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Zhao Y, Wang P, Zheng Z, Ma Q, Shi Y, Liu J. Efficacy and safety of drug-coated balloons in chronic total coronary occlusion recanalization: a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:324. [PMID: 38918738 PMCID: PMC11200994 DOI: 10.1186/s12872-024-03993-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 06/20/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND With advancements in chronic total coronary occlusion (CTO) recanalization techniques and concepts, the success rate of recanalization has been steadily increasing. However, the current data are too limited to draw any reliable conclusions about the efficacy and safety of drug-coated balloons (DCBs) in CTO percutaneous coronary intervention (PCI). Herein, we conducted a meta-analysis to confirm the efficacy of DCB in CTO PCI. METHODS We systematically searched PubMed, Web of Science and Embase from inception to July 25, 2023. The primary outcome was major advent cardiovascular events (MACE), including cardiac death, nonfatal myocardial infarction (MI), target lesion revascularization (TLR), and target vessel revascularization (TVR). The follow-up angiographic endpoints were late lumen enlargement (LLE), reocclusion and restenosis. RESULTS Five studies with a total of 511 patients were included in the meta-analysis. Across studies, patients were predominantly male (72.9-85.7%) and over fifty years old. The summary estimate rate of MACE was 13.0% (95% CI 10.1%-15.9%, I2 = 0%, p = 0.428). The summary estimate rates of cardiac death and MI were 2.2% (95% CI 0.7%-3.7%, I2 = 0%, p = 0.873) and 1.2% (95% CI -0.2-2.6%, I2 = 13.7%, p = 0.314), respectively. Finally, the pooled incidences of TLR and TVR were 10.1% (95% CI 5.7%-14.5%, I2 = 51.7%, p = 0.082) and 7.1% (95% CI 3.0%-11.2%, I2 = 57.6%, p = 0.070), respectively. Finally, the summary estimate rates of LLE, reocclusion and restenosis were 59.4% (95% CI 53.5-65.3%, I2 = 0%, p = 0.742), 3.3% (95% CI 1.1-5.4%, I2 = 0%, p = 0.865) and 17.5% (95% CI 12.9-22.0%, I2 = 0%, p = 0.623), respectively. CONCLUSION Accordingly, DCB has the potential to be used as a treatment for CTO in suitable patients.
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Affiliation(s)
- Yuhao Zhao
- Center for Coronary Artery Disease(CCAD), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Ping Wang
- Center for Coronary Artery Disease(CCAD), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Ze Zheng
- Center for Coronary Artery Disease(CCAD), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Qin Ma
- Center for Coronary Artery Disease(CCAD), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yuchen Shi
- Center for Coronary Artery Disease(CCAD), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.
| | - Jinghua Liu
- Center for Coronary Artery Disease(CCAD), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.
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Gilpin TR, Maznyczka A, Anantharam B, Dana A. Procedural Results and Long-term Outcome of Chronic Total Occlusion Percutaneous Coronary Intervention in a UK Non-surgical Centre. Interv Cardiol 2024; 19:e05. [PMID: 38808283 PMCID: PMC11131147 DOI: 10.15420/icr.2023.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/08/2023] [Indexed: 05/30/2024] Open
Abstract
Background Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has evolved a great deal over recent years, with increased procedural success and lower complication rates being reported. This study aims to evaluate the feasibility, safety and success of a dedicated CTO programme in a large UK PCI centre without on-site cardiothoracic surgery facilities. Methods Clinical and procedural data were retrospectively collected for consecutive unselected patients undergoing CTO PCI between 2015 and 2019 from the local database and regional electronic patient records. In-hospital outcomes and long-term major adverse cardiovascular events (all-cause mortality, MI, stroke and target vessel revascularisation) were recorded. Results A total of 170 patients underwent 191 CTO procedures during the study period. The mean age was 63 ± 10 years and 80.6% of patients were male (n=137). The clinical indications were: stable chronic coronary syndromes in 88.5% (n=169) of patients; staged procedures in the context of acute coronary syndromes in 1.6% (n=3); and presentation with acute coronary syndrome in 9.9% (n=19). The procedural success rate was 50.0% (n=25) for general interventional cardiologists and 90.1% (n=127) for dedicated CTO operators. In-hospital major adverse cardiovascular events occurred once (0.5%) and interhospital transfer for emergency salvage cardiac surgery was not required. Long-term follow-up data at a median duration of 3.8 years revealed 4 (2.4%) cardiac deaths, 14 (8.3%) spontaneous MI events and 10 (5.9%) target vessel revascularisations. Conclusion These data suggest CTO PCI using contemporary techniques is both safe and effective when undertaken in a high-volume non-surgical centre by experienced operators.
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Affiliation(s)
- Thomas R Gilpin
- Faculty of Medicine, University of SouthamptonSouthampton, UK
- Portsmouth Hospitals University NHS Trust, Queen Alexandra HospitalPortsmouth, UK
| | - Annette Maznyczka
- Portsmouth Hospitals University NHS Trust, Queen Alexandra HospitalPortsmouth, UK
| | - Brijesh Anantharam
- Portsmouth Hospitals University NHS Trust, Queen Alexandra HospitalPortsmouth, UK
| | - Ali Dana
- Portsmouth Hospitals University NHS Trust, Queen Alexandra HospitalPortsmouth, UK
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Vural MG, Temel HY, Turunc E, Akdemir R, Tatli E, Agac MT. Transcoronary Gradients of Mechanosensitive MicroRNAs as Predictors of Collateral Development in Chronic Total Occlusion. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:590. [PMID: 38674237 PMCID: PMC11052456 DOI: 10.3390/medicina60040590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/30/2024] [Accepted: 03/31/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: In this present study, we investigated the impact of mechanosensitive microRNAs (mechano-miRs) on the collateral development in 126 chronic total occlusion (CTO) patients, selected from 810 undergoing angiography. Materials and Methods: We quantified the collateral blood supply using the collateral flow index (CFI) and assessed the transcoronary mechano-miR gradients. Results: The patients with favorable collaterals had higher CFI values (0.45 ± 0.02) than those with poor collaterals (0.38 ± 0.03, p < 0.001). Significant differences in transcoronary gradients were found for miR-10a, miR-19a, miR-21, miR-23b, miR-26a, miR-92a, miR-126, miR-130a, miR-663, and let7d (p < 0.05). miR-26a and miR-21 showed strong positive correlations with the CFI (r = 0.715 and r = 0.663, respectively), while let7d and miR-663 were negatively correlated (r = -0.684 and r = -0.604, respectively). The correlations between cytokine gradients and mechano-miR gradients were also significant, including Transforming Growth Factor Beta with miR-126 (r = 0.673, p < 0.001) and Vascular Endothelial Growth Factor with miR-10a (r = 0.602, p = 0.002). A regression analysis highlighted the hemoglobin level, smoking, beta-blocker use, miR-26a, and miR-663 as significant CFI determinants, indicating their roles in modulating the collateral vessel development. Conclusions: These findings suggest mechanosensitive microRNAs as predictive biomarkers for collateral circulation, offering new therapeutic perspectives for CTO patients.
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Affiliation(s)
- Mustafa Gökhan Vural
- Department of Cardiology, University of Health Sciences, Ankara Training and Research Hospital, Ankara 06230, Turkey
| | - Hulya Yilmaz Temel
- Department of Bioengineering, Faculty of Engineering, Ege University, Bornova 35040, Turkey;
| | - Ezgi Turunc
- Department of Biochemistry, Faculty of Pharmacy, Izmir Katip Celebi University, Izmir 35620, Turkey;
| | - Ramazan Akdemir
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya 54050, Turkey; (R.A.); (M.T.A.)
| | - Ersan Tatli
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya 54050, Turkey; (R.A.); (M.T.A.)
| | - Mustafa Tarik Agac
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya 54050, Turkey; (R.A.); (M.T.A.)
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Galassi AR, Vadalà G, Werner GS, Cosyns B, Sianos G, Hill J, Dudek D, Picano E, Novo G, Andreini D, Gerber BLM, Buechel R, Mashayekhi K, Thielmann M, McEntegart MB, Vaquerizo B, Di Mario C, Stojkovic S, Sandner S, Bonaros N, Lüscher TF. Evaluation and management of patients with coronary chronic total occlusions considered for revascularisation. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC, the European Association of Cardiovascular Imaging (EACVI) of the ESC, and the ESC Working Group on Cardiovascular Surgery. EUROINTERVENTION 2024; 20:e174-e184. [PMID: 38343372 PMCID: PMC10836390 DOI: 10.4244/eij-d-23-00749] [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] [Received: 09/01/2023] [Accepted: 11/05/2023] [Indexed: 02/15/2024]
Abstract
Chronic total occlusions (CTOs) of coronary arteries can be found in the context of chronic or acute coronary syndromes; sometimes they are an incidental finding in those apparently healthy individuals undergoing imaging for preoperative risk assessment. Recently, the invasive management of CTOs has made impressive progress due to sophisticated preinterventional assessment, including advanced non-invasive imaging, the availability of novel and dedicated tools for CTO percutaneous coronary intervention (PCI), and experienced interventionalists working in specialised centres. Thus, it is crucial that referring physicians who see patients with CTO be aware of recent developments and of the initial evaluation requirements for such patients. Besides a careful history and clinical examination, electrocardiograms, exercise tests, and non-invasive imaging modalities are important for selecting the patients most suitable for CTO PCI, while others may be referred to coronary artery bypass graft or optimal medical therapy only. While CTO PCI improves angina and reduces the use of antianginal drugs in patients with symptoms and proven ischaemia, hibernation and/or wall motion abnormalities at baseline or during stress, the effect of CTO PCI on major cardiovascular events is still controversial. This clinical consensus statement specifically focuses on referring physicians, providing a comprehensive algorithm for the preinterventional evaluation of patients with CTO and the current evidence for the clinical effectiveness of the procedure. The proposed care track has been developed by members and with the support of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Association of Cardiovascular Imaging (EACVI), and the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery.
