Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool

Intravascular Lithotripsy Versus Rotational Atherectomy in Coronary Chronic Total Occlusions: Analysis from the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention Registry

There are limited comparative data on the use of plaque modification devices during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We compared intravascular lithotripsy (IVL) with rotational atherectomy (RA) for lesion preparation in patients who underwent CTO PCI across 50 US and non-US centers from 2019 to 2024. Of 15,690 patients who underwent CTO PCI during the study period, 436 (2.78%) underwent IVL and 381 (2.45%) RA. Patients treated with IVL had more co-morbidities and more complex CTO lesions. Antegrade wiring was the most used initial and successful crossing strategy for lesions treated with both IVL and RA, although the retrograde approach was more frequently used in IVL cases. Procedure and fluoroscopy times, and air kerma radiation doses and contrast volumes, were greater in patients treated with RA than those treated with IVL. There were no significant differences between the groups in technical success (97.2% vs 95.3%, p = 0.20), procedural success (94.7% vs 91.8%, p = 0.14), and in-hospital major adverse cardiac events (MACEs) (3.0% vs 4.2%, p = 0.47). However, coronary artery perforations were more frequent in patients who underwent RA (9.5% vs 3.2%, p <0.001). Multivariable logistic regression analysis revealed that IVL compared with RA was not independently associated with technical success, procedural success, or in-hospital MACE. In patients who undergo CTO PCI, IVL is associated with similar in-hospital MACE, technical success, and procedural success but lower incidence of coronary artery perforation compared with RA.

Optimizing the Approach and Clinical Outcomes of Women Undergoing Chronic Total Occlusion-Percutaneous Coronary Intervention

Coronary artery disease remains a leading cause of morbidity and mortality globally, with chronic total occlusions (CTOs) representing a particularly challenging subset. Percutaneous coronary intervention (PCI) for CTOs has evolved significantly over the years, driven by advancements in equipment, techniques, and operator expertise. However, women have historically been underrepresented in clinical trials and guidelines, leading to a gap in an evidence-based management tailored to their specific needs, including in CTO-PCI. This review aims to explore the nuances of CTO-PCI in women, including anatomic considerations, procedural strategies, and clinical outcomes, with the goal of optimizing their care.

Outcomes of Left Main Chronic Total Occlusion Percutaneous Coronary Interventions

BACKGROUND

Percutaneous coronary intervention (PCI) of left main (LM) chronic total occlusions (CTO) has received limited study.

METHODS

We compared the clinical and procedural characteristics and outcomes of patients who underwent LM versus non-LM CTO PCI at 41 US and non-US centers between 2012 and 2024.

RESULTS

During the study period 85 of 15,254 CTO PCIs (0.6%) performed in 14,969 patients were LM CTO PCIs. LM CTO PCI patients were older, had higher rates of dyslipidemia and heart failure and most (88.8%) had prior coronary artery bypass graft surgery (CABG). They were more likely to have moderately or severely calcified lesions (80.7% vs. 45.7%, p < 0.001) and had higher J-CTO (2.76 ± 1.17 vs. 2.37 ± 1.26, p = 0.008), PROGRESS-CTO MACE (3.56 vs. 2.57, p < 0.001), Mortality (2.45 vs. 1.68, p < 0.001), Pericardiocentesis (2.74 vs. 1.87, p < 0.001), Acute MI (1.72 vs. 0.89, p < 0.001) and Perforation (3.21 vs. 2.19, p < 0.001) scores. There was no difference in technical success (80.5% vs. 87.2%, p = 0.086) or major cardiovascular adverse events (MACE) (2.4% vs. 2.0%, p = 0.700). LM CTO PCI patients with and without prior CABG surgery had similar technical success and MACE. The retrograde approach in prior CABG patients was more likely to be performed through saphenous vein grafts.

CONCLUSIONS

LM CTO PCI is infrequently performed, is associated with high comorbidity burden and angiographic complexity but can be performed with high success and acceptable complication rates.

Short- and long-term outcomes of antegrade versus retrograde approaches in patients undergoing percutaneous coronary intervention for chronic total occlusion: A meta-analysis

BACKGROUND

Chronic Total Occlusion (CTO) involves severe coronary artery blockage that impairs blood flow and affects 15-20 % of patients undergoing coronary angiography and over 40 % with diabetes or heart failure. Percutaneous Coronary Intervention (PCI) is used to restore blood flow in such cases. The retrograde approach, developed due to lower success with the antegrade method in complex cases, improves outcomes but increases complications. This meta-analysis compares the efficacy and safety of both approaches to guide clinical practice.

METHODS

A comprehensive literature search was conducted on PubMed, Embase, Google Scholar, and Scopus until June 5, 2024, to find studies comparing antegrade and retrograde approaches in CTO-PCI patients. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were calculated using R software (version 4.4.1), with significance set at p < 0.05. Random-effects models were used for all analyses.

RESULTS

Our analysis included 22 observational studies with 49,152 CTO-PCI patients: 35,844 in the antegrade arm and 13,308 in the retrograde arm. The antegrade approach showed significantly lower risks of in-hospital outcomes, including mortality [RR: 0.45; p < 0.001], myocardial infarction [RR: 0.37; p < 0.001], major adverse cardiovascular events [RR: 0.34; p < 0.001], and cerebrovascular events [RR: 0.50; p = 0.011]. Long-term outcomes, such as all-cause mortality [RR: 0.71; p = 0.157] and myocardial infarction [RR: 0.76; p = 0.438], were comparable between both approaches.

CONCLUSION

The antegrade technique shows better outcomes and procedural advantages over retrograde revascularization, though long-term outcomes are similar. Further studies, especially randomized controlled trials are needed to confirm these findings.

Association of Proximal Vessel Tortuosity with Technical Success and Clinical Outcomes: Analysis From the Progress-CTO Registry

BACKGROUND

Proximal vessel tortuosity can hinder wiring and equipment delivery during chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

AIMS

We sought to examine the association of proximal vessel tortuosity with the short and long-term outcomes of patients undergoing CTO PCI.

METHODS

We examined the association of proximal vessel tortuosity with clinical outcomes in patients who underwent CTO PCI at 50 US and non-US centers between 2012 and 2024.

RESULTS

Of 14,141 patients, 3,974 (28.1%) had moderate or severe proximal vessel tortuosity. Patients with moderate or severe proximal vessel tortuosity had more comorbidities and more complex angiographic characteristics, such as longer lesion length and higher prevalence of side branch at the proximal cap. Lesions with moderate or severe proximal tortuosity required greater procedure and fluoroscopy time. On unadjusted analyses, moderate/severe proximal vessel tortuosity was associated with lower technical success and higher incidence of major adverse cardiac events (MACE). In multivariable analysis, moderate/severe proximal vessel tortuosity was associated with lower technical success (odds ratio [OR]: 0.77; 95% confidence intervals [CI]: 0.67, 0.89) but similar MACE (OR: 1.26; 95% CI: 0.91, 1.73). Higher operator volume (≥ 30 CTO PCI cases per year) was associated with higher technical (85.2% vs. 75.6%, p < 0.001) and procedural success (83.6% vs. 74.5%, p < 0.001) but also higher risk of perforation (6.49% vs. 3.57%, p < 0.001) but not pericardiocentesis, in lesions with moderate/severe proximal vessel tortuosity.

CONCLUSIONS

Moderate or severe proximal vessel tortuosity is independently associated with lower technical success in CTO PCI but not with MACE. High-volume operators are more likely to successfully perform CTO PCI in lesions with moderate/severe tortuosity at the cost of higher risk of perforation, without higher MACE.

Preprocedural Planning for Chronic Total Occlusion Percutaneous Coronary Intervention

Chronic total occlusions (CTO) are frequently encountered in clinical practice. Although the success rates and safety of CTO percutaneous coronary intervention (PCI) have significantly improved with the development of newer equipment, use of an algorithmic approach, and advancement in procedural techniques, CTO PCI has a higher rate of complication than does non-CTO PCI. Therefore, meticulous preprocedural planning before CTO PCI is paramount to improve success and reduce the risk of complications. In this report, we review multiple aspects of preprocedural CTO PCI planning, including procedural indications, efficacy, safety, diagnostic angiography, scoring tools for procedural success and risk prediction, and preprocedural use of computed tomography coronary angiography.

