Contemporary Incidence, Management, and Long-Term Outcomes of Percutaneous Coronary Interventions for Chronic Coronary Artery Total Occlusions

Assessment of chronical total occlusions management in France: The ENCOCHE Registry, a prospective, multicentric study

BACKGROUND

Coronary chronic total occlusions (CTO) are frequent, and coronary angioplasty has been increasingly used in recent years for lesion revascularisation. However, to date, no dedicated multicentric prospective study is available in France.

AIM

To describe the characteristics of CTO patients and to assess current treatment strategies in French catheterisation laboratory practice.

METHODS

Patients presenting with CTOs were included from 16/09/2021 to 13/12/2021 over two consecutive prospective phases. In phase I (one month), data were collected to include all patients presenting CTO at diagnostic angiography. In phase II (two months), data were collected focusing on patients who underwent CTO-PCI.

RESULTS

A total of 1303 patients (1460 CTOs) were included in 68 French centres. The mean age was 67.7±10.7 years and 84.3% of the patients were men. The prevalence of prior PCI (44.6%), and diabetes mellitus (35.6%) was high. In phase I, multivessel coronary artery disease was detected in two-thirds of cases, and most of them (88.5%) had a single CTO. The mean J-CTO score was 1.9±1.2, with a proportion of difficult and very difficult CTO (J CTO score ≥2) of 61.1%. The selected treatment was medical therapy in 57% of cases, coronary angioplasty in 30% and bypass surgery in 13%. In phase II, 528 patients were included with a mean J-CTO score of 1.8±1.2. Successful guidewire crossing through CTO lesion was obtained with an antegrade access in 89% of patients. Procedural success rate of CTO-PCI was 80%, with a rate of major in-hospital complications of 1% (death: 0.4%, MI: 0.2%, stroke: 0.2%, emergency CABG: 0.2%).

CONCLUSION

This prospective study provides a snapshot of CTOs prevalence and CTO treatment strategies in France in 2021.

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.

Smoking and 10-year risk of cardiovascular and non-cardiovascular events after contemporary coronary stenting

The impact of smoking cessation on long-term clinical outcomes after contemporary percutaneous coronary intervention (PCI) is not well known. We estimated the association of smoking and smoking cessation on the 10-year risk of cardiovascular and non-cardiovascular events in patients after contemporary PCI in a multicenter retrospective cohort of all patients having PCI with second generation drug-eluting stents in the VA Healthcare System between 2008 and 2016. Smoking status, comorbidities and clinical outcomes were extracted from the medical record and the National Death Index. Hazard ratios and 95 % confidence intervals (HR, 95 %CI) were derived from Cox Proportional Hazards Models. Estimates of events prevented from smoking cessation were derived from the differences in absolute risks between subjects who smoked and had stopped smoking. Among 29,001 patients, 10,598 (36.5 %) were current smoking patients, 13,093 (45.1 %) were former smoking patients, and 5,310 (18.3 %) never smoked. Over 10 years, 7,806 (26.9 %) subjects died with non-cardiovascular deaths exceeding cardiovascular deaths. In multivariable models, current smoking was significantly associated with increased long-term risks of all-cause death (HR = 1.27, 95 %CI = 1.19, 1.36), myocardial infarction (HR = 1.32, 95 %CI = 1.21-1.43), cancer death (HR = 2.55, 95 % CI = 2.10, 3.08), and pulmonary death (HR = 4.07, 95 % CI = 2.85, 5.83). Smoking cessation may prevent 18.5 % (95 %CI = 16.0 %, 20.9 %) all-cause deaths, 14.8 % (95 %CI = 9.8 %, 19.6 %) cardiovascular deaths, 42.6 % (95 %CI = 37.7 %, 47.2 %) cancer deaths, and 48.3 % (95 %CI = 41.8 %, 54.2 %) pulmonary deaths among smokers. Stopping smoking will likely have major impacts on non-cardiovascular events as well as cardiovascular events in patients after PCI with second generation drug-eluting stents.