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Affiliation(s)
| | - Giuseppe Vadalà
- Department of PROMISE, University of Palermo, Palermo, Italy
| | - Gerald S Werner
- Medical Department I (Cardiology), Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Bernard Cosyns
- Cardiology, Universitair Ziekenhuis Brussel, Centrum voor Hart en Vaatziekten, Brussels, Belgium
| | - Georgios Sianos
- AHEPA University General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Jonathan Hill
- Royal Brompton & Harefield Hospitals GSTT, London, United Kingdom
| | - Dariusz Dudek
- Cardiac Catheterization Laboratories, Jagiellonian University Medical College, Krakow, Poland
| | - Eugenio Picano
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Giuseppina Novo
- Department of PROMISE, University of Palermo, Palermo, Italy
| | | | - Bernhard L M Gerber
- Cardiology Department, Cliniques Universitaires St. Luc UCL, Brussels, Belgium
| | - Ronny Buechel
- Department of Nuclear Medicine, Cardiovascular Imaging, University Hospital of Zurich, Zurich, Switzerland
| | - Kambis Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Mathias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Hospital Essen, Essen, Germany
| | | | | | - Carlo Di Mario
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| | - Sinisa Stojkovic
- Faculty of Medicine, University of Belgrade, Clinic for Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Sigrid Sandner
- Cardiovascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Nikolaos Bonaros
- Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Thomas F Lüscher
- Royal Brompton & Harefield Hospitals GSTT, London, United Kingdom
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
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5
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Coulshed A, Coulshed D, Pathan F. Systematic Review of the Use of the 6-Minute Walk Test in Measuring and Improving Prognosis in Patients With Ischemic Heart Disease. CJC Open 2023; 5:816-825. [PMID: 38020329 PMCID: PMC10679465 DOI: 10.1016/j.cjco.2023.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/10/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction The 6-minute walk test (6MWT) has been used for over 30 years to assess exercise capacity in patients with respiratory disease, and more recently, in those with heart failure. However, despite being a simple and reproducible test of real-world exercise capacity, its use in patients with ischemic heart disease (IHD) is less well accepted. We sought to review systematically the evidence surrounding the 6MWT in IHD. Methods We searched the Medline, PubMed, Embase, and Scopus databases for the following key terms: "six minute walk test/6 minute walk test/6MWT" and "angina/coronary artery disease/coronary disease/IHD/ischemic heart disease." We followed Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines to select publications for full-text review and analyzed the collated data. Results A total of 1228 unique papers were found, of which 71 were chosen for full-text review and 37 for detailed analysis. Most (23) concerned the effect on 6MWT distance (6MWTd) of cardiac rehabilitation, with measurements commenced after an intervention (acute myocardial infarction, n = 4; open heart surgery (OHS), n = 5; percutaneous coronary intervention (PCI), n = 3; or other, n = 11). The effect on 6MWTd of OHS was investigated in 6 studies and of PCI in one study. The 6MWT is a useful measurement of physical capacity; data are limited on its ability to assess benefit following PCI. Conclusions The 6MWT has been studied inconsistently in IHD. The majority of data are on patients before and after CR. Data are limited concerning the effect on 6MWTd of OHS or PCI. The available data support the 6MWT as a measure of change in performance status following coronary intervention. More work is required to confirm this hypothesis.
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Affiliation(s)
- Andrew Coulshed
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David Coulshed
- Department of Cardiology, Nepean Hospital, University of Sydney, Penrith, New South Wales, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, University of Sydney, Penrith, New South Wales, Australia
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Kodeboina M, Piayda K, Jenniskens I, Vyas P, Chen S, Pesigan RJ, Ferko N, Patel BP, Dobrin A, Habib J, Franke J. Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095633. [PMID: 37174152 PMCID: PMC10177939 DOI: 10.3390/ijerph20095633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/24/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.
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Affiliation(s)
- Monika Kodeboina
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Clinic for Internal Medicine and Cardiology, Marien Hospital, 52066 Aachen, Germany
| | - Kerstin Piayda
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, 35392 Giessen, Germany
| | | | | | | | | | | | | | | | | | - Jennifer Franke
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Philips Chief Medical Office, 22335 Hamburg, Germany
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7
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Wang X, Yang X, Lu W, Pan L, Han Z, Pan S, Shan Y, Wang X, Zheng X, Li R, Zhu Y, Qin P, Shi Q, Zhou S, Zhang W, Guo S, Zhang P, Qin X, Sun G, Qin Z, Huang Z, Qiu C. Long-term outcomes of less drug-eluting stents by the use of drug-coated balloons in de novo coronary chronic total occlusion intervention: A multicenter observational study. Front Cardiovasc Med 2023; 10:1045859. [PMID: 36937919 PMCID: PMC10022494 DOI: 10.3389/fcvm.2023.1045859] [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: 09/16/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Background Data on drug-coated balloons (DCB) for de novo coronary chronic total occlusion (CTO) are limited. We aimed to investigate the long-term outcomes of substitution of drug-eluting stents (DES) by DCB. Methods We compared the outcomes of less DES strategy (DCB alone or combined with DES) and DES-only strategy in treating de novo coronary CTO in this prospective, observational, multicenter study. The primary endpoints were major adverse cardiovascular events (MACE), target vessel revascularization, myocardial infarction, and death during 3-year follow-up. The secondary endpoints were late lumen loss (LLL) and restenosis until 1-year after operation. Results Of the 591 eligible patients consecutively enrolled between January 2015 and December 2019, 281 (290 lesions) were treated with DCB (DCB-only or combined with DES) and 310 (319 lesions) with DES only. In the DCB group, 147 (50.7%) lesions were treated using DCB-only, and the bailout stenting rate was relatively low (3.1%). The average stent length per lesion in the DCB group was significantly shorter compared with the DES-only group (21.5 ± 25.5 mm vs. 54.5 ± 26.0 mm, p < 0.001). A total of 112 patients in the DCB group and 71 patients in the DES-only group (38.6% vs. 22.3%, p < 0.001) completed angiographic follow-up until 1-year, and LLL was much less in the DCB group (-0.08 ± 0.65 mm vs. 0.35 ± 0.62 mm, p < 0.001). There were no significant differences in restenosis occurrence between the two groups (20.5% vs. 19.7%, p > 0.999). The Kaplan-Meier estimates of MACE at 3-year (11.8% vs. 12.0%, log-rank p = 0.688) was similar between the groups. Conclusion Percutaneous coronary intervention with DCB is a potential "stent-less" therapy for de novo CTO lesions with satisfactory long-term clinical results compared to the DES-only approach.
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Affiliation(s)
- Xi Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinyue Yang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenjie Lu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liang Pan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhanying Han
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Sancong Pan
- Department of Cardiovascular Medicine, Jincheng People’s Hospital, Jincheng, China
| | - Yingguang Shan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xule Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaolin Zheng
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ran Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongjian Zhu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Qin
- Department of Geriatric Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiangwei Shi
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuai Zhou
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wencai Zhang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Sen Guo
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peisheng Zhang
- Department of Cardiology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaofei Qin
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guoju Sun
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhongsheng Qin
- Department of Cardiovascular Medicine, Jincheng People’s Hospital, Jincheng, China
| | - Zhenwen Huang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chunguang Qiu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Chunguang Qiu,
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Illési Á, Debreceni IB, Fejes Z, Nagy B, Hodosi K, Kappelmayer J, Csanádi Z, Szük TI. Effect of invasive therapeutic coronary interventions on endothelial cell activation and thrombin generation in patients with chronic total coronary occlusion. Thromb Res 2022; 217:64-72. [PMID: 35908382 DOI: 10.1016/j.thromres.2022.07.010] [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: 04/24/2022] [Revised: 07/06/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is commonly used treatment for chronic total occlusion (CTO). PCI can be performed in two different ways using wire escalation (WE) or subintimal dissection and reentry (DR) technique. During both procedures patients are treated with anticoagulants, however a substantial activation of coagulation cascade is expected, which may affect clinical outcome. OBJECTIVES Our aim was to compare the impact of WE and DR techniques regarding endothelial cell activation and thrombin formation. METHODS Fifty patients after CTO-PCI were enrolled into this study. Blood samples were obtained before PCI, at 48 h and 3-6 months after the intervention to measure soluble endothelium-specific markers and to investigate thrombin generation. RESULTS Twenty-nine patients were treated with WE, 21 received DR. In the DR group, soluble VCAM-1 (vascular cell adhesion molecule-1) and ICAM-1 (intercellular cell adhesion molecule-1) concentrations were gradually elevated and remained significantly increased at 3-6 months (p = 0.006 and p = 0.037, respectively) compared to pre-PCI. Furthermore, significant decrease in lagtime (p = 0.004) and time to peak (p = 0.002) with a substantial increment in peak thrombin (p = 0.001) were observed in these patients. In contrast, no significant alteration was found in the WE cohort. Clinical complications (myocardial infarction, stroke, thrombosis, revascularization) did not occur in the first 9 months of follow-up period in either group. CONCLUSION Although DR intervention induces more thrombin generation with a larger degree of endothelium activation compared to WE, this technique does not cause more clinical complications.
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Affiliation(s)
- Ádám Illési
- Department of Cardiology and Cardiac Surgery, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary; Doctoral School of Kálmán Laki, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - Zsolt Fejes
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - Béla Nagy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - Katalin Hodosi
- Institute of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - Zoltán Csanádi
- Department of Cardiology and Cardiac Surgery, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary; Doctoral School of Kálmán Laki, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - Tibor István Szük
- Department of Cardiology and Cardiac Surgery, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary; Doctoral School of Kálmán Laki, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary.