Application of Drug-Coated Balloons in Complex High Risk and Indicated Percutaneous Coronary Interventions

There is a growing trend of patients with significant comorbidities among those referred for percutaneous coronary intervention (PCI). Consequently, the number of patients undergoing complex high risk indicated PCI (CHIP) is rising. CHIP patients frequently present with factors predisposing to extensive drug-eluting stent (DES) implantation, such as bifurcation and/or heavily calcified coronary lesions, which exposes them to the risks associated with an increased stent burden. The drug-coated balloon (DCB) may overcome some of the limitations of DES, either through a hybrid strategy (DCB and DES combined) or as a leave-nothing-behind strategy (DCB-only). As such, there is a growing interest in extending the application of DCB to the CHIP population. The present review provides an outline of the available evidence on DCB use in CHIP patients, which comprise the elderly, comorbid, and patients with complex coronary anatomy. Although the majority of available data are observational, most studies support a lower threshold for the use of DCBs, particularly when multiple CHIP factors coexist within a single patient. In patients with comorbidities which predispose to bleeding events (such as increasing age, diabetes mellitus, and hemodialysis) DCBs may encourage shorter dual antiplatelet therapy duration-although randomized trials are currently lacking. Further, DCBs may simplify PCI in bifurcation lesions and chronic total coronary occlusions by reducing total stent length, and allow for late lumen enlargement when used in a hybrid fashion. In conclusion, DCBs pose a viable therapeutic option in CHIP patients, either as a complement to DES or as stand-alone therapy in selected cases.

Role of pre-procedure CCTA in predicting failed percutaneous coronary intervention for chronic total occlusions

Purpose

This study aimed to identify major lesion characteristics of chronic total occlusions (CTOs) that predict failed percutaneous coronary intervention (PCI) using pre-procedure coronary computed tomography angiography (CCTA) in combination with conventional coronary angiography (CCA).

Methods

Consecutive patients with at least one CTO of the native coronary arteries received CCTA and CCA-guided PCI, with computed tomography performed before or during PCI.

Results

A total of 76 patients with CTO were included in this study. 76 patients were divided into successful and failed PCI groups based on their PCI outcome. There were 62 (81.58 %) patients in the successful PCI group and 14 (18.42 %) in the failed PCI group. The occlusion length ≥20 mm, ostial or bifurcation lesions, negative remodeling, microchannels, and good collateral vessels were the CCTA morphologic parameters associated with PCI outcome (P<0.05). In addition, the blunt stump, occlusion length ≥20 mm, and ostial or bifurcation lesions, were the CCA morphologic parameters associated with PCI outcome (P<0.05). The multivariate regression model showed that the three independent negative predictors: blunt stump on CCA (OR: 0.63; 95 % CI: 0.23-0.98; p =0.048), occlusion length ≥20 mm on CCTA (OR: 0.37; 95 % CI: 0.32-0.71; p <0.001) and negative remodeling on CCTA (OR: 0.26; 95 % CI: 0.28-0.44; p <0.001).

Conclusion

Our study demonstrated that combining CCTA and CCA morphologic characteristics could improve PCI outcome prediction in patients with CTO compared to CCTA morphologic features alone.

A Novel Parallel Wire-based Antegrade Dissection Re-entry Technique for Failed Retrograde Attempt of Coronary Chronic Total Occlusions with Risk Nomogram Analysis

BACKGROUND

Rapid development in coronary chronic total occlusion (CTO) interventional techniques and devices have achieved a greater success rate with favorable outcomes. Antegrade dissection re-entry (ADR) technique is an important CTO crossing strategy and a desirable approach for long CTOs with good distal landing zone. However, unsuccessful procedures in contemporary CTO-percutaneous coronary intervention (PCI) remain, especially in lesions with non-interventional collaterals.

METHOD

Based on a single center experience, a hybrid interventional algorithm, parallel wire-based ADR (PW-ADR) combines the advantages of parallel wire technique (PWT) and device-based ADR to target CTO lesions with failed retrograde approach. A retrospective analysis of patients who underwent PW-ADR was performed. A risk nomogram was created to identify patients at high risk for technical failure.

RESULTS

A total of 57 patients treated with PW-ADR were ultimately included in the present study. A total of 46 (80.7%) cases achieved technical success and procedural success, with low incidence of in-hospital complications or 1-year major adverse cardiac events (MACE). The risk nomogram identified 3 predictor variables associated with technical failure of PW-ADR, including tortuous vessel, J-CTO score, and times of antegrade coronary angiography (CAG) during ADR, with promising accuracy (AUROC 0.947).

CONCLUSION

The novel hybrid CTO-PCI algorithm, PW-ADR, provided an alternative interventional approach for complex CTO lesions with a promising success rate. The risk nomogram served as a prompter for high-risk cases, which may warrant a change in treatment strategy.

Role of calcification in J-CTO score: a viewpoint of intraplaque guidewire tracking techniques

BACKGROUND

As the burden and distribution of calcification within chronic total occlusion (CTO) lesions can be diverse, its effect on CTO recanalization using multiple devices and techniques is debatable. This study investigated the role of calcification in wiring-based intraplaque tracking techniques for CTO recanalization.

METHODS

A modified J-CTO score without counting calcification was used to analyze the procedures of 458 consecutive patients who underwent CTO interventions. Failed guidewire crossing and intraplaque tracking were considered procedural failures. Recanalization time details were analyzed for successful procedures.

RESULTS

In patients with calcified CTO, the rate of procedural success only significantly declined to be lower than that of noncalcified CTO when the modified J-CTO score was ≥3 (77% vs. 94%, p = 0.008). In 422 patients with successful procedures, the presence of calcification was irrelevant to guidewire crossing time, but was accompanied with longer time from guidewire cross to final angiogram when the modified J-CTO score was 1-2 (53 ± 35 vs. 35 ± 17 [noncalcified] min, p < 0.001). Multivariate analyses showed that calcification was independently associated with procedural failure (odds ratio [OR] = 5.1, 95% confidence interval [CI] = 1.4-18.3) in lesions with modified J-CTO ≥3, and prolonged angioplasty/stenting procedures >60 min (OR = 4.8, 95% CI = 2.2-10.2) in successfully recanalized lesions with modified J-CTO score 1-2.

CONCLUSIONS

Using intraplaque guidewire tracking, calcification was unfavorable for very difficult CTO lesions, and caused prolongation of angioplasty time for lesions with moderate complexity. This suggested that the role of calcification in the J-CTO score could be altered when different recanalization techniques were applied for CTO interventions.

Research frontiers and hotspots of coronary chronic total occlusion: A bibliometric analysis

By analyzing the relevant literature, we can accurately grasp the current status of diagnosis and treatment of chronic total occlusion of coronary artery, and clarify the development trend, research frontiers and hotspots of this disease. A literature search with "chronic total occlusion" as the title was performed in the Web of Science database. The title, author, abstract, keywords, institution, publication, country, reference, and other endnotes of the selected literature were exported in the form of text. The author, country, institution, and keywords of the literature were analyzed through Citespace and VOSviewer. The United States has the highest proportion of articles. The institution with the largest number of publications in this field is the Minneapolis Heart Institute Foundation. Brilakis Emmanouil S is the author with the most published articles. The journal system with the largest number of articles in this field is Cardiac Cardiovascular Systems. The keywords with the highest frequency are "chronic total occlusion," "percutaneous coronary intervention," "recanalization," and "revascularization." The burst detection analysis of hot keywords shows that "algorithm," "management," and "mortality" are the research hotspots in this field in recent years. At present, the research on this disease mainly focuses on the opening of occluded coronary arteries through various treatment methods. In the near future and the next few years, the research hotspots may be the scoring system algorithms for the treatment of chronic total occlusion of coronary artery and the management strategies for patients.

Wire Escalation And De-escalation Techniques in Antegrade and Retrograde Approaches to Chronic Total Occlusion Percutaneous Coronary Interventions

Coronary chronic total occlusions (CTO) are frequently identified during coronary angiography and remain the most challenging subset of coronary artery lesions to treat; however, advancements in techniques and materials have greatly improved success rates. Various crossing algorithms have been developed to standardise the approach to CTO interventions based on angiographic criteria. Antegrade wiring is typically the initial strategy of choice, particularly in cases of short and straight CTOs with tapered proximal cap. Similarly, retrograde crossing can be achieved through retrograde wiring, although this approach has a very low success rate. This review aims to outline how to perform a CTO analysis, clarify the fundamental features of guidewires and provide insights into both antegrade and retrograde wire-based approaches.

The evaluation of combined fractional flow reserve and dynamic SPECT in chronic total occlusion

Background

Chronic total occlusion (CTO) is the most challenging subset in percutaneous coronary intervention (PCI), but the optimal selection of patients and indication for such procedures remain a subject of debate. We sought to investigate the role of physiological function in treatment decisions of CTO PCI by measuring fractional flow reserve (FFR) and Dynamic SPECT imaging in this study.

Methods

All the FFR of CTO vessel were measured before and immediately after CTO revascularization, and Dynamic SPECT imaging were detected before PCI in patients with an identified CTO.

Results

A total of 53 patients with single-vessel CTO lesions were included in this cohort study. The mean FFR value was 0.34 ± 0.09 at baseline. Immediately after successful CTO PCI, the FFR value significantly increased to 0.79 ± 0.11. The regional coronary flow reserve (CFR) of CTO vessels was 1.62 ± 0.64, which was significantly and positively correlated with the baseline FFR value (r = 0.607, p = 0.005). The area under the ROC curve of the baseline FFR for the detection of ischemia was 0.923 (p < 0.001). The diagnostic performance in terms of sensitivity and specificity was 83.3 % and 85.7 % for baseline FFR with a ROC-optimized cutoff value of 0.35.