Association between the pan-immune-inflammation value and coronary collateral circulation in chronic total coronary occlusive patients

BACKGROUND

Inflammation and immunity play important roles in the formation of coronary collateral circulation (CCC). The pan-immune-inflammation value (PIV) is a novel marker for evaluating systemic inflammation and immunity. The study aimed to investigate the association between the PIV and CCC formation in patients with chronic total occlusion (CTO).

METHODS

This retrospective study enrolled 1150 patients who were diagnosed with CTO through coronary angiographic (CAG) examinations from January 2013 to December 2021 in China. The Cohen-Rentrop criteria were used to catagorize CCC formation: good CCC formation (Rentrop grade 2-3) and poor CCC formation group (Rentrop grade 0-1). Based on the tertiles of the PIV, all patients were classified into three groups as follows: P1 group, PIV ≤ 237.56; P2 group, 237.56< PIV ≤ 575.18; and P3 group, PIV > 575.18.

RESULTS

A significant relationship between the PIV and the formation of CCC was observed in our study. Utilizing multivariate logistic regression and adjusting for confounding factors, the PIV emerged as an independent risk factor for poor CCC formation. Notably, the restricted cubic splines revealed a dose-response relationship between the PIV and risk of poor CCC formation. In terms of predictive accuracy, the area under the ROC curve (AUC) for PIV in anticipating poor CCC formation was 0.618 (95% CI: 0.584-0.651, P < 0.001). Furthermore, the net reclassification index (NRI) and integrated discrimination index (IDI) for PIV, concerning the prediction of poor CCC formation, were found to be 0.272 (95% CI: 0.142-0.352, P < 0.001) and 0.051 (95% CI: 0.037-0.065, P < 0.001), respectively. It's noteworthy that both the NRI and IDI values were higher for PIV compared to other inflammatory biomarkers, suggesting its superiority in predictive capacity.

CONCLUSIONS

PIV was associated with the formation of CCC. Notably, PIV exhibited potential as a predictor for poor CCC formation and showcased superior predictive performance compared to other complete blood count-based inflammatory biomarkers.

Long-term outcomes after revascularization in chronic total and non-total occluded coronary arteries: A regionwide cohort study

BACKGROUND

Understanding the prognostic impact of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) is crucial for patient management. Previous studies have primarily been studying prognostic impact of successful versus unsuccessful CTO PCI. This study investigated the prognostic impact of successful and unsuccessful percutaneous coronary intervention (PCI) of chronic total occluded coronary arteries (CTO) with non-CTO PCI as reference.

METHODS

Patients treated with PCI from 2009 to 2019 in the Central Region of Denmark were included in a population-based cohort study. We compared successful and unsuccessful CTO PCI with non-CTO PCI. Exclusion criteria was myocardial infarction within 30 days. Primary outcome was difference in a composite major adverse cardio- and cerebrovascular events (MACCE) encompassing all-cause death, any myocardial infarction, stroke, hospitalization for heart failure or revascularization tracked via nationwide registries.

RESULTS

Of 21,141 screened patients, 10,638 were enrolled: 9,065 underwent non-CTO PCI, 1,300 had successful CTO PCI, and 273 had unsuccessful CTO PCI. Median follow-up time was 5.9 [3.5;9.0] years and 4,750 MACCEs were recorded. Compared to non-CTO PCI, the adjusted MACCE rate for successful CTO PCI was equivalent (Hazard Ratio (HR): 0.98, 95% Confidence Interval (CI): 0.90-1.07, p = 0.71). In contrast, unsuccessful CTO PCI was associated with a higher MACCE rate (HR: 1.22, 95% CI: 1.04-1.43, p<0.01). HR was adjusted for age, body-mass index, previous revascularization, smoking, kidney disease, two or three-vessel disease, left ventricular ejection fraction, diabetes and comorbidities.

CONCLUSIONS

The pre-specified hypothesis was accepted. Successful CTO PCI was associated with equivalent long-term outcomes as non-CTO PCI, and unsuccessful CTO PCI was identified as a high-risk group associated to worse outcomes.