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9
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Melotti E, Belmonte M, Gigante C, Mallia V, Mushtaq S, Conte E, Neglia D, Pontone G, Collet C, Sonck J, Grancini L, Bartorelli AL, Andreini D. The Role of Multimodality Imaging for Percutaneous Coronary Intervention in Patients With Chronic Total Occlusions. Front Cardiovasc Med 2022; 9:823091. [PMID: 35586657 PMCID: PMC9108201 DOI: 10.3389/fcvm.2022.823091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPercutaneous coronary intervention (PCI) of Chronic total occlusions (CTOs) has been traditionally considered a challenging procedure, with a lower success rate and a higher incidence of complications compared to non-CTO-PCI. An accurate and comprehensive evaluation of potential candidates for CTO-PCI is of great importance. Indeed, assessment of myocardial viability, left ventricular function, individual risk profile and coronary lesion complexity as well as detection of inducible ischemia are key information that should be integrated for a shared treatment decision and interventional strategy planning. In this regard, multimodality imaging can provide combined data that can be very useful for the decision-making algorithm and for planning percutaneous CTO recanalization.AimsThe purpose of this article is to appraise the value and limitations of several non-invasive imaging tools to provide relevant information about the anatomical characteristics and functional impact of CTOs that may be useful for the pre-procedural assessment and follow-up of candidates for CTO-PCI. They include echocardiography, coronary computed tomography angiography (CCTA), nuclear imaging, and cardiac magnetic resonance (CMR). As an example, CCTA can accurately delineate CTO location and length, distal coronary bed, vessel tortuosity and calcifications that can predict PCI success, whereas stress CMR, nuclear imaging and stress-CT can provide functional evaluation in terms of myocardial ischemia and viability and perfusion defect extension.
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Affiliation(s)
- Eleonora Melotti
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Marta Belmonte
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Carlo Gigante
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Vincenzo Mallia
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Saima Mushtaq
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Edoardo Conte
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Danilo Neglia
- Fondazione Toscana G. Monasterio, Pisa, Italy
- Istituto di Scienze della Vita Scuola Superiore Sant'Anna, Pisa, Italy
| | - Gianluca Pontone
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Luca Grancini
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Antonio L. Bartorelli
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy
- *Correspondence: Daniele Andreini
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10
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Goodney P, Shah S, Hu YD, Suckow B, Kinlay S, Armstrong DG, Geraghty P, Patterson M, Menard M, Patel MR, Conte MS. A systematic review of patient-reported outcome measures patients with chronic limb-threatening ischemia. J Vasc Surg 2022; 75:1762-1775. [PMID: 35085747 PMCID: PMC9524582 DOI: 10.1016/j.jvs.2021.11.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/08/2021] [Indexed: 01/23/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral artery disease and diabetes continue to rise in our aging population, the public health impact of CLTI has escalated. Patient-reported outcome measures (PROMs) have become common and important measures for clinical evaluation in both clinical care and research. PROMs are important for the measurement of clinical effectiveness and cost effectiveness and for shared decision-making on treatment options. However, the PROMs used to describe the experience of patients with CLTI are heterogeneous, incomplete, and lack specific applicability to the underlying disease processes and diverse populations. For example, certain PROMs exist for patients with extremity wounds, and other PROMs exist for patients with pain, and still others exist for patients with vascular disease. Despite this multiplicity of tools, no single PROM encompasses all of the components necessary to describe the experiences of patients with CLTI. This significant unmet need is evident from both published reports and contemporary large-scale clinical trials in the field. In this systematic review, we review the current use of PROMs for patients with CLTI in clinical practice and in research trials and highlight the gaps that need to be addressed to develop a unifying PROM instrument for CLTI.
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Affiliation(s)
- Philip Goodney
- Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
| | - Samir Shah
- Vascular Surgery, University of Florida, Gainesville, Fla
| | - Yiyuan David Hu
- Geisel School of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Bjoern Suckow
- Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Scott Kinlay
- Cardiovascular Medicine, Boston Medical Center, Boston, Mass
| | - David G Armstrong
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, Calif
| | - Patrick Geraghty
- Vascular Surgery, Washington University in St. Louis, St. Louis, Mo
| | | | - Matthew Menard
- Vascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | - Michael S Conte
- Vascular Surgery, University of California, San Francisco, San Francisco, Calif
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11
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Procedural Outcomes in Patients Treated with Percutaneous Coronary Interventions within Chronic Total Occlusions Stratified by Gender. J Clin Med 2022; 11:jcm11051419. [PMID: 35268510 PMCID: PMC8911020 DOI: 10.3390/jcm11051419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
It has been demonstrated that gender differences are related to different procedural and long-term clinical outcomes among a general patient population treated using percutaneous coronary interventions (PCI). The objective of our analysis was to conduct assessment regarding the relationship between gender and procedural outcomes in patients treated for PCI regarding chronic total occlusions (CTO), based on a large, real-life registry. Data used to conduct the following analysis was derived from the national registry of percutaneous coronary interventions (ORPKI), upheld in co-operation with the Association of Cardiovascular Interventions (AISN) of the Polish Cardiac Society. The study involved data procured from the registry within the period from January 2014 to December 2020. All subsequent CTO procedures recorded in the registry during that period were included in the analysis. We assessed the correlation between gender and the overall rate of periprocedural complications, procedure-related mortality, and success evaluated as TIMI flow grade 3 after the procedure by univariate and multivariable modeling. At the time of conducting our investigation, there were 162 existing and active CathLabs, at which 747,033 PCI procedures were carried out during the observational period. Of those, 14,903 (1.99%) were CTO-PCI procedures, and 3726 were women (25%). The percentage share between genders did not experience any significant changes during the consecutive years observed in the current analysis. Overall periprocedural complication rate was greater among women than men (3.45% vs. 2.31%, p = 0.02). A comparable relationship was noted for procedural mortality (0.7% vs. 0.2%, p = 0.006), while procedural success occurred more often in the case of women (69.3% vs. 65.2%, p < 0.001). Women were found to be more frequently affected by periprocedural complications (OR = 1.553; 95%CI: 1.212−1.99, p < 0.001) as well as procedural success (OR = 1.294; 95%CI: 1.151−1.454, p < 0.001), evaluated using multivariable models. Based on the current analysis performed on all-comer patients treated using PCI in CTO, women are affected by more frequent procedural complication occurrence as well as greater procedural success compared to men.
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12
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Farrukh Mustafa S, Zafar MR, Vira A, Halalau A, Rabah M, Dixon S, Hanson I. In-hospital outcomes of patients with chronic kidney disease undergoing percutaneous coronary intervention for chronic total occlusion: a systematic review and meta-analysis. Coron Artery Dis 2021; 32:681-688. [PMID: 33587359 DOI: 10.1097/mca.0000000000001026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The relative safety and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in patients with chronic kidney disease (CKD) have not been well defined. We performed a systematic review and meta-analysis of observational studies to assess in-hospital outcomes in this population. METHODS We searched MEDLINE, EMBASE, and Cochrane Library databases from inception to April 2020 for all clinical trials and observational studies. Five observational studies with a total of 6769 patients met our inclusion criteria. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR <60 ml/min/1.73m2 in CKD group and ≥ 60 ml/min/1.73m2 in non-CKD group). The primary outcome was in-hospital mortality. Secondary outcomes were acute kidney injury, coronary injury (perforation, dissection or tamponade), stroke and procedural success. Mantel-Haenszel random-effects model was used to calculate the odds ratio (OR) and 95% confidence intervals (CI). RESULTS In-hospital mortality was significantly higher among patients with CKD undergoing PCI for CTO (OR: 5.16, 95% CI: 2.60-10.26, P < 0.00001). Acute kidney injury (OR: 2.54, 95% CI: 1.89-3.40, P < 0.00001) and major bleeding (OR: 2.58, 95% CI: 1.20-5.54, P < 0.01) were also more common in the CKD group. No significant difference was observed in the occurrence of stroke (OR: 2.36, 95% CI: 0.74-7.54, P < 0.15) or coronary injury (OR: 1.38, 95% CI: 0.98-1.93, P < 0.06) between the two groups. Non-CKD patients had a higher likelihood of procedural success compared to CKD patients (OR: 0.66, 95% CI: 0.57-0.77, P < 0.00001). CONCLUSION Patients with CKD undergoing PCI for CTO have a significantly higher risk of in-hospital mortality, acute kidney injury and major bleeding when compared to non-CKD patients. They also have a lower procedural success rate.
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Affiliation(s)
| | - Meer R Zafar
- Division Cardiology, Department of Medicine, Jacob's School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Amit Vira
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
- Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Maher Rabah
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak
- Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Simon Dixon
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak
- Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Ivan Hanson
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak
- Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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13
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A Novel Clinical Scoring Model for Interventional Therapy in Chronic Total Occlusion of the Coronary Artery. J Interv Cardiol 2021; 2021:9988943. [PMID: 34629988 PMCID: PMC8463195 DOI: 10.1155/2021/9988943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/30/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022] Open
Abstract
Objective With the rapid development of technology and experience, the current percutaneous coronary intervention of chronic total occlusion (CTO-PCI) preoperative scoring model needs to be updated. This study aimed to evaluate the clinical value of the operator-CTO score in predicting the outcome of interventional therapy for chronic total occlusion of the coronary artery. Methods The data of 144 lesions in 130 patients with CTO were analyzed prospectively. The CTO procedures were performed by 10 operators with different skills and experiences. Before the procedures, J-CTO, progress, ORA, recharge, and operator-CTO scores were determined. Then, the clinical, imaging, and procedural data of patients in different operator-CTO score groups and between different operators were compared. The final focus was on comparing the predictive ability of each score on the outcome of CTO-PCI. Results The overall technical and procedural success rates were 90.9% and 88.9%, respectively. A decreasing trend in the technical success of CTO-PCI was observed according to the operator-CTO score hierarchy of “easy (≤2 points), moderate (3 points), difficult (4 points), and extremely difficult (≥5 points)” (99.0%, 87.5%, 53.8%, and 25.0%, respectively). All five scoring models were well calibrated, and the area under the curve (AUC) for the operator-CTO score was 0.901 (95% CI: 0.821–0.982, P < 0.01), larger than the AUC for the remaining four scoring models, showing excellent ability to predict technical outcomes. Conclusion The operator-CTO score is a new clinical scoring tool that can predict the outcome of CTO-PCI and can be used to grade the difficulty of the procedure, with the potential to work well with a broad group of operators.