Conclusions

A significant correlation was found between the CFR derived from dynamic SPECT and baseline FFR. An FFR of <0.35 before CTO PCI can be taken as the cutoff for the presence of inducible ischemia, which was a useful index for therapy options.

Retrograde approach for recanalization in stumpless chronic total occlusion: A case report

Chronic total occlusive disease of the coronary arteries is the most challenging disease in the field of coronary intervention. When the anterograde approach is not feasible, the retrograde approach remains the only strategy.

Combined antegrade and retrograde dissection and re-entry techniques: A two-in-one chronic total occlusion procedure

Treatment of chronic total occlusions (CTOs) by percutaneous coronary intervention (PCI) is technically challenging, with exponential difficulty in the presence of specific anatomical features. We present a complex case where procedural success was achieved by sequential PCIs to two separate CTOs in a 'two-in-one' procedure.

Chronic total occlusion percutaneous coronary intervention of anomalous coronary arteries: insights from the PROGRESS CTO registry

BACKGROUND

There is limited information about the frequency and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in anomalous coronary arteries (ACA).

METHODS

We examined the clinical and angiographic characteristics and procedural outcomes of CTO PCI in ACA among 14,173 patients who underwent 14,470 CTO PCIs at 46 US and non-US centers between 2012 and 2023.

RESULTS

Of 14,470 CTO PCIs, 36 (0.24%) were CTO PCIs in an ACA. ACA patients had similar baseline characteristics as those without an ACA. The type of ACA in which the CTO lesion was found were as follows: anomalous origin of the right coronary artery (ARCA) (17, 48.5%), anomalous origin of left circumflex coronary artery (9, 25.7%), left anterior descending artery and left circumflex artery with separate origins (4, 11.4%), anomalous origin of the left anterior descending artery (2, 5.7%), dual left anterior descending artery (2, 5.7%) and woven coronary artery 1 (2.8%). The Japan CTO score was similar between both groups (2.17 ± 1.32 vs 2.38 ± 1.26, p = 0.30). The target CTO in ACA patients was more likely to have moderate/severe tortuosity (44% vs 28%, p = 0.035), required more often use of retrograde approach (27% vs 12%, p = 0.028), and was associated with longer procedure (142.5 min vs 112.00 min [74.0, 164.0], p = 0.028) and fluoroscopy (56 min [40, 79 ml] vs 42 min [25, 67], p = 0.014) time and higher contrast volume (260 ml [190, 450] vs 200 ml [150, 300], p = 0.004) but had similar procedural (91.4% vs 85.6%, p = 0.46) and technical (91.4% vs 87.0%, p = 0.59) success. No major adverse cardiac events (MACE) were seen in ACA patients (0% [0] vs 1.9% [281] in non-ACA patients, p = 1.00). Two coronary perforations were reported in ACA CTO PCI (p = 0.7 vs. non-ACA CTO PCI).

CONCLUSIONS

CTO PCI of ACA comprise 0.24% of all CTO PCIs performed in the PROGRESS CTO registry and was associated with higher procedural complexity but similar technical and procedural success rates and similar MACE compared with non-ACA CTO PCI.

Validation of the coronary artery specific chronic total occlusion percutaneous coronary intervention angiographic difficulty scores in the PROGRESS-CTO registry

BACKGROUND

The J-CTO investigators recently developed angiographic difficulty scores for each of the three major coronary arteries in patients undergoing first-attempt chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in de novo occlusions.

METHODS

We examined the performance of the individual J-CTO scores in a large multicenter registry.

RESULTS

The CTO lesion location was as follows: right coronary artery (RCA) 3,805 (54%), left anterior descending artery (LAD) 2,303 (33%), and left circumflex (LCX) 935 (13%). Patients in the PROGRESS-CTO registry were younger, more likely to be female, and had higher J-CTO scores compared with the J-CTO registry. Increasing difficulty scores were associated with lower technical success in the PROGRESS-CTO registry (score 0: 94.4 % - score ≥3: 82.6% for the RCA difficulty score; score 0: 96.4% - score ≥3: 86.1 for the LAD difficulty score; and score 0: 95.4% - score ≥3: 81.2% for the LCX difficulty score). The C-statistic of the coronary artery specific J-CTO scores in the PROGRESS-CTO registry were: LAD 0.69 (95% confidence intervals [CI], 0.64-0.73), LCX 0.63 (95% CI, 0.57-0.69), and RCA 0.61 (95-% CI, 0.58-0.64) with good calibration (Hosmer-Lemeshow p-value >0.05 for all). The AUC of the classic J-CTO score for LAD lesions was similar with the LAD J-CTO score (p-for-difference = 0.26), but worse for LCX (p-for-difference = 0.04) and RCA lesions (p-for-difference = 0.04).

CONCLUSION

In the PROGRESS-CTO registry, the coronary artery specific J-CTO scores did not improve prediction of the technical success of CTO-PCI compared with the classic J-CTO score.

Comparison between tip-detection method and retrograde approach for chronic total occlusion percutaneous coronary intervention

BACKGROUND

The tip-detection method and the retrograde approach have been acknowledged as a second-line strategies for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) when conventional antegrade wiring strategies are ineffective. The aim of this study is to compare the efficacy between both strategies for complex CTO PCI.

METHODS

We retrospectively enrolled 170 consecutive CTO PCI cases and separated them into 295 adopted strategies. The rate of successful lesion crossing and its association with the time spent for each strategy were compared between the tip-detection method and the retrograde approach.

RESULTS

We observed fifty-six attempts with the tip-detection methods with 46 (82.1%) successful lesion crossings. Sixty-one retrograde approaches were performed, in which 29 (47.5%) cases achieved procedural success. In the successful attempts, the wire-manipulation time was significantly shorter in the tip-detection method [20.0 (12.2-36.7) min] than the retrograde approach [35.0 (20.7-49.7) min] (p = 0.008). Cox-regression analysis showed time-dependent advantage for the tip-detection method over the retrograde approach [hazard ratio (HR) = 2.93, 95% CI = 1.84-4.67, p < 0.001]. Incomplete tip-detection CTO crossing (taking > 30 min) was seen in severely tortuous lesions [odds ratio 0.26, 95% confidence interval 0.06-0.97, p = 0.037].

CONCLUSION

The tip-detection method can reduce the wire-manipulation time for successful CTO PCI compared with the retrograde approach. However, the success rate of the tip-detection method is hampered by severe lesion tortuosity.

[Evaluation of the economic impact and the patient pathway in the treatment of chronic total occlusion]

OBJECTIVES

Chronic total occlusion (CTO) of coronary arteries is defined as complete absence of antegrade coronary flow without iodine passage, since more than 3 months. Coronary revascularization is a highly resource-intensive angioplasty procedure involving numerous medical devices (MDs). Its consumption and associated costs are not covered by either the medical act classification (CCAM) or the hospitalization fees and additional MD funding. The primary aim of this study is to analyze the financial sustainability of this activity for a public healthcare institution and to assess the budgetary impact of CTO treatment on the most expensive items of expenditure. The secondary aim is to describe the patient's intra-hospital pathway.

METHODS

CTO revascularization stays are categorized under the code 05K06 "Vascular Stents without Myocardial Infarction". Major cost items were identified using national coded expenditure data and compared with those from our cost study. Every CTO intervention from January to November 2021 were retrospectively retrieved. Establishment purchase prices in 2021 were used to determine MD costs. Clinical data were extracted from electronic patient records. Operative data (procedure duration, professionals involved, and MD used) were extracted. Human Resources (HR) costs were integrated into the calculations. A Sankey diagram was created. Data are expressed as mean±standard deviation.

RESULTS

In our study, 41 patients underwent 45 interventions. The median was 65 years. Seventy-eight percent of interventions were successful with a median duration of 113minutes. Two hundred and two different MD references were used, with 27% reimbursed additionally and 73% funded within the homogeneous group of stays (HGS). The total cost of MD described in the coded expenditure data is 2142€, of which 721€ is funded within the HGS. In our cohort, it represented averages of 2736€±1393€ and 1710€±926€, respectively. Regarding HR, the total cost described in the coded expenditure data was 442€ compared to 410€±169€ in our cohort. Finally, patient pathway analysis showed an average length of stay (LOS) of 1.8 days. Two pathways were identified depending on admission context: weekday hospitalization or cardiac intensive care.

CONCLUSIONS

CTO revascularization is a planned intervention with a short LOS and a highly standardized patient pathway. Our study highlights a proliferation of MD references used during CTO revascularization due to innovative industrial developments. The cost differential with coded expenditure data confirms the need for a revision of the procedure and its categorization within an HGS, which is currently non-specific.

