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O'Brien JM, Dautov R, Sapontis J. Chronic Total Occlusions: A State-of-the-Art Review. Heart Lung Circ 2024; 33:764-772. [PMID: 38565438 DOI: 10.1016/j.hlc.2024.01.031] [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: 07/30/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 04/04/2024]
Abstract
The percutaneous management of chronic total occlusions (CTO) is a well-established sub-specialty of Interventional Cardiology, requiring specialist equipment, training, and techniques. The heterogeneity of approaches in CTO has led to the generation of multiple algorithms to guide operators in their management. The evidence base for management of CTOs has suffered from inconsistent descriptive and quantitative terminology in defining the nature of lesions and techniques utilised, as well as seemingly contradictory data about improvement in ventricular function, symptoms of angina, and mortality from large-scale registries and randomised controlled trials. Through this review, we explore the history of CTO management and its supporting evidence in detail, with an outline of limitations of CTO-percutaneous coronary intervention and a look at the future of this growing field within cardiology.
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Affiliation(s)
- Joseph M O'Brien
- Victorian Heart Hospital, Cardiology, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Monash University, Melbourne, Vic, Australia. joseph.o'
| | - Rustem Dautov
- Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - James Sapontis
- Victorian Heart Hospital, Cardiology, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
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Januszek R, De Luca G, Siłka W, Bryniarski L, Malinowski KP, Surdacki A, Wańha W, Bartuś S, Piotrowska A, Bartuś K, Pytlak K, Siudak Z. Single versus Dual-Operator Approaches for Percutaneous Coronary Interventions within Chronic Total Occlusion-An Analysis of 27,788 Patients. J Clin Med 2023; 12:4684. [PMID: 37510798 PMCID: PMC10380720 DOI: 10.3390/jcm12144684] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Since the treatment of chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) is associated with high procedural complexity, it has been suggested to use a multi-operator approach. This study was aimed at evaluating the procedural outcomes of single (SO) versus dual-operator (DO) CTO-PCI approaches. (2) Methods: This retrospective analysis included data from the Polish Registry of Invasive Cardiology Procedures (ORPKI), collected between January 2014 and December 2020. To compare the DO and SO approaches, propensity score matching was introduced with equalized baseline features. (3) Results: The DO approach was applied in 3604 (13%) out of 27,788 CTO-PCI cases. Patients undergoing DO CTO-PCI experienced puncture-site bleeding less often than the SO group (0.1% vs. 0.3%, p = 0.03). No differences were found in the technical success rate (successful revascularization with thrombolysis in myocardial infarction flow grade 2/3) of the SO (72.4%) versus the DO approach (71.2%). Moreover, the presence of either multi-vessel (MVD) or left main coronary artery disease (LMCA) (odds ratio (OR), 1.67 (95% confidence interval (CI), 1.20-2.32); p = 0.002), as well as lower annual and total operator volumes of PCI and CTO-PCI, could be noted as factors linked with the DO approach. (4) Conclusions: Due to the retrospective character, the findings of this study have to be considered only as hypothesis-generating. DO CTO-PCI was infrequent and was performed on patients who were more likely to have LMCA lesions or MVD. Operators collaboratively performing CTO-PCIs were more likely to have less experience. Puncture-site bleeding occurred less often in the dual-operator group; however, second-operator involvement had no impact on the technical success of the intervention.
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Affiliation(s)
- Rafał Januszek
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Kraków, Poland
| | - Giuseppe De Luca
- Division of Cardiology, AOU Policlinico G. Martino, University of Messina, 98166 Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, 20161 Milan, Italy
| | - Wojciech Siłka
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Kraków, Poland
| | - Leszek Bryniarski
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Kraków, Poland
| | - Krzysztof Piotr Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Andrzej Surdacki
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Kraków, Poland
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-635 Katowice, Poland
| | - Stanisław Bartuś
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Kraków, Poland
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Aleksandra Piotrowska
- Faculty of Medicine and Health Sciences, Jan Kochanowski University, 25-369 Kielce, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Kraków, Poland
| | - Kamil Pytlak
- Faculty of Medicine and Health Sciences, Jan Kochanowski University, 25-369 Kielce, Poland
| | - Zbigniew Siudak
- Faculty of Medicine and Health Sciences, Jan Kochanowski University, 25-369 Kielce, Poland
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Aljabbary T, Katyukha A, Elbaz-Greener G, Gressmann K, Bagai A, Graham JJ, Vijayaraghavan R, Kalra S, Vo M, Wijeysundera HC. Overview of Contemporary Chronic Total Occlusion Percutaneous Coronary Intervention Techniques: A Narrative Systematic Review. CJC Open 2021; 3:1273-1281. [PMID: 34888507 PMCID: PMC8636234 DOI: 10.1016/j.cjco.2021.05.018] [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: 04/17/2021] [Accepted: 05/31/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite the abundance of coronary chronic total occlusions (CTO) percutaneous coronary intervention (PCI) studies, the literature is not easy to digest for both general PCI operators and CTO PCI specialists because of the many varied terms used for approaches and inconsistency in terminology. This inconsistency makes it challenging to understand the advantages and disadvantages of these different approaches and, most importantly, their downstream clinical outcomes. Accordingly, we conducted a systematic review of all published studies on CTO PCI to describe techniques and algorithms used in the last decade to provide an overview on the efficacy and safety of contemporary CTO PCI techniques. METHODS We performed a comprehensive search of the PubMed, EMBASE, and the Cochrane library databases for manuscripts about PCI of CTOs. We included studies published between the years 2005 and 2019. We categorized studies into those using a single approach (antegrade, retrograde) and those with a prespecified algorithm (ie, hybrid approach). RESULTS Fifty-five observational studies including 28,907 patients who underwent CTO were included in this review. CTO PCI generally carries low risk of major procedural complications, with angiographic success rates being higher in studies that used an algorithmic vs single technical approach. CONCLUSIONS This systematic review highlights the wide variation in definitions and practices in CTO PCI and calls for standardization in terminology and practice.