Procedural Results and Long-term Outcome of Chronic Total Occlusion Percutaneous Coronary Intervention in a UK Non-surgical Centre

Background

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has evolved a great deal over recent years, with increased procedural success and lower complication rates being reported. This study aims to evaluate the feasibility, safety and success of a dedicated CTO programme in a large UK PCI centre without on-site cardiothoracic surgery facilities.

Methods

Clinical and procedural data were retrospectively collected for consecutive unselected patients undergoing CTO PCI between 2015 and 2019 from the local database and regional electronic patient records. In-hospital outcomes and long-term major adverse cardiovascular events (all-cause mortality, MI, stroke and target vessel revascularisation) were recorded.

Results

A total of 170 patients underwent 191 CTO procedures during the study period. The mean age was 63 ± 10 years and 80.6% of patients were male (n=137). The clinical indications were: stable chronic coronary syndromes in 88.5% (n=169) of patients; staged procedures in the context of acute coronary syndromes in 1.6% (n=3); and presentation with acute coronary syndrome in 9.9% (n=19). The procedural success rate was 50.0% (n=25) for general interventional cardiologists and 90.1% (n=127) for dedicated CTO operators. In-hospital major adverse cardiovascular events occurred once (0.5%) and interhospital transfer for emergency salvage cardiac surgery was not required. Long-term follow-up data at a median duration of 3.8 years revealed 4 (2.4%) cardiac deaths, 14 (8.3%) spontaneous MI events and 10 (5.9%) target vessel revascularisations.

Conclusion

These data suggest CTO PCI using contemporary techniques is both safe and effective when undertaken in a high-volume non-surgical centre by experienced operators.

Relationship between homocysteine and chronic total coronary occlusion: a cross-sectional study from southwest China

BACKGROUND

Chronic total coronary occlusion is among the most complex coronary artery diseases. Elevated homocysteine is a risk factor for coronary artery diseases. However, few studies have assessed the relationship between homocysteine and chronic total coronary occlusion.

METHODS

1295 individuals from Southwest China were enrolled in the study. Chronic total coronary occlusion was defined as complete occlusion of coronary artery for more than three months. Homocysteine was divided into quartiles according to its level. Univariate and multivariate logistic regression models, receiver operating characteristic curves, and subgroup analysis were applied to assess the relationship between homocysteine and chronic total coronary occlusion.

RESULTS

Subjects in the higher homocysteine quartile had a higher rate of chronic total coronary occlusion (P < 0.001). After adjustment, the odds ratio for chronic total coronary occlusion in the highest quartile of homocysteine compared with the lowest was 1.918 (95% confidence interval 1.237-2.972). Homocysteine ≥ 15.2 μmol/L was considered an independent indicator of chronic total coronary occlusion (odds ratio 1.53, 95% confidence interval 1.05-2.23; P = 0.0265). The area under the receiver operating characteristic curve was 0.659 (95% confidence interval, 0.618-0.701; P < 0.001). Stronger associations were observed in elderly and in those with hypertension and diabetes.

CONCLUSIONS

Elevated homocysteine is significantly associated with chronic total coronary occlusion, particularly in elderly and those with hypertension and diabetes.

Coronary chronic total occlusion on coronary CT angiography: what radiologists should know?

Coronary chronic total occlusion (CTO) often occurs in patients with obstructive coronary artery disease, which remains one of the greatest challenges for interventional cardiologists. Coronary computed tomography angiography (CCTA) with its emerging post-processing techniques can provide a detailed assessment of CTO lesions before percutaneous coronary intervention (PCI), playing an important role in the clinical management of CTO PCI, from early diagnosis, pre-procedural outcome prediction, the crossing algorithm planning, intraprocedural guidance, and finally post-procedural assessment and follow-up. In addition, the feasibility of CT perfusion (CTP) in patients with CTO has been validated. Combined CCTA and CTP have the great potential to be the one-stop-shop imaging modality for assessing both anatomy and function of CTO lesions. This review aims to make radiologists understand the role of CCTA in the diagnosis and assessment of CTO lesions, thus assisting interventionalists in optimizing CTO PCI crossing strategies with the expertise of radiologists.Critical relevance statement The anatomical features of CTO on CCTA can reveal the complexity of CTO lesions and are associated with CTO PCI outcome, thus helping interventionalists optimize CTO PCI crossing strategies.Key points • CTO is the common lesion in invasive coronary angiography, and CTO PCI is technically difficult and its success rate is relatively low.• Length, collaterals, and attenuation-related signs can help distinguish CTO from subtotal occlusion.• The anatomical features of CTO lesions can help grade the difficulty of CTO PCI and predict procedural outcomes and long-term outcomes of CTO PCI.• The real-time fusion of CCTA with fluoroscopic angiography can be applied in highly complicated CTO lesions.• After CTO PCI, CCTA can help guide a second CTO PCI re-entry or follow up stent patency.