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14
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Wu X, Zhang D, Liu H, Li S, Fu C, Liu J, Cui J. A Clinical Analysis of the Treatment of Chronic Coronary Artery Occlusion With Antegrade Dissection Reentry. Front Surg 2021; 8:609403. [PMID: 34136525 PMCID: PMC8200522 DOI: 10.3389/fsurg.2021.609403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to investigate the efficacy and safety of antegrade dissection re-entry (ADR) technique in the percutaneous coronary intervention (PCI) to open chronic total occlusion (CTO) lesions. Methods: The baseline, angiographic results, PCI success rate, and major adverse cardiac events (MACE) during the 12 months of follow-up were compared between 48 patients who did not use ADR in the treatment of CTO lesions (control group) and 50 patients who used ADR (treatment group). Results: The control group comprised 48 patients who had 52 CTO lesions, and the treatment group comprised 50 patients who had 58 CTO lesions. The success rate of PCI in the treatment group (89.7 vs. 71.2%, P = 0.047) was significantly higher than in the control group, where six patients had in-stent restenosis (ISR, ISR-CTO) that were all recanalized. The mean PCI time (71 ± 25 min vs. 95 ± 33 min, P = 0.041), X-ray exposure time (42 ± 17 min vs. 71 ± 22 min, P = 0.032), contrast agent dosage (98 ± 26 ml vs. 178 ± 63 ml, P = 0.029), MACE incidence during the 12 months of follow-up (22.0 vs. 41.7%, P = 0.046) and recurrent myocardial infarction incidence (10.0 vs. 27.1%, P = 0.047) were significantly lower in the treatment group than in the control group. The differences were all statistically significant. Conclusion: It is safe and effective to use the ADR technique in PCI for coronary artery CTO lesions. The technique shortens the operation time, reduces the radiation dose of doctors and patients and the use dose of contrast agents, and improves patients' prognoses.
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Affiliation(s)
- Xiangjun Wu
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| | - Dan Zhang
- Department of Cardiology, Zouping People's Hospital Affiliated to Shandong First Medical University, Zouping, China
| | - Haitao Liu
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| | - Shuai Li
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chao Fu
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| | - Jiyuan Liu
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| | - Jiayu Cui
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
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15
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Zografos T, Tsiafoutis I, Tsoumeleas A, Floropoulou C, Gkini C, Koutouzis M. Chronic Total Occlusion PCI Techniques in 2020. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00914-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Shoaib A, Mohamed M, Curzen N, Ludman P, Zaman A, Rashid M, Nolan J, Azam ZA, Kinnaird T, Mamas MA. Clinical outcomes of percutaneous coronary intervention for chronic total occlusion in prior coronary artery bypass grafting patients. Catheter Cardiovasc Interv 2021; 99:74-84. [PMID: 33942465 DOI: 10.1002/ccd.29691] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/12/2021] [Accepted: 03/23/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the clinical characteristics and outcomes in patients with stable angina who have undergone chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in native arteries with or without prior coronary artery bypass grafting (CABG) surgery in a national cohort. BACKGROUND There are limited data on outcomes of patients presenting with stable angina undergoing CTO PCI with previous CABG. METHODS We identified 20,081 patients with stable angina who underwent CTO PCI between 2007-2014 in the British Cardiovascular Intervention Society database. Clinical, demographical, procedural and outcome data were analyzed in two groups; group 1-CTO PCI in native arteries without prior CABG (n = 16,848), group 2-CTO PCI in native arteries with prior CABG (n = 3,233). RESULTS Patients in group 2 were older, had more comorbidities and higher prevalence of severe left ventricular systolic dysfunction. Following multivariable analysis, no significant difference in mortality was observed during index hospital admission (OR:1.33, CI 0.64-2.78, p = .44), at 30-days (OR: 1.28, CI 0.79-2.06, p = .31) and 1 year (OR:1.02, CI 0.87-1.29, p = .87). Odds of in-hospital major adverse cardiovascular events (MACE) (OR:1.01, CI 0.69-1.49, p = .95) and procedural complications (OR:1.02, CI 0.88-1.18, p = .81) were similar between two groups but procedural success rate was lower in group 2 (OR: 0.34, CI 0.31-0.39, p < .001). The adjusted risk of target vessel revascularization (TVR) remained similar between the two groups at 30-days (OR:0.68, CI 0.40-1.16, P-0.16) and at 1 year (OR:1.01, CI 0.83-1.22, P-0.95). CONCLUSION Patients with prior CABG presenting with stable angina and treated with CTO PCI in native arteries had more co-morbid illnesses but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality, MACE or TVR.
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Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Nick Curzen
- Medicine department, University of Southampton, Southampton, UK
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Azfar Zaman
- Freeman Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - James Nolan
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Ziyad A Azam
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Tim Kinnaird
- Cardiology department, University Hospital of Wales, Cardiff, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
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Bryniarski L, Opolski MP, Wójcik J, Lesiak M, Pawłowski T, Drozd J, Wojakowski W, Surowiec S, Dąbrowski M, Witkowski A, Dudek D, Grygier M, Bartuś S. Chronic total occlusion percutaneous coronary intervention in everyday clinical practice - an expert opinion of the Association of Cardiovascular Interventions of the Polish Cardiac Society. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 17:6-20. [PMID: 33868413 PMCID: PMC8039914 DOI: 10.5114/aic.2021.104763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 11/17/2022] Open
Abstract
Coronary chronic total occlusions (CTO) are increasingly encountered during invasive and non-invasive coronary angiography and remain the most challenging lesions for percutaneous revascularization. During recent years success rates and safety outcomes of CTO percutaneous coronary intervention (PCI) have substantially improved, particularly due to the introduction of new techniques and dedicated equipment as well as specialized training programs of CTO operators. Significantly, the steady advances in CTO PCI techniques have coincided with the new data from randomized clinical trials supporting the role of percutaneous recanalization of CTO in relieving angina and improving the quality of life. The current expert consensus document outlines the rationale, clinical outcomes as well as technical, safety and reimbursement issues of CTO PCI. In addition, the requirements for achieving and maintaining competency in CTO PCI among interventional cardiologists are discussed. Finally, we present the modified hybrid algorithm (the so-called Polish hybrid algorithm) providing some unique refinements to the contemporary CTO PCI strategies. Continuous efforts (including active engagement with the payer) are urgently needed to increase guideline-recommended referrals to CTO PCI, and thus improve the quality of life of CTO patients in Poland.
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Affiliation(s)
- Leszek Bryniarski
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maksymilian P. Opolski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Jarosław Wójcik
- Hospital of Invasive Cardiology IKARDIA, Lublin/Nałęczów, Poland
| | - Maciej Lesiak
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Pawłowski
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Jakub Drozd
- Department of Cardiology, SP ZOZ MSWiA, Lublin, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Sławomir Surowiec
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej Dąbrowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Dariusz Dudek
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Grygier
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Stanisław Bartuś
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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Impact of Chronic Kidney Disease on Chronic Total Occlusion Revascularization Outcomes: A Meta-Analysis. J Clin Med 2021; 10:jcm10030440. [PMID: 33498733 PMCID: PMC7865303 DOI: 10.3390/jcm10030440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 11/26/2022] Open
Abstract
Objectives: To examine the impact of revascularization and associated clinical outcomes of chronic kidney disease (CKD) chronic total occlusion (CTO) and non-CKD CTO groups. Background: The influence of CKD on clinical outcomes after percutaneous coronary intervention (PCI) for CTO lesions is unknown, and there is no systemic review of this topic to date. Methods: We searched the PubMed, Embase, ProQuest, ScienceDirect, Cochrane Library, ClinicalKey, Web of Science, and ClinicalTrials Databases for articles published between 1 January 2010 and 31 March 2020. CKD was defined as estimated glomerular filtration rate of <60 mL/min/1.73 m2 according to the Modification of Diet in Renal Disease formula. Data included demographics, lesion distributions, incidence of contrast-induced nephropathy (CIN), acute kidney injury (AKI), procedural success rate, mortality, and target lesion revascularization (TLR)/target vessel revascularization (TVR). Results: Six studies were ultimately included in this systematic review. A high prevalence (25.5%; range, 19.6–37.9%) of CKD was noted in the CTO population. In the non-CKD group, outcomes were better: less incidence of CIN or AKI (odds ratio (OR), 2.860; 95% confidence interval (CI), 1.775–4.608), higher procedural success rate (OR, 1.382; 95% CI, 1.036–1.843), and lower long-term mortality (OR, 4.502; 95% CI, 3.561–5.693). The incidence of TLR/TVR (OR, 1.118; 95% CI, 0.888–1.407) did not differ between groups. Conclusions: In the CKD CTO PCI population, a lower procedural success rate, a higher incidence of CIN or AKI, and higher in-hospital and long-term mortality rate were noted due to more complex lesions and more comorbidities. However, the incidence of TLR/TVR did not differ between groups.
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Assaf A, Diletti R, Hoogendijk MG, van der Graaf M, Zijlstra F, Szili-Torok T, Yap SC. Vulnerability for ventricular arrhythmias in patients with chronic coronary total occlusion. Expert Rev Cardiovasc Ther 2020; 18:487-494. [PMID: 32684000 DOI: 10.1080/14779072.2020.1793671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The presence of a chronic total occlusion (CTO) is associated with an increased risk of ventricular arrhythmias. AREAS COVERED This review provides an overview of the relationship between CTO and ventricular arrhythmias, arrhythmogenic mechanisms, and the effect of revascularization. EXPERT OPINION Studies in recipients of an implantable cardioverter-defibrillator (ICD) have shown that a CTO is an independent predictor of appropriate ICD therapy. The myocardial territory supplied by a CTO is a pro-arrhythmogenic milieu characterized by scar tissue, large scar border zone, hibernating myocardium, residual ischemia despite collaterals, areas of slow conduction, and heterogeneity in repolarization. Restoring coronary flow by revascularization might be associated with electrical homogenization as reflected by a decrease in QT(c) dispersion, decrease in T wave peak-to-end interval, reduction of late potentials, and decrease in scar border zone area. Future research should explore whether CTO revascularization results in a lower burden of ventricular arrhythmias. Furthermore, risk stratification of CTO patients without severe LV dysfunction is interesting to identify potential ICD candidates. Potential tools for risk stratification are the use of electrocardiographic parameters, body surface mapping, electrophysiological study, and close rhythm monitoring using an insertable cardiac monitor.