Percutaneous Coronary Intervention for Aorto-Ostial Chronic Total Occlusion: Evaluating Lesion Complexity and Procedural Outcomes

BACKGROUND

PCI for aorto-ostial CTO remains challenging. The techniques for guidewire in aorto-ostial CTO may differ from those used in non-aorto-ostial CTOs, influenced by clinical and angiographic characteristics.

OBJECTIVES

This study aimed to assess the technical aspects and outcomes of percutaneous coronary intervention (PCI) in patients with aorto-ostial chronic total occlusion (CTO).

METHODS

This analysis included 420 patients with ostial CTO from the Japanese CTO-PCI Expert Registry, spanning January 2014 to December 2022. It examined the strategies and procedural outcomes of CTO PCI.

RESULTS

Ostial CTO represented 420 of 10,814 (3.9%) of all CTO PCI cases. Within this subset, aorto-ostial CTO accounted for 218 of 420 (52%) cases. The technical success rate for aorto-ostial CTO was 88% (191/218). Aorto-ostial CTOs exhibited longer lesion lengths and were more likely to present with challenges such as distal target lumen ambiguity, calcification, and tortuosity compared with non-aorto-ostial CTOs. The retrograde approach was more commonly used in aorto-ostial CTO, with retrograde direct crossing being the most successful technique, especially in cases of flush CTO. A multivariate logistic analysis identified several factors significantly associated with unsuccessful aorto-ostial CTO PCI, including difficulties in engaging a guiding catheter, estimating the collateral channel (as assessed by the J-Channel score), and tortuosity.

CONCLUSIONS

Aorto-ostial CTOs are more complex and frequently require a retrograde approach. The availability of suitable interventional collateral channels is crucial for the success of these procedures.

A new angiographic scoring for grading the difficulty of recanalization for symptomatic non-acute middle cerebral artery occlusions

Background

Endovascular recanalization is a feasible option for treating symptomatic non-acute middle cerebral artery occlusion (MCAO) patients. Hence, we aimed to establish a new angiographic scoring to grade the recanalization difficulty of MCAO to determine the suitable patients for endovascular treatment.

Methods

We retrospectively analyzed a total of 113 consecutive recurrent symptomatic non-acute MCAO patients who underwent endovascular recanalization from July 2015 to August 2021 in four Chinese comprehensive stroke centers. All patients were reappraised using a new angiographic scoring based on the stump morphology, the MCA occlusion length, MCA bend, and the distal vascular bed of MCAO. We used the final results to establish the patients' outcomes.

Results

The total successful recanalization and perioperative complication rates were 83.2% (94/113) and 15.9% (18/113), respectively. No deaths occurred within 30 days. Moreover, 96.9, 90, 87.5, 52.6, and 50% of the patients achieved recanalization with scores of 0, 1, 2, 3, and 4 (p < 0.001), respectively. However, the perioperative complication rate showed the opposite trend. (3.1% vs. 7.5% vs. 6.3% vs. 52.6% vs. 50%; p < 0.001). The median time of successful microwire crossing of the occlusion lesion (TMO) in the score 0 group was shorter than the other groups (2 min, 9 min, 8.5 min, 14 min, and 20 min; p < 0.001). When a score of 2 was used as the optimal cut-off point, the sensitivity and specificity were 86.2 and 63.2%, respectively.

Conclusion

The new angiographic scoring can effectively predict the successful recanalization rate, perioperative complication rate, and TMO of endovascular recanalization for non-acute MCAO. It can also be used as an effective clinical evaluation tool to determine the suitable non-acute MCAO patients for recanalization, especially with a score ≤ 2.

Intravascular lithotripsy in heavily calcified chronic total occlusion: procedural and one-year clinical outcomes

BACKGROUND

Calcification within chronic total occlusions (CTO) is strongly associated with worse outcomes. Despite the excellent success and safety of intravascular lithotripsy (IVL) in heavily calcified lesions, evidence in CTO remains scarce.

AIM

This study aimed to evaluate the procedural and long-term clinical outcomes of IVL in heavily calcified CTO.

METHODS

Patients who underwent IVL between 2019 and 2024 from an ongoing prospective multicenter registry were eligible for inclusion. Patients were therefore classified in CTO and non-CTO groups. The efficacy and safety endpoints of CTO percutaneous coronary interventions were defined according to the CTO-ARC consensus. In-hospital major adverse cardiovascular events (MACE) included cardiac death, nonfatal myocardial infarction and target lesion revascularization (TVR).

RESULTS

A total of 404 patients underwent IVL, of which the treated lesion was a CTO in 33 (8.2%). The mean J-CTO score was 2.3 ± 1.1. Device success showed no significant difference between CTO and non-CTO groups (100% vs 98.4%; p = 0.35). Comparable technical success with residual stenosis <30% was observed in both groups (90.1% in CTO vs 89.2% in non-CTO, p = 0.83). The incidence of MACE was similar across groups during hospital stays (CTO 6.0% vs. non-CTO 1.9%, p = 0.12), at 30-day (CTO 9.1% vs. non-CTO 3.0%, p = 0.07), and at 12-month follow-up (CTO 9.1% vs. non-CTO 7.3%, p = 0.70).

CONCLUSION

IVL provides high procedural success and consistent clinical outcomes in both CTO and non-CTO cases, reinforcing its role in managing heavily calcified coronary lesions.

Impact of sex on myocardial perfusion following percutaneous coronary intervention of chronic total coronary occlusions

OBJECTIVES

We sought to investigate the impact of sex on myocardial perfusion changes following chronic total coronary occlusion (CTO) percutaneous coronary intervention (PCI) as measured by [15O]H2O positron-emission tomography (PET) perfusion imaging.

BACKGROUND

CTO PCI has been associated with an increase in myocardial perfusion, yet females are less likely to undergo revascularization. As such, data on the impact of sex on myocardial perfusion following CTO PCI is scarce.

METHODS

A total of 212 patients were prospectively enrolled and underwent CTO PCI combined with [15O]H2O PET perfusion imaging prior to and 3 months after PCI. Hyperemic myocardial blood flow (hMBF, mL·min-1·g-1) and coronary flow reserve (CFR) allocated to the CTO territory were quantitatively assessed.

RESULTS

This study comprised 34 (16 %) females and 178 (84 %) males. HMBF at baseline did not differ between sexes. Females showed a higher increase in hMBF than males (Δ1.34 ± 0.67 vs. Δ1.06 ± 0.74, p = 0.044), whereas post-PCI hMBF was comparable (2.59 ± 0.85 in females vs. 2.28 ± 0.84 in males, p = 0.052). Female sex was independently associated with a higher increase in hMBF after correction for clinical covariates. CFR increase after revascularization was similar in females and males (Δ1.47 ± 0.99 vs. Δ1.30 ± 1.14, p = 0.711).

CONCLUSIONS

The present study demonstrates a greater recovery of stress perfusion in females compared to males as measured by serial [15O]H2O PET imaging. In addition, a comparable increase in CFR was found in females and males. These results emphasize the benefit of performing CTO PCI in both sexes.

CLINICAL PERSPECTIVE

What is new? What are the clinical implications?

Advances in Technology and Technique in Percutaneous Coronary Intervention: A Clinical Review

Percutaneous coronary intervention (PCI) has become the standard procedure for patients with angina and acute coronary syndrome. From the perspective of technology and technique, PCI has advanced over the last four decades, resulting in considerably improved clinical outcomes in patients with coronary artery disease in the current era. In this review article, we summarize recent advances, promising technologies, and areas for research in the field of PCI.

The Role of Coronary Imaging in Chronic Total Occlusions: Applications and Future Possibilities

Chronic total occlusions (CTOs) represent a challenging scenario in coronary artery disease (CAD). The prevalence of CTOS in patients undergoing coronary angiography underscores the need for effective diagnostic and therapeutic strategies. Coronary angiography, while essential, offers limited insights into lesion morphology, vessel course, and myocardial viability. In contrast, coronary imaging techniques-including optical coherence tomography (OCT), intravascular ultrasound (IVUS), and coronary computed tomography angiography (CCTA)-provide comprehensive insights for each stage of CTO percutaneous coronary intervention (PCI). OCT facilitates the assessment of plaque morphology and stent optimization, despite low evidence and several limitations in CTO-PCI. IVUS offers deeper penetration, allowing managing proximal cap scenarios and guiding subintimal navigation. CCTA provides a non-invasive, three-dimensional view of coronary anatomy, enabling the precise evaluation of myocardial mass at risk and detailed procedural planning. Despite their individual limitations, these imaging modalities have enhanced the success rates of CTO-PCI, thus reducing procedural and long-term complications and improving patient outcomes. The future of CTO management lies in further technological advancements, including hybrid imaging, artificial intelligence (AI) integration, and improved fusion imaging. These innovations promise to refine procedural precision and personalize interventions, ultimately improving the care of patients with complex coronary artery disease.