In-Hospital Outcomes Following Surgical Revascularization of Chronic Total Coronary Occlusions

Background and Objectives: Patients with chronic total occlusions of the coronary arteries are either treated with PCI or referred for surgical revascularization. We analyzed the patients with chronic occluded coronary arteries that were surgically treated and aimed to describe the anatomical characteristics, revascularization rates, and in-hospital outcomes achieved with coronary artery bypass grafting. Methods: Angiographic data of 2005 patients with coronary artery disease treated in our institution between January 2005 and December 2014 were retrospectively analyzed. A total of 1111 patients with at least one coronary total occlusion were identified. We reviewed the preoperative coronary angiograms and surgical protocols to determine the presence, localization, and revascularization of coronary occlusions. We also evaluated the perioperative data and in-hospital outcomes. Results: The median age of the study population was 68 years (25th-75th percentiles, 61.0-74.0). Three-vessel disease was present in 94.8% of patients and the rest (5.8%) had a two-vessel disease. The localizations of the occlusions were as follows: 68.4% in the RCA system, 26.4% in the LAD, and 28.5% in the LCX system. Multiple occlusions were present in 22.6% of the patients. Complete coronary total occlusion revascularization was achieved in 86.1% of the patients. The overall in-hospital mortality was 2.3%. The median in-hospital stay was 14.0 days. After logistic regression analysis, age (odds ratio 3.44 [95% confidence interval, 1.81-6.53], p < 0.001, for a 10-year increase) and the presence of peripheral artery disease (odds ratio 3.32 [1.39-7.93], p = 0.007) were the only statistically significant independent predictors of in-hospital mortality. Conclusions: A high revascularization rate and favorable in-hospital outcomes are achieved with coronary artery bypass surgery in patients with multi-vessel diseases and coronary total occlusions. Older age and the presence of peripheral artery disease are independent predictors of in-hospital mortality. A long-term follow-up and the type of graft (arterial vs. venous) used would bring more useful data for this type of revascularization.

Outcomes of Transcatheter Aortic Valve Replacement With and Without Index Chronic Total Occlusion of Coronary Artery: A Propensity Matched Analysis

Transcatheter aortic valve replacement (TAVR) utilization is increasing, along with procedural success. Coronary angiography is frequently performed before the TAVR procedure for coronary artery disease workup. Chronic total occlusion (CTO) of the coronary artery shares common risk factors with aortic stenosis and could be challenging, especially in terms of procedural safety. The outcomes of TAVR among patients with concomitant CTO are not extensively studied. We analyzed the National Inpatient Sample database between October 2015 and December 2020 to evaluate the clinical characteristics, procedural safety, and outcomes among patients who underwent TAVR who had concomitant CTO lesions. A total of 304,330 TAVRs were performed between 2015 and 2020, 5,235 of which (1.72%) were in patients with TAVR-CTO and 299,095 (98.28%) in those with TAVR-no CTO. After propensity matching, there was no difference in the odds of in-hospital mortality (adjusted odds ratio [aOR] 1.28, 95% confidence interval [CI] 0.94 to 1.75, p = 0.11). However, TAVR-CTO was associated with an increased incidence of acute myocardial infarction (aOR 1.27, 95% CI 1.05 to 1.53, p = 0.01), cardiac arrest (aOR, 2.60, 95% CI 1.64 to 4.11, p <0.0001), and need for mechanical circulatory support (aOR 2.6, 95% CI 1.88 to 3.59, p <0.0001). There was no difference in the incidence of stroke, major bleeding, complete heart block, or requirement for permanent pacemaker between the 2 groups. However, the TAVR-CTO cohort had a slightly greater length of stay and total hospitalization cost. TAVR is a relatively safe procedure among those with concomitant CTO lesions; however, it is associated with a greater incidence of acute myocardial infarction, cardiac arrest, and requirement for mechanical circulatory support.