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Affiliation(s)
- Amira Assaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Mark G Hoogendijk
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Marisa van der Graaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
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20
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Peri-Okonny PA, Spertus JA, Grantham JA, Gosch K, Kirtane A, Sapontis J, Lombardi W, Karmpaliotis D, Moses J, Nicholson W, Salisbury AC. Physical Activity After Percutaneous Coronary Intervention for Chronic Total Occlusion and Its Association With Health Status. J Am Heart Assoc 2020; 8:e011629. [PMID: 30922149 PMCID: PMC6509725 DOI: 10.1161/jaha.118.011629] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Patients with chronic total occlusion (CTO) may not participate in regular exercise because of refractory angina. Exercise participation after percutaneous coronary intervention (PCI) for CTO (CTO PCI) and the association of exercise with health status after CTO PCI is unknown. Methods and Results Overall, 1000 patients enrolled in the Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion OPEN CTO is a registry were asked about participation in regular exercise at baseline and 12 months after CTO PCI, and the frequency of exercise (<1, 1–2, ≥3 times/week) was collected among exercisers. Health status was assessed using the Seattle Angina Questionnaire (SAQ). Multivariable regression assessed 12‐month health status change across 4 groups defined by exercise frequency at baseline and 12 months after CTO PCI (no regular exercise at baseline and 12 months, reduced, increased, and consistent exercise at 12 months). Among 869 patients with complete exercise data, the proportion that exercised regularly increased from 33.5% at baseline to 56.6% 12 months after CTO PCI (P<0.01). Predictors of regular exercise at 12 months included baseline exercise, smoking, baseline and increase in SAQ scores for angina frequency, physical limitation, quality of life, and summary. After multivariable adjustment, consistent or increased exercise frequency was associated with significantly greater improvement in SAQ scores for angina frequency, physical limitation, quality of life, and summary (P<0.01). Conclusions Participation in regular exercise increased significantly 12 months after CTO PCI, and patients who had greater health status benefit after PCI were more likely to exercise regularly at 12 months. CTO PCI may enable coronary artery disease patients with limiting symptoms to engage in regular exercise and to support better long‐term outcomes.
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Affiliation(s)
| | - John A Spertus
- 1 Saint Luke's Mid America Heart Institute Kansas City MO.,2 University of Missouri-Kansas City Kansas City MO
| | - J Aaron Grantham
- 1 Saint Luke's Mid America Heart Institute Kansas City MO.,2 University of Missouri-Kansas City Kansas City MO
| | - Kensey Gosch
- 1 Saint Luke's Mid America Heart Institute Kansas City MO
| | | | | | | | | | | | | | - Adam C Salisbury
- 1 Saint Luke's Mid America Heart Institute Kansas City MO.,2 University of Missouri-Kansas City Kansas City MO
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21
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Tian J, Zuo H, Zhang L, Zhang M, Zhang D, Zhang M, Zhou Y, He Y, Mi H, Yang X, Huang R, Song X. The success of opening concurrent chronic total occlusion lesion to improve cardiac function trial in patients with multi-vessel disease (SOS-moral): Study protocol of a prospective multicenter study. Medicine (Baltimore) 2020; 99:e20349. [PMID: 32481325 PMCID: PMC7249893 DOI: 10.1097/md.0000000000020349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS The purpose of the present trial is to determine whether opening co-existing chronic total occlusions (CTOs) using percutaneous coronary interventions (PCIs) improves cardiac function in patients with multi-vessel disease (MVD). Patients with MVD are defined as having at least one additional major vessel exhibiting no less than 75% stenosis combined with the presence of a CTO artery. METHODS AND RESULTS Patients will be prospectively recruited who meet the following criteria:Patients presenting with no necrosis of myocardial tissue in the territory of the CTO will be excluded. Recruited patients will be randomized into 2 groups: those undergoing PCI of only the non-CTO artery (non-CTO PCI group), and those undergoing PCI of the non-CTO artery concurrently with the CTO artery (CTO-PCI group). The primary outcome will be the change in cardiac function evaluated via CMR at a 12-month of follow-up appointment, which will be compared to a baseline measurement. Secondary outcomes include occurrence of major cardiac events, CMR-assessed myocardial viability in the CTO-supplied territory, and quality of life assessed by Seattle angina questionnaire, Patient Health Questionnaire 9 and Generalized Anxiety Disorder Scale-7 after 12-month follow-up. CONCLUSION The SOS-moral trial will provide data necessary to determine whether to open concurrent CTOs among MVD patients with CMR-detected necrotic myocardial tissue.
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Affiliation(s)
| | | | - Lijun Zhang
- Department of Radiology, Beijing Anzhen Hospital
| | | | | | | | | | - Yi He
- Department of Radiology, Beijing Friendship Hospital
| | - Hongzhi Mi
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing
| | | | - Rongchong Huang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian
- The Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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22
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Keulards DCJ, Karamasis GV, Alsanjari O, Demandt JPA, Van't Veer M, Zelis JM, Dello SA, El Farissi M, Konstantinou K, Tang KH, Kelly PA, Keeble TR, Pijls NHJ, Davies JR, Teeuwen K. Recovery of Absolute Coronary Blood Flow and Microvascular Resistance After Chronic Total Occlusion Percutaneous Coronary Intervention: An Exploratory Study. J Am Heart Assoc 2020; 9:e015669. [PMID: 32316813 PMCID: PMC7428549 DOI: 10.1161/jaha.119.015669] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background This study aimed to investigate longitudinal physiological changes in the recanalized coronary chronic total occlusion (CTO) vessel and its dependent myocardium after successful percutaneous coronary intervention (PCI). Methods and Results In this pilot study, 25 patients scheduled for elective CTO PCI with viable myocardium and angiographically visible collaterals were included. Absolute coronary blood flow and absolute microvascular resistance were measured invasively using continuous thermodilution. Measurements were performed immediately after successful CTO PCI and at short‐term follow‐up. In a subgroup of patients, physiological measurements were performed at the predominant donor vessel before CTO PCI, immediately afterwards, and at follow‐up. Absolute coronary blood flow in the recanalized CTO artery increased from 148±53 mL/min immediately after PCI to 221±77 mL/min at follow‐up (P<0.001). In agreement, absolute resistance in the myocardial territory perfused by the CTO artery, decreased from 545±255 Wood units immediately after the procedure to 387±128 Wood units at follow‐up (P=0.014). There were no significant changes in the absolute coronary blood flow and resistance in the predominant donor between baseline and follow‐up. Positive remodeling of the distal CTO vessel with an increase in lumen diameter was observed. Conclusions After successful CTO PCI, blood flow in the recanalized artery and microvascular function of the dependent myocardium are not immediately normal but recover over time.
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Affiliation(s)
| | - Grigoris V Karamasis
- Essex Cardiothoracic Centre Basildon United Kingdom.,School of Medicine Anglia Ruskin University Chelmsford United Kingdom
| | - Osama Alsanjari
- Essex Cardiothoracic Centre Basildon United Kingdom.,School of Medicine Anglia Ruskin University Chelmsford United Kingdom
| | | | - Marcel Van't Veer
- Catharina Hospital Eindhoven The Netherlands.,Eindhoven University of Technology Eindhoven The Netherlands
| | - Jo M Zelis
- Catharina Hospital Eindhoven The Netherlands
| | | | | | - Klio Konstantinou
- Essex Cardiothoracic Centre Basildon United Kingdom.,School of Medicine Anglia Ruskin University Chelmsford United Kingdom
| | - Kare H Tang
- Essex Cardiothoracic Centre Basildon United Kingdom
| | - Paul A Kelly
- Essex Cardiothoracic Centre Basildon United Kingdom
| | - Thomas R Keeble
- Essex Cardiothoracic Centre Basildon United Kingdom.,School of Medicine Anglia Ruskin University Chelmsford United Kingdom
| | - Nico H J Pijls
- Catharina Hospital Eindhoven The Netherlands.,Eindhoven University of Technology Eindhoven The Netherlands
| | - John R Davies
- Essex Cardiothoracic Centre Basildon United Kingdom.,School of Medicine Anglia Ruskin University Chelmsford United Kingdom
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23
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Malik AO, Spertus JA, Grantham JA, Peri-Okonny P, Gosch K, Sapontis J, Moses J, Lombardi W, Karmpaliotis D, Nicholson WJ, Al Badarin F, Salisbury AC. Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention in Patients With Renal Dysfunction. Am J Cardiol 2020; 125:1046-1053. [PMID: 31955832 DOI: 10.1016/j.amjcard.2019.12.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 10/25/2022]
Abstract
Although contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is performed with high success rates, 10% to 13% of patients presenting with CTOs have chronic kidney disease (CKD), and the comparative safety, efficacy, and health status benefit of CTO PCI in these patients, has not been well defined. We examined the association of baseline renal function with periprocedural major adverse cardiovascular and cerebral events and health status outcomes in 957 consecutive patients (mean age 65.3 ± 10.3 years, 19.4% women, 90.3% white, 23.6 CKD [estimated glomerular filtration rate {eGFR} < 60]) in the OPEN-CTO (Outcomes, Patients Health Status, and Efficiency in Chronic Total Occlusions Registry) study. Hierarchical multivariable regression models were used to examine the independent association of baseline eGFR with technical success, periprocedural complications and change in health status, using Seattle Angina Questionnaire (SAQ) over 1 year. Crude rates of acute kidney injury were higher (13.5% vs 4.4%, p <0.001) and technical success lower (81.8% vs 88.4%, p = 0.01) in patients with CKD. There were no significant differences in other periprocedural complications. After adjustment for confounding factors, there was no significant association of baseline eGFR with technical success or periprocedural major adverse cardiovascular and cerebral events (death, myocardial infarction, emergent bypass surgery, stroke, perforation), whereas patients with lower eGFR had higher rates of acute kidney injury. The difference in SAQ summary score, between patients on the 10th and 90th percentile for baseline eGFR distribution was not clinically significant (1 month: -0.91; 1 year: -3.06 points). In conclusion, CTO PCI success, complication rates, and the health status improvement after CTO PCI are similar in patients across a range of baseline eGFRs.
