable vascular scaffolds versus second generation drug-eluting stents for percutaneous treatment of chronic total coronary occlusions: Technical and procedural outcomes from the GHOST-CTO registry

OBJECTIVES

We aimed at comparing the acute performance of bioresorbable scaffolds (BRS) and second-generation drug-eluting stents (DES) for the treatment of chronic total occlusions (CTO).

BACKGROUND

There is a lack of knowledge regarding the use of BRS in CTO.

METHODS

Key outcomes of interest were technical and procedural success. Technical success was defined as successful stent delivery and implantation, postprocedural residual diameter stenosis <30% within the treated segment, and restoration of thrombolysis in myocardial infarction (TIMI) grade 3 flow. Procedural success was defined as technical success with no in-hospital major adverse cardiac events (MACE).

RESULTS

Between May 2013 and May 2014, 32 patients underwent CTO percutaneous coronary intervention (PCI) with the Absorb BRS (Abbott Vascular, Santa Clara, CA) and were compared with a historical control group of 54 patients who had undergone CTO PCI with second-generation DES. Baseline characteristics were similar between the BRS and DES groups, with the exception of a larger mean reference vessel diameter in the BRS group (2.92 ± 0.34 vs 2.50 ± 0.68; P < 0.001). Technical success was less likely to be achieved in the BRS group compared with the DES group (78.1% vs 96.3%, P = 0.012). Procedural success rates were 78.1% and 94.4% in the BRS and DES group, respectively (P = 0.035).

CONCLUSIONS

Compared with second-generation DES for PCI of CTO lesions, BRS were associated with lower rates of technical and procedural success. © 2016 Wiley Periodicals, Inc.

Predictors of successful percutaneous coronary intervention in chronic total coronary occlusions

Introduction

Percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTOs) is one of the most challenging procedures of interventional cardiology and is associated with increased risk of significant complications. However, debate continues in regard to which factors adversely influence the success rate of PCI and whether the benefits of revascularization of CTO outweigh the risks and challenges.

Aim

To analyze the relationship between lesion characteristics and overall success rates as well as in-hospital outcomes after PCI for CTO.

Material and methods

We retrospectively examined the procedural outcomes of 173 consecutive native coronary artery CTO PCIs performed from February 2012 to March 2013 (78% men; mean age: 60.3 ±12.1 years).

Results

The CTO target vessel was the right coronary artery (53.8%), circumflex (10.4%) and left anterior descending artery (35.8%), respectively. The retrograde approach was used in 13.9% of all procedures. Successful revascularization was achieved in 83.2% of patients. Major complications occurred in 13.3% of patients. In multivariate analysis, bridge collaterals, severe calcification and tortuosity as well as tandem occlusions were independent predictors of procedural failure, whereas existence of micro-channels was the only predictor of procedural success.

Conclusions

Revascularization of coronary CTOs may be performed with high success and low major complication rates. Bridge collaterals, severe calcification and tortuosity, tandem/multiple occlusions and micro-channels were independent predictors of successful CTO revascularization.

Utility of the SYNTAX score in predicting outcomes after coronary intervention for chronic total occlusion

BACKGROUND

Chronic total occlusion (CTO) lesions are a challenging issue. When dealing with complex CTO lesions in patients undergoing percutaneous coronary intervention (PCI), it is important to evaluate not only the CTO lesion itself but also atherosclerotic lesions of the whole coronary artery tree. The utility of the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery Trial) score in patients with CTO undergoing PCI is unclear.

METHODS

This retrospective study included 304 consecutive patients with CTO lesions who underwent PCI. Primary endpoints were procedural failure and major adverse cardiac events (MACE) within 30 days. The SYNTAX and J-CTO (Multicenter CTO Registry in Japan) scores were assessed before the procedures, and patients were divided into two groups according to SYNTAX criteria: high (> 22; n = 158) and low (≤ 22; n = 146) SYNTAX scores.

RESULTS

Procedural success was achieved in 252 patients (82.9 %). Patients with a high SYNTAX score had significantly lower procedural success than those with a low SYNTAX score (74.7 % versus 91.8 %, p < 0.0001). There were 13 MACE (8.2 %) in patients with high SYNTAX scores and two MACE (1.4 %) in those with low scores. The SYNTAX and J-CTO scores had odds ratios of 3.33 (95 %CI, 1.44-7.74) and 3.64 (95 %CI, 1.24-10.66) for procedural failure. A higher SYNTAX score (> 22) was also an independent predictor of 30-day MACE after PCI (odds ratio = 4.80, 95 %Cl 1.03-22.42).

CONCLUSION

The SYNTAX score is predictive of procedural failure, as is the J-CTO score. Furthermore, a higher SYNTAX score is strongly associated with an increased risk of 30-day MACE. The SYNTAX score is useful for clinical decision making when treating patients with complex CTO lesions.

Long-term clinical outcomes after percutaneous coronary intervention for chronic total occlusions

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.