The Utility of CT Coronary Angiography in Chronic Total Occlusion Percutaneous Coronary Intervention

Chronic total occlusion (CTO) of the coronary arteries is a relatively common finding in routine coronary angiography. Of late, there has been considerable improvement in the success rate of percutaneous intervention for coronary CTO, attributed to technological advancement and skills development. CT coronary angiogram (CTCA) is a simple, non-invasive, and cost-effective test that aids in the diagnosis and management of coronary artery disease, including CTOs. The development of multi-slice CT and the use of 3D volume rendering images has revolutionised the diagnostic abilities of CTCA, with improvements in imaging quality and detailed anatomical and morphological characterisation of the plaque disease. In CTO percutaneous intervention, CTCA is used in pre-procedural planning, applying scoring systems to predict the likely success of the intervention as well as the post-procedural evaluation and follow-up. This review examines the different uses of CTCA in CTO intervention, its impact on successful recanalisation and the areas for future consideration.

Multiple Biomarkers to Predict Major Adverse Cardiovascular Events in Patients With Coronary Chronic Total Occlusions

Background

There are limited tools available to predict the long-term prognosis of persons with coronary chronic total occlusions (CTO).

Objectives

We evaluated performance of a blood biomarker panel to predict cardiovascular (CV) events in patients with CTO.

Methods

From 1251 patients in the CASABLANCA study, 241 participants with a CTO were followed for an average of 4 years for occurrence of major adverse CV events (MACE, CV death, non-fatal myocardial infarction or stroke) and CV death/heart failure (HF) hospitalization. Results of a biomarker panel (kidney injury molecule-1, N-terminal pro-B-type natriuretic peptide, osteopontin, and tissue inhibitor of metalloproteinase-1) from baseline samples were expressed as low-, moderate-, and high-risk.

Results

By 4 years, a total of 67 (27.8%) MACE events and 56 (23.2%) CV death/HF hospitalization events occurred. The C-statistic of the panel for MACE through 4 years was 0.79. Considering patients in the low-risk group as a reference, the hazard ratio of MACE by 4 years was 6.65 (95% confidence interval [CI]: 2.98-14.8) and 12.4 (95% CI:5.17-29.6) for the moderate and high-risk groups (both P <0.001). The C-statistic for CVD/HF hospitalization by 4 years was 0.84. Compared to the low-risk score group, the moderate and high-risk groups had hazard ratios of 5.61 (95% CI: 2.33-13.5) and 15.6 (95% CI: 6.18, 39.2; both P value <0.001).

Conclusion

A multiple biomarker panel assists in evaluating the risk of adverse outcomes in patients with coronary CTO. These results may have implications for patient care and could have a role for clinical trial enrichment.

Clinical Trial

CASABLANCA, ClinicalTrials.gov Identifier: NCT00842868.

National Trends of Percutaneous Mechanical Support Utilization During Percutaneous Coronary Interventions in Chronic Total Occlusion