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24
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Wang Y, Zhao HW, Wang CF, Zhang XJ, Tao J, Cui CS, Meng QK, Zhu Y, Luo DF, Hou AJ, Luan B. Efficacy and safety of standard and low dose ticagrelor versus clopidogrel in east AsianPatients with chronic total occlusion undergoing percutaneous coronary intervention: a single center retrospective study. BMC Cardiovasc Disord 2020; 20:109. [PMID: 32138662 PMCID: PMC7057632 DOI: 10.1186/s12872-019-01307-0] [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: 10/02/2019] [Accepted: 12/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with coronary chronic total occlusion (CTO) require effective antiplatelet therapy after percutaneous coronary intervention (PCI). Ticagrelor has more pronounced platelet inhibition than clopidogrel. However, the most appropriate dose of ticagrelor in East Asian populations remains unclear. METHOD We compared ticagrelor (180 mg loading dose, 90 mg twice daily thereafter and 120 mg loading dose, 60 mg twice daily thereafter) and clopidogrel (300 mg loading dose, 75 mg daily thereafter) for prevention of cardiovascular events in 525patients with CTO undergoing PCI. RESULTS The rate of in-hospital major adverse cardiac and cerebral events (MACCE) was not different between the groups. At 1-year follow-up, target vessel revascularization (TVR) in both ticagrelor groups were significantly lower than that in the clopidogrel group (p = 0.047); TVR was significantly decreased in 60 mg ticagrelor compared to standard dose clopidogrel (p = 0.046). At 1-year follow-up, overall MACCE in both ticagrelor groups were significantly lower than that in the clopidogrel group (p = 0.023). Kaplan-Meier analysis showed MACCE-free survival was significantly higher in both ticagrelor groups than in the clopidogrel group (p = 0.024). During hospitalization, minor bleeding was significant increased in the 90 mg ticagrelor group (p = 0.021). At 1-year follow-up, risk of major and minor bleeding were significantly increased in the 90 mg ticagrelor group. CONCLUSION In East Asian patients with CTO undergoing PCI, 60 mg ticagrelor was as effective as 90 mg, at the same time significantly reduced risk of bleeding.
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Affiliation(s)
- Yong Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - Hong-Wei Zhao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - Cheng-Fu Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - Xiao-Jiao Zhang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - Jie Tao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - Chun-Sheng Cui
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - Qing-Kun Meng
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - Yu Zhu
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - De-Feng Luo
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China
| | - Ai-Jie Hou
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China.
| | - Bo Luan
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, Liaoning Province, China.
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25
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Wang Y, Zhao HW, Wang CF, Zhang XJ, Tao J, Cui CS, Meng QK, Zhu Y, Luo DF, Hou AJ, Luan B. Incidence, Predictors, and Prognosis of Coronary Slow-Flow and No-Reflow Phenomenon in Patients with Chronic Total Occlusion Who Underwent Percutaneous Coronary Intervention. Ther Clin Risk Manag 2020; 16:95-101. [PMID: 32110027 PMCID: PMC7038390 DOI: 10.2147/tcrm.s233512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/04/2020] [Indexed: 01/17/2023] Open
Abstract
Background The incidence and prognosis of coronary slow-flow (CSF) and no-reflow phenomenon (NRP) in patients with coronary chronic total occlusion (CTO) who underwent percutaneous coronary intervention (PCI) remain unclear. Methods This single-center prospective study aimed to investigate the incidence of CSF/NRP during CTO interventional therapy, determine predictors of CSF/NRP, and evaluate its effect on patient outcomes. Results In this study, 552 patients with CTO who underwent PCI were included. CSF/NRP occurred in 16.1% of them. They had higher incidences of diabetes mellitus (53.9% vs 36.3%, p=0.002) and hypertension (50.6% vs 37.1%, p=0.018) and a lower incidence of retrograde filling grade >2 (34.8% vs 47.1%, p=0.036). Patients with CSF/NRP had a higher neutrophil ratio (55.6±19.4 vs 52.4±18.3, p=0.038) and levels of low-density lipoprotein (LDL; 3.0±0.8 vs 2.8±0.6, p=0.029), fasting glucose (FG; 8.3±1.3 vs 6.8±1.1, p=0.005), uric acid (332.6±82.9 vs 308.2±62.8, p=0.045), and high-sensitivity C-reactive protein (Hs-CRP; 9.8±4.8 vs 7.3±3.9, p=0.036). A multivariate logistic regression analysis revealed that diabetes mellitus (odds ratio [OR], 1.962; 95% confidence interval [CI]: 1.198–2.721; p=0.042), mean platelet volume (MPV; OR,1.284; 95% CI, 1.108–1.895; p=0.046), LDL cholesterol (LDL-C; OR, 1.383; 95% CI, 1.105–2.491; p=0.036), FG (OR, 2.095; 95% CI, 1.495–2.899; p=0.018), Hs-CRP(OR, 2.218; 95% CI, 1.556–3.519; p=0.029), and retrograde filling of grade >2 (OR, 0.822; 95% CI, 0.622–0.907; p=0.037) were independent predictors of CSF/NRP in CTO patients who underwent PCI. Kaplan-Meier analysis revealed that the patients in the CSF/NRP group had a significantly lower cumulative major cardiac and cerebrovascular events (MACCE)-free survival than those in the non-CSF/NRP group (p<0.0001). Conclusion Of the patients with CTO who underwent PCI, 16.1% developed CSF/NRP and had a significantly lower cumulative MACCE-free survival rate. Diabetes mellitus; higher levels of MPV, LDL-C, FG, and Hs-CRP; and a lower incidence of retrograde filling grade >2 were independent predictors of CSF/NRP in CTO patients who underwent PCI. Thus, they can be used for risk stratification.
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Affiliation(s)
- Yong Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Hong-Wei Zhao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Cheng-Fu Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Xiao-Jiao Zhang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Jie Tao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Chun-Sheng Cui
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Qing-Kun Meng
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Yu Zhu
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - De-Feng Luo
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Ai-Jie Hou
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
| | - Bo Luan
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang City, Liaoning Province, 110016, People's Republic of China
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26
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Vasiliev DK, Rudenko BA. Modern considerations of myocardial revascularization in coronary chronic total occlusion. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-6-69-74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- D. K. Vasiliev
- National Medical Research Center for Preventive Medicine
| | - B. A. Rudenko
- National Medical Research Center for Preventive Medicine
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27
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van Veelen A, van Dongen IM, Elias J, Råmunddal T, Eriksen E, van der Schaaf RJ, Claessen BEPM, Postema PG, Henriques JPS. Exercise testing after chronic total coronary occlusion revascularization in patients with STEMI and a concurrent CTO: A subanalysis of the EXPLORE-trial. Catheter Cardiovasc Interv 2019; 94:536-545. [PMID: 30968546 DOI: 10.1002/ccd.28282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/29/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To assess the effect of chronic total occlusion percutaneous coronary intervention (CTO PCI) on ventricular ectopy (VE) and symptomatology during exercise testing. BACKGROUND During exercise, the hypoxic myocardium in the CTO-territory can act as a substrate for VE and could lead to anginal complaints. METHODS In the EXPLORE-trial, 302 ST-segment elevation myocardial infarction (STEMI)-patients were randomized to CTO PCI or no-CTO PCI. For this sub-study, we analyzed all available exercise electrocardiograms (X-ECGs) at 4 months follow-up on symptoms and electrocardiographic parameters. RESULTS A total of 155 X-ECGs were available, 80 in the CTO PCI group (51.6%) and 75 in the no-CTO PCI group (48.4%). There were no differences regarding exercised time, achieved endurance, ST-deviation nor maximum heart-rate. The percentage of patients experiencing chest-pain during exercise was lower in the CTO PCI group (0% vs. 8.5%, p = .03). Also, there was a trend towards a higher maximum systolic blood pressure (SBP, 185 mmHg vs. 175, p = .09). No difference in VE was found between randomization groups, but patients with successful CTO PCI had a higher frequency of VE, compared to failed and no-CTO PCI (26% vs. 8%, p = .02). This did not result in higher frequencies of sustained ventricular arrhythmias or mortality. CONCLUSION In conclusion, in STEMI-patients, CTO PCI is associated with a small reduction of chest-pain during exercise and tended to be associated with an increase of maximum SBP. The observation that successful CTO PCI was associated with more VE during exercise, compared with failed/no-CTO PCI needs further exploration.
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Affiliation(s)
- Anna van Veelen
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, The Netherlands
| | - Ivo M van Dongen
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, The Netherlands.,Department of Cardiology, OLVG Hospital, Amsterdam, The Netherlands
| | - Joëlle Elias
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, The Netherlands
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erlend Eriksen
- Department of Cardiology, Haukeland University Hospital, Bergen, Norway
| | | | - Bimmer E P M Claessen
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, The Netherlands.,Department of Cardiology, Mount Sinai Hospital, New York City, New York
| | - Pieter G Postema
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, The Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, The Netherlands
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28
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Young MN, Secemsky EA, Kaltenbach LA, Jaffer FA, Grantham JA, Rao SV, Yeh RW. Examining the Operator Learning Curve for Percutaneous Coronary Intervention of Chronic Total Occlusions. Circ Cardiovasc Interv 2019; 12:e007877. [DOI: 10.1161/circinterventions.119.007877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Advances in chronic total occlusion percutaneous coronary intervention (CTO PCI) techniques have led to increased procedural success rates among operators. While utilization of CTO PCI has disseminated widely, the learning curve for new operators has not been well-defined.
Methods:
Between July 2009 and December 2015, 93 875 CTO PCI cases were extracted from the CathPCI Registry. We delineated a cohort of new CTO operators performing <10 CTO PCI cases per given year. In-hospital outcomes for subsequent CTO PCIs were stratified by the number of prior cases accrued by each operator. Multivariable regression models were used to estimate differences in outcomes with increasing experience. The primary outcome was major adverse cardiovascular events defined as the composite of death, myocardial infarction, stroke, tamponade, or urgent coronary artery bypass grafting.