Evaluation of Success and Complications Scores for Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the Latin American Registry

Chronic total occlusion (CTO) percutaneous coronary intervention is a complex procedure and is associated with considerable risk of complications. Several success and complication scores have been developed; however, data regarding their external validation in other populations such as Latin America are scarce. This study aimed to evaluate the accuracy of the main predictors of success and complications in a broad cohort of procedures in the Latin American (LATAM) CTO registry. From April 2008 to December 2023, 3,706 consecutive procedures listed in the LATAM CTO registry were screened. Of these, 2,835 procedures had sufficient information to analyze the Multicenter CTO Registry in Japan (J-CTO); Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS); Ostial location, Rentrop grade, and Age (ORA); Clinical and Lesion-related Score (CL-score); and EuroCTO Score (CASTLE) success scores. The complication scores were PROGRESS (MACE, mortality, and pericardiocentesis) and Outcomes, Patient health status, and Efficiency iN Chronic Total Occlusion hybrid procedures (OPEN-CTO),OPEN-CLEAN. The J-CTO and CASTLE scores demonstrated the highest areas under the curve (AUC) of 0.718 and 0.703, respectively. The AUC value for the CL-score was 0.685, whereas the PROGRESS score had an AUC of 0.598 and the ORA AUC was 0.545. The level of agreement between scores was low; only 4% of the procedures were classified as difficult or very difficult by all scores and <1% were classified as easy by all 5 scores. Of the complication scores, PROGRESS mortality (AUC 0.651) and PROGRESS MACE (AUC 0.588) showed the best performance, identifying groups with >10% event rate. These results may improve the selection of revascularization techniques, especially for patient demographics that are historically underrepresented in CTO research.

Who Should Undergo Chronic Total Occlusions Percutaneous Coronary Intervention and When?: An Evidence-Based Approach to the Patient Referred for Percutaneous Coronary Intervention of Chronic Total Occlusion

Chronic total occlusions (CTO) of the coronary arteries are common among patients presenting to the cardiac catheterization laboratory, and data suggests a worse overall prognosis in patients with CTOs. Percutaneous coronary intervention (PCI) of CTOs has been shown to improve anginal symptoms in observational studies and in a limited number of randomized trials. However, CTO PCI has not been shown to lead to a reduction in other important end points such as myocardial infarction or death. Furthermore, despite recent advances in the field, CTO PCI still carries higher risks and a lower likelihood of success compared with non-CTO PCI. Thus, determining which patients may be appropriate for CTO PCI is challenging and must involve a comprehensive risk-benefit analysis and discussion with the patient. Therefore, we review the currently available data regarding CTO PCI, including the clinical outcomes, the role of preprocedural ischemia testing, and various procedural success and risk stratification scores. Finally, we present our approach to the patient referred for CTO PCI.

Development and validation of a nomogram for major adverse cardiovascular events after chronic total occlusion percutaneous coronary intervention for ischemic heart failure

BACKGROUND

Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is an available means of revascularization in patients with ischemic heart failure (IHF). However, the prognosis of IHF patients undergoing CTO-PCI remains unclear due to the lack of reliable clinical predictive tools.

AIM

This study aimed to establish a nomogram for major adverse cardiovascular events (MACE) after CTO-PCI in IHF patients.

METHODS

Sixty-seven potential predictive variables for MACE in 560 IHF patients undergoing CTO-PCI were screened using least absolute shrinkage and selection operator regression. A nomogram was constructed based on multivariable Cox regression to visualize the risk of MACE, and then evaluation was carried out using the concordance index (C-index), time-independent receiver operating characteristic (timeROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

During a median follow-up of 32.0 months, there were 208 MACE occurrences. Seven variables were selected for nomogram construction: age, left ventricular ejection fraction, left ventricular end-diastolic diameter, N-terminal precursor B-type diuretic peptide, bending, and use of intravascular ultrasound and beta-blockers. The C-index was 0.715 (0.680-0.750) and the internal validation result was 0.715 (0.676-0.748). The timeROC area under the curve at 6 months, 1 year, and 2 years was 0.750 (0.653-0.846), 0.747 (0.690-0.804), and 0.753 (0.708-0.798), respectively. The calibration curves and DCA showed the nomogram had acceptable calibration and clinical applicability.

CONCLUSIONS

We developed a simple and efficient nomogram for MACE after CTO-PCI in IHF patients, which helps in early risk stratification and postoperative management optimization.

Transradial and Transfemoral Access for Retrograde Chronic Total Occlusion Percutaneous Coronary Interventions: A Comparison of the Clinical Features and Prognostic Implications

Objective

The research was carried out to determine and compare the efficiency of completely transradial access (cTRA) and transfemoral access (TFA) in retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Background

The cases of retrograde chronic total occlusion (CTO) percutaneous coronary intervention usually need the dual access. The transradial method is now used more frequently in CTO PCI, and improves the safety of CTO PCI.

Methods

This retrospective, observational study was carried out in a single center. Participants were patients who underwent dual-access retrograde CTO PCI from January 2017 to October 2023, categorized into two groups: cTRA (biradial access) and TFA (bifemoral, or combined radial and femoral access). All patients in the cTRA group received conventional radial access. All punctures of the femoral artery were performed without fluoroscopic or ultrasound guidance. None of the patients in the TFA group accepted any arterial closure devices. Clinical, angiographic and procedural characteristics and the occurrence of in-hospital major adverse cardiovascular events (MACE) of the cTRA and TFA procedures were recorded.

Results

This research involved 187 CTO PCI procedures with dual access, of which 88 were done using cTRA and the rest (99) were carried out through TFA. The J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) score was lower in the cTRA group than TFA group (2.1± 0.6 vs 3.0± 0.8; P <0.001). The technical success (84.1% vs 82.8%; P= 0.817), procedural success (80.7% vs 79.8%; P= 0.906) and in-hospital MACE rates (5.7% vs 4.0%; P= 0.510) were the same for both groups. For a J-CTO score of 3 or higher, technical success rate was significantly lower in the cTRA group than the TFA group (58.1% vs 74.2%; P < 0.001).

Conclusion

In the retrograde CTO PCI, the percentages of success and in-hospital MACE were similar for both cTRA and TFA. Meanwhile, cTRA may be used for simpler lesions (J-CTO score < 3) as compared to TFA.

Effects of a prior failed attempt on the outcomes of subsequent chronic total occlusion-percutaneous coronary intervention

Objectives

Patients undergoing a prior failed attempt of chronic total occlusion-percutaneous coronary intervention (CTO-PCI) represent a challenging subgroup across all patients undergoing CTO-PCI. There are limited data on the effects of a prior failed attempt on the outcomes of subsequent CTO-PCI. We aimed to compare the procedural results and 24-month outcomes of prior-failed-attempt CTO-PCI with those of initial-attempt CTO-PCI.

Methods

Patients who underwent attempted CTO-PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 24-month major adverse cardiac events (MACE) between patients who underwent prior-failed-attempt and initial-attempt CTO-PCI. MACE was defined as a composite of cardiac death, target vessel-related myocardial infarction, and ischemia-driven target vessel revascularization (TVR) during follow-up.

Results

In total, 484 patients who underwent CTO-PCI (prior-failed-attempt, n = 49; initial-attempt, n = 435) were enrolled during the study period. After propensity score matching (1:3), 147 patients were included in the initial-attempt group. The proportion of the Japanese-CTO (J-CTO) score ≥2 was higher in the patients who underwent prior failed attempt than in those who underwent initial attempt (77.5% vs. 38.8%, p < 0.001). The retrograde approach was more often adopted in the prior-failed-attempt group than in the initial-attempt group (32.7% vs. 3.4%,  [P< 0.001). Successful CTO revascularization rates were significantly lower in the prior-failed attempt-group than in the initial attempt group (53.1% vs. 83.3%, P < 0.001). The multivariate analysis revealed that J-CTO score ≥2 [odds ratio (OR), 0.359; 95% confidence interval (CI), 0.159-0.812; P = 0.014], intravascular ultrasound procedure (OR, 4.640; 95% CI, 1.380-15.603; P = 0.013), and prior failed attempt (OR, 0.285; 95% CI, 0.125-0.648; P = 0.003) were the independent predictors for successful CTO revascularization. There were no significant differences in major procedural complications (2.0% vs. 0.7%, p = 0.438) and MACE rates (4.1% vs. 8.8%, p = 0.438) between the groups, mainly due to the TVR rate (4.1% vs. 8.2%, P = 0.522).

Conclusions

Compared with initial-attempt CTO-PCI, prior-failed-attempt CTO-PCI deserves more attention, since it is associated with a lower successful CTO revascularization rate. Prior failed attempt, J-CTO score ≥2, and IVUS procedure are the determining factors for predicting successful CTO revascularization. There are no significantly different unfavorable outcomes between patients who undergo prior-failed-attempt and initial-attempt CTO-PCI.

Predicting Successful Chronic Total Occlusion Crossing With Primary Antegrade Wiring Using Machine Learning

BACKGROUND

There is limited data on predicting successful chronic total occlusion crossing using primary antegrade wiring (AW).