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Affiliation(s)
- Talal Aljabbary
- Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Andriy Katyukha
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Akshay Bagai
- Terrence Donnelly Heart Center, St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - John J. Graham
- Terrence Donnelly Heart Center, St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | | | - Sanjog Kalra
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Minh Vo
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Harindra C. Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Yamamoto M, Tsuchikane E, Kagase A, Shimura T, Teramoto T, Kimura M, Matsuo H, Kawase Y, Suzuki Y, Kano S, Habara M, Nasu K, Kinoshita Y, Terashima M, Matsubara T, Suzuki T. Novel proctorship effectively teaches interventionists coronary artery chronic total occlusion lesions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:407-412. [PMID: 29169983 DOI: 10.1016/j.carrev.2017.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Interventionists' experience and skills are essential factors for successful chronic total occlusion-percutaneous coronary intervention (CTO-PCI). However, the construction of theoretical strategy independent from interventionists' procedure may also improve it. We sought to assess the feasibility of CTO-PCI using an educational system supported by a single expert proctor. METHODS A total of 160 patients underwent CTO-PCI between 2009 and 2016 at 92 Japanese centers in the Hands-on proctorship project. The CTO-PCI strategy was discussed with all participants and their specialists, before and during the procedure. We divided patients into 2 groups based on the CTO-PCI experience of their interventionist: (1) the less experienced group (CTO-PCI ≤50 cases, n=65) and (2) the more experienced group (CTO-PCI >50 cases, n=95). Baseline characteristics, procedural complications, and clinical outcomes were compared between groups. RESULTS No significant differences in patient age, sex, prevalence for coronary risk factors, and lesion complexity was observed between groups. The retrograde approach was used equivalently between groups (55.4% vs. 60.0%, p=0.56), and procedural success rates were similar (96.9% vs. 90.5%, p=0.12). The rate of proctor's bailout for recanalization were not frequent between groups (4.6% vs. 5.3%, p=0.85). No procedure-related mortality was noted in either group. In addition, no significant differences in procedural cardiac complications, including coronary dissection, perforation, or tamponade, were observed between groups (10.8% vs. 14.7%, p=0.47). CONCLUSIONS The expert-supported CTO-PCI maintained high success rates regardless of interventionists' experience. This highlights the importance of theoretical strategy for the management patients undergoing CTO-PCI.
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Affiliation(s)
- Masanori Yamamoto
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan.
| | - Etsuo Tsuchikane
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan.
| | - Ai Kagase
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Tetsuro Shimura
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Tomohiko Teramoto
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Masashi Kimura
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Yoshiaki Kawase
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | - Yoriyasu Suzuki
- Department of Cardiovascular Medicine, Nagoya Heart Center, Nagoya, Aichi, Japan
| | - Seiji Kano
- Department of Cardiovascular Medicine, Nagoya Heart Center, Nagoya, Aichi, Japan
| | - Maoto Habara
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Kenya Nasu
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Yoshihisa Kinoshita
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Mitsuyasu Terashima
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Tetsuo Matsubara
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
| | - Takahiko Suzuki
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Toyohashi, Aichi, Japan
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Ward MR. Dedicated CTO-PCI Centres: 'If you Build it they will Come'. Heart Lung Circ 2016; 25:637-8. [PMID: 27241702 DOI: 10.1016/j.hlc.2016.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Michael R Ward
- Department of Cardiology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
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