Results:
Among 70 916 cases performed by 7251 new operators, procedure success rate was 61.4% and major adverse cardiovascular event rate was 4.2%. Meanwhile, the rate of major bleeding was 4.0%, myocardial infarction 2.0%, mortality 0.6%, tamponade 0.3%, and renal failure 0.2%. Adjusted regression models demonstrated piecewise linear improvements in guidewire crossing, stent placement, and procedure success with accrued volume, albeit with increased contrast use, fluoroscopy time, and bleeding. Major adverse cardiovascular event rates were stable beyond the 12th case (odds ratio per 5 case increase 1.00; 95% CI, 0.98–1.03,
P
=0.7980).
Conclusions:
Among a large number of new CTO PCI operators in the United States, there exists an experiential learning curve for procedural success. However, there were higher rates of bleeding despite case experience, while major adverse cardiovascular events remained relatively unchanged after initiation.
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Affiliation(s)
- Michael N. Young
- Cardiology Division, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH (M.N.Y.)
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., R.W.Y.)
| | - Lisa A. Kaltenbach
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.A.K., S.V.R.)
| | - Farouc A. Jaffer
- Cardiology Division, Massachusetts General Hospital, Boston (F.A.J.)
| | - James A. Grantham
- St Luke’s Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City (J.A.G.)
| | - Sunil V. Rao
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.A.K., S.V.R.)
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., R.W.Y.)
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Galassi AR, Werner GS, Boukhris M, Azzalini L, Mashayekhi K, Carlino M, Avran A, Konstantinidis NV, Grancini L, Bryniarski L, Garbo R, Bozinovic N, Gershlick AH, Rathore S, Di Mario C, Louvard Y, Reifart N, Sianos G. Percutaneous recanalisation of chronic total occlusions: 2019 consensus document from the EuroCTO Club. EUROINTERVENTION 2019; 15:198-208. [DOI: 10.4244/eij-d-18-00826] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Schumacher SP, Stuijfzand WJ, Opolski MP, van Rossum AC, Nap A, Knaapen P. Percutaneous Coronary Intervention of Chronic Total Occlusions: When and How to Treat. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:513-522. [DOI: 10.1016/j.carrev.2018.07.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/24/2018] [Accepted: 07/24/2018] [Indexed: 01/31/2023]
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Bhatnagar UB, Shrestha A, Petrasko M, Stys TP, Stys AT. Current Evidence and Rationale of Percutaneous Therapy for Chronic Total Coronary Occlusions. Curr Probl Cardiol 2019; 44:100412. [PMID: 30975448 DOI: 10.1016/j.cpcardiol.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/03/2019] [Indexed: 11/28/2022]
Abstract
The prevalence of chronic total occlusion (CTO) lesions in coronary arteries is notably high in patients with significant coronary artery disease. However, only a relatively small fraction of observed CTOs classically go for revascularization. Recent advances in techniques and equipment has greatly improved the success rates of CTO revascularization while reducing complications. There has also been an increasing body of evidence regarding clinical benefit of CTO revascularization. However, until recently majority of the evidence was observational and based on data from large multicenter registries. Recent randomized studies have reported on clinical benefits of CTO revascularization particularly with relief of angina. However, there is heterogeneity of results among different studies and the magnitude of benefit is not consistently seen in all studies. This article reviews the existing literature on the current evidence regarding clinical benefits and other rationale for CTO revascularization.
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Wang Y, Zhao HW, Wang CF, Fan CY, Zhang XJ, Zhu Y, Luo DF, Yu GN, Hou AJ, Luan B. Efficacy and safety of bivalirudin during percutaneous coronary intervention in high‐bleeding‐risk elderly patients with chronic total occlusion: A prospective randomized controlled trial. Catheter Cardiovasc Interv 2019; 93:825-831. [PMID: 30724035 DOI: 10.1002/ccd.28087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 12/29/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Yong Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Hong-Wei Zhao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Cheng-Fu Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Chun-Yu Fan
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Xiao-Jiao Zhang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Yu Zhu
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - De-Feng Luo
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Guo-Ning Yu
- Department of Science and Education, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Ai-Jie Hou
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
| | - Bo Luan
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, Liaoning, People's Republic of China
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Anantha-Narayanan M, Garcia S. Contemporary Approach to Chronic Total Occlusion Interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:1. [PMID: 30659365 DOI: 10.1007/s11936-019-0704-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Chronic total occlusion (CTO) poses one of the greatest technical challenges to interventional cardiologists. Despite recent advancements in techniques and clinical trials showing significant benefits of CTO percutaneous coronary interventions (PCI), the proportion of patients with untreated CTOs remains high. We therefore aim to perform a comprehensive review of the various techniques available, recent advancements, benefits, and complications associated with CTO PCI. RECENT FINDINGS Three randomized clinical trials examining the benefits of CTO PCI have recently been presented. Scoring systems have been developed to facilitate pre-procedural estimation of success and complications of CTO PCI. Technological enhancements in coronary wires and other interventional equipment along with dedicated training for CTO operators have improved the likelihood of successful recanalization of CTOs. CTO PCI has been shown to improve patient symptoms and quality of life. It is therefore important to have an in-depth knowledge of the various CTO techniques, appropriate equipment, and complications when performing these complex procedures. Clinicians should weigh the risks and benefits and choose the appropriate patient population who may benefit from revascularization.
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Affiliation(s)
- Mahesh Anantha-Narayanan
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Santiago Garcia
- Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 E 28th Street, Suite 300, Minneapolis, MN, 55407, USA.
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Finn MT, Doshi D, Cleman J, Song L, Maehara A, Hatem R, Redfors B, Kalra S, Fried JA, Liao M, Batres C, Moses JW, Parikh MA, Collins MB, Nazif TM, Fall KN, Green P, Kirtane AJ, Ali ZA, Leon MB, Mintz GS, Karmpaliotis D. Intravascular ultrasound analysis of intraplaque versus subintimal tracking in percutaneous intervention for coronary chronic total occlusions: One year outcomes. Catheter Cardiovasc Interv 2018; 93:1048-1056. [PMID: 30489684 DOI: 10.1002/ccd.27958] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/12/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVES We sought to determine the 1-year outcomes of patients receiving successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures comparing subintimal versus intraplaque wire tracking patterns. BACKGROUND CTO PCI utilizes both intraluminal and subintimal wire tracking to achieve successful percutaneous revascularization. Intravascular ultrasound (IVUS) can be used to precisely determine the path of wire tracking. METHODS From 2014 to 2016, data from patients undergoing CTO PCI were collected in a single-center database. The primary composite endpoint was target vessel failure (TVF) defined as cardiovascular death, target vessel myocardial infarction (MI), or target vessel revascularization (TVR). RESULTS In total 157 patients with successful CTO PCI and concomitant IVUS imaging completed 1-year follow-up. Subintimal tracking was detected in 53.5% of cases and those patients had a higher incidence of prior PCI, prior coronary artery bypass grafting, and higher J-CTO score. At 1-year, the unadjusted rate of TVF in the subintimal tracking group was higher than the intraplaque group (17.9 vs. 6.9%, HR 2.74, 95% CI 1.00-7.54, P = 0.04), driven by numerically higher rates of TVR and peri-procedural MI. After multivariable adjustment, no significant differences in the rates of the TVF between subintimal vs. intraplaque groups were present at 1-year (TVF: HR 1.51, 95% CI 0.38-6.00, P = 0.55). Landmark analysis excluding in-hospital events showed no significant differences in TVF to 1-year. CONCLUSIONS IVUS-detected subintimal tracking was observed in over half of successful CTO PCI cases and correlated with baseline and angiographic factors that contributed to the overall rate of TVF at 1-year.
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Affiliation(s)
- Matthew T Finn
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Darshan Doshi
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Jacob Cleman
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Lei Song
- Department of Cardiology, National Center for Cardiovascular Disease, China Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Akiko Maehara
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Raja Hatem
- Department of Cardiology, Hôpital du Sacré-Coeur, Montreal, Québec, Canada
| | - Björn Redfors
- Department of Cardiology, Cardiovascular Research Foundation, New York, New York.,Department of Cardiology, University of Gothenburg, Gothenburg, Sweden
| | - Sanjog Kalra
- Department of Cardiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania
| | - Justin A Fried
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Ming Liao
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Candido Batres
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Jeffery W Moses
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Manish A Parikh
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Michael B Collins
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Tamim M Nazif
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Khady N Fall
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Phillip Green
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Ajay J Kirtane
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Ziad A Ali
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Martin B Leon
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Gary S Mintz
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
| | - Dimitri Karmpaliotis
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York.,Department of Cardiology, Cardiovascular Research Foundation, New York, New York
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Obedinskiy AA, Kretov EI, Boukhris M, Kurbatov VP, Osiev AG, Ibn Elhadj Z, Obedinskaya NR, Kasbaoui S, Grazhdankin IO, Prokhorikhin AA, Zubarev DD, Biryukov A, Pokushalov E, Galassi AR, Baystrukov VI. The IMPACTOR-CTO Trial. JACC Cardiovasc Interv 2018; 11:1309-1311. [DOI: 10.1016/j.jcin.2018.04.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 04/10/2018] [Indexed: 10/28/2022]
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Update in the Percutaneous Management of Coronary Chronic Total Occlusions. JACC Cardiovasc Interv 2018; 11:615-625. [DOI: 10.1016/j.jcin.2017.10.052] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/10/2017] [Accepted: 10/24/2017] [Indexed: 12/12/2022]
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Association of Stress Test Risk Classification With Health Status After Chronic Total Occlusion Angioplasty (from the Outcomes, Patient Health Status and Efficiency in Chronic Total Occlusion Hybrid Procedures [OPEN-CTO] Study). Am J Cardiol 2018; 121:558-563. [PMID: 29289358 DOI: 10.1016/j.amjcard.2017.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 11/20/2022]
Abstract
Stress testing is endorsed by the American College of Cardiology/American Heart Association Appropriate Use Criteria to identify appropriate candidates for Chronic Total Occlusion (CTO) Percutaneous Coronary Intervention (PCI). However, the relation between stress test risk classification and health status after CTO PCI is not known. We studied 449 patients in the 12-center OPEN CTO registry who underwent stress testing before successful CTO PCI, comparing outcomes of patients with low-risk (LR) versus intermediate to high-risk (IHR) findings. Health status was assessed using the Seattle Angina Questionnaire Angina Frequency (SAQ AF), Quality of Life (SAQ QoL), and Summary Scores (SAQ SS). Stress tests were LR in 40 (8.9%) and IHR in 409 (91.1%) patients. There were greater improvements on the SAQ AF (LR vs IHR 14.2 ± 2.7 vs 23.3 ± 1.3 points, p <0.001) and SAQ SS (LR vs IHR 20.8 ± 2.3 vs 25.4 ± 1.1 points, p = 0.03) in patients with IHR findings, but there was no difference between groups on the SAQ QoL domain (LR vs IHR 24.8 ± 3.4 vs 27.3 ± 1.6 points, p = 0.42). We observed large health status improvements after CTO PCI in both the LR and IHR groups, with the greatest reduction in angina among those with IHR stress tests. Although patients with higher risk studies may experience greater reduction in angina symptoms, on average, patients with LR stress tests also experienced large improvements in symptoms after CTO PCI, suggesting patients with refractory symptoms should be considered appropriate candidates for CTO PCI regardless of stress test findings.