OBJECTIVES

The aim of this study was to develop and validate a machine learning (ML) prognostic model for successful chronic total occlusion crossing using primary AW.

METHODS

We used data from 12,136 primary AW cases performed between 2012 and 2023 at 48 centers in the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) to develop 5 ML models. Hyperparameter tuning was performed for the model with the best performance, and the SHAP (SHapley Additive exPlanations) explainer was implemented to estimate feature importance.

RESULTS

Primary AW was successful in 6,965 cases (57.4%). Extreme gradient boosting was the best performing ML model with an average area under the receiver-operating characteristic curve of 0.775 (± 0.010). After hyperparameter tuning, the average area under the receiver-operating characteristic curve of the extreme gradient boosting model was 0.782 in the training set and 0.780 in the testing set. Among the factors examined, occlusion length had the most significant impact on predicting successful primary AW crossing followed by blunt/no stump, presence of interventional collaterals, vessel diameter, and proximal cap ambiguity. In contrast, aorto-ostial lesion location had the least impact on the outcome. A web-based application for predicting successful primary AW wiring crossing is available online (PROGRESS-CTO website) (https://www.progresscto.org/predict-aw-success).

CONCLUSIONS

We developed an ML model with 14 features and high predictive capacity for successful primary AW in chronic total occlusion percutaneous coronary intervention.

Impact of Bifurcation Involvement and Location in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the EuroCTO Registry

Bifurcation involvement close to or within the occluded segment poses increasing difficulties for chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). However, this variable is not considered in the angiography-based CTO scoring systems nor has been extensively investigated in large multicenter series. Accordingly, we analyzed a CTO-PCI registry involving 92 European centers to explore the incidence, angiographic and procedural characteristics, and outcomes specific to CTO-PCIs with bifurcation involvement. A total of 3,948 procedures performed between January and November 2023 were examined (33% with bifurcation involvement). Among bifurcation lesions, 38% and 37% were located within 5 mm of the proximal and distal cap, respectively, 16% within the CTO body, and in 9% of cases proximal and distal bifurcations coexisted. When compared with lesions without bifurcation involvement, CTO bifurcation lesions had higher complexity (J-CTO 2.33 ± 1.21 vs 2.11 ± 1.27, p <0.001) and were associated with higher use of additional devices (dual-lumen microcatheter in 27.6% vs 8.4%, p <0.001, and intravascular ultrasound in 32.2% vs 21.7%, p <0.001). Radiation dose (1,544 [836 to 2,819] vs 1,298.5 [699.1 to 2,386.6] mGy, p <0.001) and contrast volume (230 [160 to 300] vs 190 [130 to 250] ml, p <0.001) were also higher. Technical success was similar (91.5% with bifurcation involvement vs 90.4% without bifurcation involvement, p = 0.271). However, the bifurcation lesions within the CTO segment (intralesion) were associated with lower technical success than the other bifurcation-location subgroups (83.7% vs 93.3% proximal, 93.4% distal, and 89.0% proximal and distal, p <0.001). On multivariable analysis, the presence of an intralesion bifurcation was independently associated with technical failure (odds ratio 2.04, 95% confidence interval 1.24 to 3.35, p = 0.005). In conclusion, bifurcations are present in approximately one-third of CTOs who underwent PCI. PCI of CTOs with bifurcation can be achieved with high success rates except for bifurcations within the occluded segment, which were associated with higher technical failure.

Antegrade Wire Tracking of the Retrograde Tract (ATRT): A Novel Technique for Percutaneous Coronary Intervention for Chronic Total Occlusion

BACKGROUND

Chronic total occlusion (CTO) lesions are the most challenging subset of coronary lesions. For lesions with a failed antegrade approach, the initial retrograde, followed by a combined retrograde and antegrade approach, remains the mainstay of therapy.

OBJECTIVE

The study evaluated a technique of initial retrograde followed by an antegrade approach to treat lesions with a failed antegrade approach.

METHODS

We have adopted this technique to treat 31 CTO lesions with a failed antegrade approach, where a floppy wire was advanced antegrade through the tract created by a retrograde balloon advanced over the retrograde wire (antegrade wire tracking of the retrograde tract (ATRT)), which was advanced into the aorta retrogradely.

RESULT

In 31 patients with failed antegrade approaches, the ATRT technique was tried, which was successful in 25 patients (the success rate was 80.6%). There was a failure to cross the microchannel in four patients, although angiographically, it looked promising. In two patients, it was impossible to advance the microcatheter or the smallest profile balloon retrogradely until the entire length of the CTO body. So, a reverse controlled antegrade and retrograde subintimal tracking (CART) was performed on these two patients excluded from the study.

CONCLUSION

ATRT is a useful technique for CTO percutaneous coronary intervention (PCI) for patients with failed antegrade approaches with acceptable success rates. The procedure is safe in terms of procedural complications.

Safety and Effectiveness of a Novel Microcatheter in Coronary Chronic Total Occlusions-The BIOMICS Study

Background

Chronic total occlusion (CTO) remains the most complex anatomical subset of lesions in percutaneous coronary intervention (PCI), often requiring advanced techniques and technologies, including the use of microcatheters.

Methods

The BIOMICS study is a premarket first-in-human prospective, multicenter, open-label, single-arm trial investigating the safety and efficacy of a novel coronary microcatheter (BioMC, Biosensors International) in 100 patients with symptoms of ischemia undergoing elective CTO-PCI. The primary efficacy end point of the study was device success defined according to the CTO-ARC (Chronic Total Occlusion Academic Research Consortium) criteria namely the ability of the microcatheter to successfully facilitate placement of a guide wire beyond the occluded coronary segment. The primary safety end point was the incidence of in-hospital cardiac death or myocardial infarction at hospital discharge.

Results

Hundred patients were recruited between March 2022 and January 2023. The primary efficacy end point was achieved in 75% of patients (95% CI, 65.3%-83.1%; P < .0001 for superiority compared to the prespecified performance goal of 54%). The primary safety end point of in-hospital cardiac death or myocardial infarction was observed in 2% of the patients. There were no study device-related coronary perforations or device failures.

Conclusions

The use of a novel coronary microcatheter during CTO-PCI was associated with a high device success and an excellent safety profile.

Emergency coronary artery bypass surgery after chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry

BACKGROUND

Emergency coronary artery bypass surgery (eCABG) is a serious complication of chronic total occlusion (CTO) percutaneous coronary artery intervention (PCI).

METHODS

We examined the incidence and outcomes eCABG among 14,512 CTO PCIs performed between 2012 and 2023 in a large multicenter registry.

RESULTS

The incidence of eCABG was 0.12% (n = 17). Mean age was 68 ± 6 years and 69% of the patients were men. The most common reason for eCABG was coronary perforation (70.6%). eCABG patients had larger target vessel diameter (3.36 ± 0.50 vs. 2.90 ± 0.52; p = 0.003), were more likely to have moderate/severe calcification (85.7% vs. 45.8%; p = 0.006), side branch at the proximal cap (91.7% vs. 55.4%; p = 0.025), and balloon undilatable lesions (50% vs. 7.4%; p = 0.001) and to have undergone retrograde crossing (64.7% vs. 30.8%, p = 0.006). eCABG cases had lower technical (35.3% vs. 86.7%; p < 0.001) and procedural (35.3% vs. 86.7%; p < 0.001) success and higher in-hospital mortality (35.3% vs. 0.4%; p < 0.001), coronary perforation (70.6% vs. 4.6%; p < 0.001), pericardiocentesis (47.1% vs. 0.8%; p < 0.001), and major bleeding (11.8% vs. 0.5%; p < 0.001).

CONCLUSIONS

The incidence of eCABG after CTO PCI was 0.12% and associated with high in-hospital mortality (35%). Coronary perforation was the most common reason for eCABG.

Retrograde Coronary Chronic Total Occlusion Intervention (JR-CTO) Score: From the Japanese CTO-PCI Expert Registry

BACKGROUND

Despite the effectiveness of the retrograde approach for chronic total occlusion (CTO) lesions, there are no standardized tools to predict the success of retrograde percutaneous coronary intervention (PCI).

OBJECTIVES

The aim of this study was to develop a prediction tool to identify CTO lesions that will achieve successful retrograde PCI.

METHODS

This study evaluated data from 2,374 patients who underwent primary retrograde CTO-PCI and were enrolled in the Japanese CTO-PCI Expert Registry between January 2016 and December 2022 (NCT01889459). All observations were randomly assigned to the derivation and validation cohorts at a 2:1 ratio. The prediction score for guidewire failure in retrograde CTO-PCI was determined by assigning 1 point for each factor and summing all accrued points.

RESULTS

The JR-CTO score (moderate-severe calcification, tortuosity, Werner collateral connection grade ≤1, and nonseptal collateral channel) demonstrated a C-statistic for guidewire failure of 0.72 (95% CI: 0.67-0.76) and 0.71 (95% CI: 0.64-0.77) in the derivation and validation cohorts, respectively. Patients with lower scores had higher guidewire and technical success rates and decreased guidewire crossing time and procedural time (P < 0.01).