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Huang Z, Ma D, Zhang B, Folson AA, Lin J, Wu K, Liao H, Zhong Z. Epicardial collateral channel for retrograded recanalization of chronic total occlusion percutaneous coronary intervention: Predictors of failure and procedural outcome. J Interv Cardiol 2018; 31:23-30. [PMID: 28929594 DOI: 10.1111/joic.12441] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/17/2017] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES This study set out to identify significant lesion features of chronic total occlusion (CTO) that predict successful retrograde recanalization via epicardial collateral channels (CCs). BACKGROUND Epicardial CCs remain essential in retrograde percutaneous coronary intervention (PCI) of CTO. However, the unpredictability of success and occurrence of complications limit the application of epicardial CCs for retrograde PCI technique for CTO. METHODS 103 retro-recanalization cases were analyzed using epicardial CCs with successful recanalization as an end point. Clinical and angiography data were collected. RESULTS The total success rate was 76.3%. Independent predictors associated with technical success included CCs tortuosity, side branch at CCs tortuosity, inadequate CCs Size and inadequate CCs exit location. Assigning a score of one for each variable, four levels of difficulty were obtained and formed the EPI-CTO score (Epicardial CTO). This score had significant predictive value for the likelihood of successful recanalization (AUC: 0.94, 95%CI: 0.89-0.98). Coronary and CCs perforation occurred in 6 and 10 cases respectively. Four cases including two coronary and two CCs perforations had tamponade that needed pericardiocentesis. CONCLUSIONS Using epicardial CCs for retrograde approach of CTO PCI is effective. Complication rate was acceptable. We found four independent predictors relative to procedure success.
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Affiliation(s)
- Zehan Huang
- Shantou University Medical College, Shantou, China
| | - Dunliang Ma
- Second Division of the Cardiology Department, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong, China
| | - Bin Zhang
- Second Division of the Cardiology Department, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong, China
| | | | - Jingye Lin
- Second Division of the Cardiology Department, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong, China
| | - Kaize Wu
- Second Division of the Cardiology Department, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong, China
| | - Hongtao Liao
- Second Division of the Cardiology Department, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong, China
| | - Zhian Zhong
- Second Division of the Cardiology Department, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong, China
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Affiliation(s)
- Peter Tajti
- Minneapolis Heart Institute Abbott Northwestern Hospital, Minneapolis, MN
- Department of Invasive Cardiology, Second Department of Internal Medicine and Cardiology Center, University of Szeged, Hungary
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute Abbott Northwestern Hospital, Minneapolis, MN
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX
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Goel PK, Khanna R, Pandey CM, Ashfaq F. Long-term outcomes post chronic total occlusion intervention-implications of completeness of revascularization. J Interv Cardiol 2018; 31:293-301. [PMID: 29314289 DOI: 10.1111/joic.12480] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 10/24/2017] [Accepted: 10/29/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Long term clinical outcomes post chronic total occlusion (CTO) intervention may depend not only on CTO success/failure alone but also on Completeness of revascularization. OBJECTIVES To determine long term outcomes post CTO intervention and relate them to both success versus failure and Complete Revascularization (CR) versus Incomplete Revascularization (IR). METHODS Consecutive patients taken up for CTO intervention with at-least one CTO vessel between Jan 2006 to Dec 2015 were included. Clinical, procedural and follow up details were recorded in a pre-specified custom made software. Primary endpoint of the study was survival free of major adverse event individual, death, myocardial infarction (MI), repeat revascularisation (percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) and recurrent or continued angina. Each individual adverse event was considered as a secondary end point. RESULTS A total of 632 patients were enrolled in study with follow up data available in 549 (86%) constituting the study group with 490 (89.3%) success and 59 (11.7%) failure. Complete revascularization (CR) was obtained in 410 (74.7%). Follow up was median 2.9 years with inter-quartile range 1.1-4.8 years. Kaplan Meier survival analysis showed a better EFS with both CTO success versus failure (P = 0.03)and CR versus IR (P = 0.017). Individual adverse outcomes however were not significantly different in CTO success versus failure group but significantly better when analyzed with respect to CR versus IR including death (P = 0.049) and recurrent angina (P = 0.024). Repeat intervention and MI were not different by either analysis. CONCLUSIONS Successful CTO PCI results in a better long term event free survival but the difference between the groups is more if analyzed with respect to completeness of revascularization rather than CTO success/failure alone.
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Affiliation(s)
- Pravin K Goel
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Roopali Khanna
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - C M Pandey
- Department of Biostatistics and Health Informatic, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Fauzia Ashfaq
- Department of Cardiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Elbaz-Greener G, Wijeysundera HC. Coronary Chronic Total Occlusions: Time to Abandon a Culture of Therapeutic Nihilism? Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.117.004295. [PMID: 29237747 DOI: 10.1161/circoutcomes.117.004295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gabby Elbaz-Greener
- From the Division of Cardiology and Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Ontario, Canada (G.E.G., H.C.W.); University of Toronto, Ontario, Canada (G.E.G., H.C.W.); Institute for Clinical Evaluative Sciences, Ontario, Canada (H.C.W.); and Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (H.C.W.)
| | - Harindra C Wijeysundera
- From the Division of Cardiology and Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Ontario, Canada (G.E.G., H.C.W.); University of Toronto, Ontario, Canada (G.E.G., H.C.W.); Institute for Clinical Evaluative Sciences, Ontario, Canada (H.C.W.); and Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (H.C.W.).
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Danek BA, Karatasakis A, Tajti P, Sandoval Y, Karmpaliotis D, Alaswad K, Jaffer F, Yeh RW, Kandzari DE, Lembo NJ, Patel MP, Mahmud E, Choi JW, Doing AH, Lombardi WL, Wyman RM, Toma C, Garcia S, Moses JW, Kirtane AJ, Hatem R, Ali ZA, Parikh M, Karacsonyi J, Rangan BV, Khalili H, Burke MN, Banerjee S, Brilakis ES. Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention. Am J Cardiol 2017; 120:1285-1292. [PMID: 28826896 DOI: 10.1016/j.amjcard.2017.07.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/26/2017] [Accepted: 07/07/2017] [Indexed: 01/12/2023]
Abstract
Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.
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Weeraman D, Mannakkara NN, Gerber RT. Contemporary Evidence, Treatment Strategies, and Indications for Chronic Total Occlusion-Percutaneous Coronary Intervention. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10310401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Deshan Weeraman
- Department of Cardiology, Eastbourne District General Hospital, East Sussex Healthcare NHS Trust, Eastbourne, UK
| | - Nilanka N. Mannakkara
- Department of Cardiology, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, UK
| | - Robert T. Gerber
- Department of Cardiology, Eastbourne District General Hospital, East Sussex Healthcare NHS Trust, Eastbourne, UK; Department of Cardiology, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, UK
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Gao L, Wang Y, Liu Y, Cao F, Chen Y. Long-term clinical outcomes of successful revascularization with drug-eluting stents for chronic total occlusions: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2017; 89:574-581. [PMID: 28318134 DOI: 10.1002/ccd.26934] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/04/2017] [Accepted: 01/07/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To determine whether successful percutaneous coronary intervention (PCI) using drug-eluting stents (DESs) have beneficial effects on long-term outcomes in patients with chronic total occlusions (CTOs) compared with failed PCIs for CTOs. BACKGROUND Several observational studies have evaluated the long-term clinical outcomes of successful PCIs using DESs for CTOs. However, the results of these studies were inconsistent and inconclusive. METHODS We searched five online electronic databases to identify all the publications assessing the long-term outcomes of successful and failed PCIs using DESs for CTOs. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by STATA software. RESULTS A total of nine studies involving 5958 CTO patients who underwent successful PCI and 1511 CTO patients who underwent failed PCI were included in this meta-analysis. The results of the analysis indicated that successful CTO PCIs using DESs were associated with lower long-term all-cause mortality(OR = 0.55, 95% CI = 0.45-0.67, P < 0.001), lower risk of myocardial infarction (OR = 0.45, 95% CI = 0.23-0.74, P = 0.002), lower risk of major adverse cardiac events (MACEs, OR = 0.44, 95% CI = 0.27-0.72, P = 0.001), and less incidence of subsequent coronary artery bypass grafting (OR = 0.10, 95% CI = 0.05-0.21, P < 0.001) than failed CTO PCIs. However, there was no difference in the incidence of target vessel revascularization (OR = 1.06, 95% CI = 0.17-6.60, P > 0.05) between the two groups. CONCLUSION Successful CTO PCI using DESs can reduce long-term all-cause mortality and the risks of MI, MACEs, and CABG in patients with CTOs. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Lei Gao
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yabin Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yuqi Liu
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Feng Cao
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
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Azzalini L, Torregrossa G, Puskas JD, Brilakis ES, Lombardi WL, Karmpaliotis D, Nakamura S, Colombo A, Carlino M. Percutaneous revascularization of chronic total occlusions: Rationale, indications, techniques, and the cardiac surgeon's point of view. Int J Cardiol 2017; 231:90-96. [DOI: 10.1016/j.ijcard.2017.01.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 01/03/2017] [Indexed: 11/24/2022]
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