CONCLUSIONS

The JR-CTO (Japanese Retrograde Chronic Total Occlusion) score, a simple 4-item score that predicts successful guidewire crossing in patients undergoing retrograde CTO-PCI, has the potential to support clinical decision-making for the retrograde approach.

The added value of coronary CTA in chronic total occlusion percutaneous coronary intervention: a systematic review and meta-analysis

OBJECTIVES

To systematically investigate and summarize the utility of coronary computed tomographic angiography (CCTA) in the management of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI).

METHODS

The authors searched the four databases between 2005 and 2023 for studies investigating the role of CCTA and invasive coronary angiograms (ICA) images when used as the pre-procedural tool for CTO-PCI. Efficacy and safety of CCTA in CTO-PCI treatment as a pre-procedural assessment tool was evaluated.

RESULTS

Forty-seven studies were finally chosen for this systematic review. CCTA had a high degree of agreement with ICA when applied for J-CTO scoring system. A J-CTO (Multicenter CTO Registry in Japan) score > 3, together with calcification, occlusion length ≥ 20 mm, blunt stump, and bending > 45° were shared imaging risk factors on both ICA and CCTA for technique failure and guidewire crossing over 30 min. Additionally, negative remodeling and multiple diseased vessel were significant indicators on CCTA. Although patients with pre-procedural CCTA showed a trend of higher success rate and easier guidewire crossing, and CCTA showed a slightly higher predictive accuracy for process success, no significant improvement in post-PCI major adverse cardiac events of using CCTA for assessment has been achieved.

CONCLUSIONS

CCTA is a safe and effective pre-operative tool of CTO-PCI. Except for the shared imaging risk factors with ICA for a hard CTO-PCI including calcification, occlusion length ≥ 20 mm, blunt stump, bending > 45°, and J-CTO score > 3, factors like negative remodeling and multiple diseased vessel were also recognized as significant pre-operative assessment indicators on CCTA.

CLINICAL RELEVANCE STATEMENT

A pre-procedural assessment based on coronary computed tomographic angiography has the potential to aid in the management of chronic total occlusion percutaneous coronary intervention.

KEY POINTS

• A coronary computed tomographic angiography-based pre-procedural assessment can help chronic total occlusion-percutaneous coronary intervention management. • The recognized high-risk features detected via coronary computed tomographic angiography and invasive coronary angiograms are comparable in detecting difficult lesions and chronic total occlusion-percutaneous coronary intervention failure. • Coronary computed tomographic angiography has an additional value to be a safe and effective pre-procedural assessment tool for chronic total occlusion-percutaneous coronary intervention.

Chronic Total Occlusions: A State-of-the-Art Review

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.

Same-day discharge after large-bore access in percutaneous coronary intervention of chronic total coronary occlusions

BACKGROUND

Same-day discharge (SDD) in patients undergoing percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is appealing because of the increased patient comfort. However, data on SDD following large-bore vascular access are scarce.

AIMS

We investigated the feasibility and safety of SDD in patients undergoing large-bore CTO PCI.

METHODS

Between 2013 and 2023, 948 patients were prospectively enrolled in a single-centre CTO registry and underwent CTO PCI. SDD was pursued in all patients. Large-bore access was defined as the use of ≥7 French (Fr) sheaths in ≥1 access site. A logistic regression analysis was used to identify predictors for non-SDD. Clinical follow-up was obtained at 30 days.

RESULTS

SDD was observed in 62% of patients. Large-bore access was applied in 99% of the cohort. SDD patients were younger and more often male, with lower rates of renal insufficiency and prior coronary artery bypass grafting. Local access site bleeding (odds ratio [OR] 8.53, 95% confidence interval [CI]: 5.24-13.87) and vascular access complications (OR 7.23, 95% CI: 1.98-26.32) made hospitalisation more likely, with vascular access complications occurring in 3%. At 30 days, the hospital readmission rate was low in both SDD and non-SDD patients (5% vs 7%; p=non-significant). Finally, SDD was not a predictor for major adverse cardiovascular events (MACE) at follow-up.

CONCLUSIONS

Same-day discharge can be achieved in the majority of patients undergoing CTO PCI with large-bore (≥7 Fr) access. Similar low hospital readmission and MACE rates between SDD and non-SDD patients at 30 days demonstrate the feasibility and safety of SDD.

Controlled antegrade and retrograde subintimal tracking (CART) for recanalisation of chronic total occlusions

BACKGROUND

Controlled antegrade and retrograde subintimal tracking (CART) is rarely performed in contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

AIMS

We aimed to analyse the indications, procedural characteristics, and outcomes of CART at a high-volume CTO programme.

METHODS

We included all patients undergoing a retrograde CTO PCI in which CART was performed at our institution between January 2019 and November 2023. The primary endpoint was technical success.

RESULTS

Of 1,582 CTO PCI, the retrograde approach was performed in 603 procedures (38.1%), and CART was used in 45 cases (7.5%). The mean age was 69.1±10.3 years, 93.3% were male, and prior coronary artery bypass graft surgery was present in 68.9%. The most common target CTO vessel was the right coronary artery (48.9%). Anatomical complexity was high (Multicentre CTO Registry of Japan [J-CTO] score of 3.6±0.9). The most common collateral used for CART was a saphenous vein graft (62.2%). Advanced calcium modification was required in 15.6% of cases. CART was successful in 73.3%. Technical and procedural success was 82.2%. Coronary perforation was diagnosed in 4 subjects (8.9%), but only 1 patient (2.2%) suffered tamponade and required pericardiocentesis. No other in-hospital major adverse cardiac events were diagnosed.

CONCLUSIONS

CART is a useful technique in selected, very complex CTOs tackled with the retrograde approach. Success rates were high, while complication rates were low, considering the high anatomical complexity and baseline patient risk.

The active pulling technique to solve microcatheter-uncrossable lesions in retrograde chronic total occlusion percutaneous coronary intervention

BACKGROUND

It is not uncommon to encounter retrograde microcatheter-uncrossable lesions in retro-recanalization of Chronic Total Occlusion (CTO) cases, existing solutions were time-consuming or complicated to operate. Therefore, the present study aimed to propose and evaluate the feasibility, safety of a novel technique termed Active Pulling retrograde microcatheter crossing Technique (APT) during retrograde CTO percutaneous coronary intervention (PCI).

METHODS

We retrospectively collected retrograde CTO-PCI cases from February 2017 to April 2023, only cases with the retrograde wire successfully crossed the CTO lesion were analyzed. The baseline clinical characteristics, angiographic characteristics, procedural details, and in-hospital major adverse cardiac events (MACEs) were compared.

RESULTS

A total of 80 CTO cases were divided into the APT group and the non-APT group according to whether the APT was applied in the procedure. The APT group had a higher rate of device success than the non-APT group (100% vs. 85%, P = 0.013), with shorter duration (5.3 ± 3.8 vs. 18.6 ± 5.9 min, P < 0.001) and a smaller number of retrograde microcatheters were used (P < 0.001). In the APT group, the average air kerma radiation exposure was lower (2.7 ± 1.2 vs. 4.3 ± 1.7 Gy, P < 0.001), the fluoroscopy time (69.0 ± 15.0 vs. 88.1 ± 18.9 min, P < 0.001) and the procedure time (116.2 ± 22.2 vs. 131.6 ± 28.7 min, P = 0.009) was shorter than the non-APT group. The technical success rate of both groups reached 100% while the procedure success rate was higher in the APT group than the non-APT group (100% vs. 85%, P = 0.13).

CONCLUSIONS

The APT is an easy and safe technique that can greatly improve procedural efficiency without adding other instruments, and allows the retrograde microcatheter to quickly crossing the CTO body after successful retrograde wire externalization.

Tip Detection-Antegrade Dissection and Re-Entry With New Puncture Wire in CTO Intervention: Revolution Through 3D-Wiring

Background

The authors devised the tip detection (TD) method and developed AnteOwl WR intravascular ultrasound to standardize intravascular ultrasound-based 3-dimensional wiring for intraplaque tracking in chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). The TD method also allowed antegrade dissection and re-entry (ADR). Combining TD-ADR with Conquest Pro 12 Sharpened Tip (CP12ST) wire, a new ADR wire with the strongest penetration force developed to date, enabled re-entry anywhere except calcification sites.

Objectives

This study investigated the efficacy and feasibility of TD-ADR by comparison of procedural outcomes with Stingray-ADR in CTO-PCI.

Methods

Twenty-seven consecutive CTO cases treated by TD-ADR with CP12ST wire between August 2021 and April 2023 and 27 consecutive CTO cases treated by Stingray-ADR with Conquest 8-20 (CP20) wire between March 2018 and July 2021 were retrospectively enrolled as the TD-ADR by CP12ST wire group and Stingray-ADR by CP20 wire group, respectively, from 4 facilities that could share technical information on these procedures.

Results

The success rate of the ADR procedure was significantly improved (27 of 27 cases [100%] vs 18 of 27 cases [67%], respectively; P = 0.002) and total procedural time was significantly reduced (median procedural time: 145.0 [Q1-Q3: 118.0-240.0] minutes vs 185.0 [Q1-Q3: 159.5-248.0] minutes, respectively; P = 0.028) in the TD-ADR by CP12ST wire group compared to the Stingray-ADR by CP20 wire group. There were few in-hospital major adverse cardiac and cerebrovascular events or no complications in either group.

Conclusions

TD-ADR by CP12ST wire can standardize highly accurate ADR in CTO-PCI.

Validation of the BCIS CHIP Score in chronic total occlusion percutaneous coronary intervention

BACKGROUND

The complex high-risk indicated percutaneous coronary intervention (CHIP) score is a tool developed using the British Cardiovascular Intervention Society (BCIS) database to define CHIP cases and predict in-hospital major adverse cardiac or cerebrovascular events (MACCE).

AIM

To assess the validity of the CHIP score in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

METHODS

We evaluated the performance of the CHIP score on 8341 CTO PCIs from the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) performed at 44 centers between 2012 and 2023.

RESULTS

In our cohort, 7.8% (n = 647) of patients had a CHIP score of 0, 50.2% (n = 4192) had a CHIP score of 1-2, 26.2% (n = 2187) had a CHIP score of 3-4, 11.7% (n = 972) had a CHIP score of 5-6, 3.3% (n = 276) had a CHIP score of 7-8, and 0.8% (n = 67) had a CHIP score of 9+. The incidence of MACCE for a CHIP score of 0 was 0.6%, reaching as high as 8.7% for a CHIP score of 9+, confirming that a higher CHIP score is associated with a higher risk of MACCE. The estimated increase in the risk of MACCE per one score unit increase was 100% (95% confidence interval [CI]: 65%-141%). The AUC of the CHIP score model for predicting MACCE in our cohort was 0.63 (95% CI: 0.58-0.67). There was a positive correlation between the CHIP score and the PROGRESS-CTO MACE score (Spearman's correlation: 0.37; 95% CI: 0.35-0.39; p < 0.001).

CONCLUSIONS

The CHIP score has modest predictive capacity for MACCE in CTO PCI.

The Characteristics of Primary Retrograde Approach Selection for Native Coronary Chronic Occlusion With Short Occlusion Length from the Japanese CTO-PCI Expert Registry

Although the coronary chronic total occlusion (CTO) crossing algorithm has been published, the characteristics associated with the first strategy selection for short-length lesions <20 mm is still debatable. This study aimed to determine the characteristics associated with primary retrograde approach (PRA) for native CTO with short occlusion length in percutaneous coronary intervention (PCI). Between January 2014 and December 2021, we examined data on 4,088 lesions in the Japanese CTO-PCI Expert Registry with occlusion lengths <20 mm. Then, the characteristics for short-length CTO, which was performed by way of the PRA, were assessed. PRA was performed in 785 patients (19.2%). The guidewire success rate was 93.6%, and the technical success rate was 91.3%. Previous coronary artery bypass grafting, chronic kidney disease, and 6 lesion/anatomic characteristics (i.e., blunt stump, distal runoff <1 mm, CTO lesion tortuosity, reattempt procedures, ostial location, and the presence of collateral channel grade 2) were associated with PRA (p <0.05). Moreover, hemodialysis was an independent factor of unsuccessful anterograde guidewire crossing, along with distal runoff <1 mm, the existence of calcification, and CTO lesion tortuosity (all p <0.05). In clinical settings, these independent factors for PRA in short-length CTO can help in selecting the CTO-PCI strategy.

Retrograde chronic total occlusion percutaneous coronary intervention via ipsilateral collaterals

BACKGROUND

There is limited data on retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) via ipsilateral epicardial collaterals (IEC).

AIMS

To compare the clinical and angiographic characteristics, and outcomes of retrograde CTO PCI via IEC versus other collaterals in a large multicenter registry.

METHODS

Observational cohort study from the Prospective Global registry for the study of Chronic Total Occlusion Intervention (PROGRESS-CTO).

RESULTS

Of 4466 retrograde cases performed between 2012 and 2023, crossing through IEC was attempted in 191 (4.3%) cases with 50% wiring success. The most common target vessel in the IEC group was the left circumflex (50%), in comparison to other retrograde cases, where the right coronary artery was most common (70%). The Japanese CTO score was similar between the two groups (3.13 ± 1.23 vs. 3.06 ± 1.06, p = 0.456); however, the IEC group had a higher Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score (1.95 ± 1.02 vs. 1.27 ± 0.92, p < 0.0001). The most used IEC guidewire was the SUOH 03 (39%), and the most frequently used microcatheter was the Caravel (43%). Dual injection was less common in IEC cases (66% vs. 89%, p < 0.0001). Technical (76% vs. 79%, p = 0.317) and procedural success rates (74% vs. 79%, p = 0.281) were not different between the two groups. However, IEC cases had a higher procedural complications rate (25.8% vs. 16.4%, p = 0.0008), including perforations (17.3% vs. 9.0%, p = 0.0001), pericardiocentesis (3.1% vs. 1.2%, p = 0.018), and dissection/thrombus of the donor vessel (3.7% vs. 1.2%, p = 0.002).

CONCLUSION

The use of IEC for retrograde CTO PCI was associated with similar technical and procedural success rates when compared with other retrograde cases, but higher incidence of periprocedural complications.

Impact of a Chronic Total Coronary Occlusion on the Incidence of Appropriate Implantable Cardioverter-Defibrillator Shocks and Mortality: A Substudy of the Dutch Outcome in ICD Therapy (DO-IT)) Registry

BACKGROUND

Chronic total coronary occlusions (CTO) substantially increase the risk for sudden cardiac death. Among patients with chronic ischemic heart disease at risk for sudden cardiac death, an implantable cardioverter defibrillator (ICD) is the favored therapy for primary prevention of sudden cardiac death. This study sought to investigate the impact of CTOs on the risk for appropriate ICD shocks and mortality within a nationwide prospective cohort.

METHODS AND RESULTS

This is a subanalysis of the nationwide Dutch-Outcome in ICD Therapy (DO-IT) registry of primary prevention ICD recipients in The Netherlands between September 2014 and June 2016 (n=1442). We identified patients with chronic ischemic heart disease (n=663) and assessed available coronary angiograms for CTO presence (n=415). Patients with revascularized CTOs were excluded (n=79). The primary end point was the composite of all-cause mortality and appropriate ICD shocks. Clinical follow-up was conducted for at least 2 years. A total of 336 patients were included, with an average age of 67±9 years, and 20.5% was female (n=69). An unrevascularized CTO was identified in 110 patients (32.7%). During a median follow-up period of 27 months (interquartile range, 24-32), the primary end point occurred in 21.1% of patients with CTO (n=23) compared with 11.9% in patients without CTO (n=27; P=0.034). Corrected for baseline characteristics including left ventricular ejection fraction, and the presence of a CTO was an independent predictor for the primary end point (hazard ratio, 1.82 [95% CI, 1.03-3.22]; P=0.038).

CONCLUSIONS

Within this nationwide prospective registry of primary prevention ICD recipients, the presence of an unrevascularized CTO was an independent predictor for the composite outcome of all-cause mortality and appropriate ICD shocks.

Percutaneous Coronary Intervention Offers Clinical Benefits to Diabetic Patients With Stable Chronic Total Occlusion

Whether percutaneous coronary intervention for chronic total occlusion (CTO-PCI) in diabetic patients offers more benefits compared with initial medical therapy (CTO-MT) is unclear. In this study, diabetic patients with one CTO (clinical manifestations: stable angina or silent ischemia) were enrolled. Consecutively, enrolled patients (n = 1605) were assigned to different groups: CTO-PCI (1044 [65.0%]) and initial CTO-MT (561 [35%]). After a median follow-up of 44 months, CTO-PCI tended to be superior to initial CTO-MT in major adverse cardiovascular events (adjusted hazard-ratio [aHR]: .81, 95% conference-interval: .65-1.02) and significantly superior in cardiac death (aHR: .58 [.39-.87]) and all-cause death (aHR: .678[.473-.970]). Such superiority mainly attributed to a successful CTO-PCI. CTO-PCI tended to be performed in patients with younger age, good collaterals, left anterior descending branch CTO, and right coronary artery CTO. While, those with left circumflex CTO and severe clinical/angiographic situations were more likely to be assigned to initial CTO-MT. However, none of these variables influenced the benefits of CTO-PCI. Thus, we concluded that for diabetic patients with stable CTO, CTO-PCI (mainly successful CTO-PCI) offered patients survival benefits over initial CTO-MT. These benefits were consistent regardless of clinical/angiographic characteristics.