Coronary chronic total occlusion (CTO) is common in patients with multivessel coronary artery disease. Percutaneous coronary artery (PCI) interventions have shown favorable outcomes in patients with CTO. Nevertheless, the data regarding the utilization of mechanical circulatory support in CTO PCIs is not well established. We sought to investigate the trends in utilization and periprocedural complications in this population. Using the National Inpatient Sample database from 2011 to 2019, we identified patients diagnosed with CTO who underwent PCI. We investigated the presence of a linear trend in the utilization of mechanical circulatory support (MCS) during those procedures and the associated periprocedural complications using the Cochran-Armitage method. A total of 208,123 patients who were diagnosed with CTO and underwent PCI from 2011 to 2019, of which in 6,319 patients MCS was used during the procedure. Patients in the MCS group were older (67.4 vs 66.4 years), less likely to be women (24.0% vs 26.4%), and equally likely to be African-American (9.4% vs 8.8%) with a higher burden of co-morbidities in terms of coronary artery disease, congestive heart failure, and atrial fibrillation (p <0.001 for all). Using the Cochrane-Armitage method, we found a statistically significant linear uptrend in the utilization of MCS from 269 (1.4%) to 990 cases (7.0%) from 2011 to 2019. Using multivariable logistic regression, female gender, renal failure, alcohol abuse, coagulopathy, and fluid and electrolyte disorders were identified as independent predictors of mortality in CTO PCI procedures assisted with MCS (p ≤0.007). In conclusion, the utilization of MCS in CTO PCI procedures has been increasing over the years. Female gender and renal failure are independently associated with a higher mortality risk.

External validation of the PROGRESS-CTO complication risk scores: Individual patient data pooled analysis of 3 registries

BACKGROUND

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with a considerable risk of complications, and risk stratification is of utmost importance.

AIMS

To assess the clinical usefulness of the recently developed PROGRESS-CTO (NCT02061436) complication risk scores in an independent cohort.

METHODS

Individual patient data pooled analysis of 3 registries was performed.

RESULTS

Of the 4569 patients who underwent CTO PCI, 102 (2.2%) had major adverse cardiovascular events (MACE). Patients with MACE were older (69 ± 11 vs. 65 ± 10, p < 0.001), more likely to have a history of prior coronary artery bypass graft surgery, and unfavorable angiographic characteristics J-CTO score (2.4 ± 1.2 vs. 2.1 ± 1.3, p = 0.007), including blunt stump (59% vs. 49%, p = 0.047). Technical success was lower in patients with MACE (59% vs. 86%, p < 0.001). The area under the receiver operating characteristic curve of the PROGRESS-CTO complication risk models were as follows: MACE 0.72 (95% confidence interval [CI], 0.67-0.76), mortality 0.73 (95% CI, 0.61-0.85), and pericardiocentesis 0.69 (95% CI, 0.62-0.77) in the validation dataset. The observed complication rates increased with higher PROGRESS-CTO complication scores. The PROGRESS-CTO MACE score showed good calibration in this external cohort, with MACE rates similar to the original study: 0.7% (score 0-1), 1.5% (score 2), 2.2% (score 3), 3.8% (score 4), 4.9% (score 5), 5.8% (score 6-7).

CONCLUSION

Given the good discriminative performance, calibration, and ease of calculation, the PROGRESS-CTO complication scores could help assess the risk of complications in patients undergoing CTO PCI.

Contemporary Management Before Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

BACKGROUND

Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system.

METHODS

We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates.

RESULTS

Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]).

CONCLUSIONS

Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.

Improvement of angiographic and clinical outcomes of percutaneous coronary intervention for chronic total occlusion after implementation of a dedicated team: a single-centre experience

INTRODUCTION

In a Dutch heart centre, a dedicated chronic total occlusion (CTO) team was implemented in June 2017. The aim of this study was to the evaluate treatment success and clinical outcomes before and after this implementation.

METHODS

A total of 662 patients who underwent percutaneous coronary intervention (PCI) for a CTO between January 2013 and June 2020 were included and divided into pre- and post-CTO team groups. The primary endpoint was the angiographic success rate of CTO-PCI. Secondary endpoints included angiographic success stratified by complexity using the J‑CTO score and the following clinical outcomes: in-hospital complications and myocardial infarction, target vessel revascularisation, all-cause mortality, quality of life (QoL) and major adverse cardiac events (MACE) at 30-day and 1‑year follow-up.

RESULTS

Compared with the pre-CTO team group, the success rate in the post-CTO team group was higher after the first attempt (81.4% vs 62.7%; p < 0.001) and final attempt (86.7% vs 73.8%; p = 0.001). This was mainly driven by higher success rates for difficult and very difficult CTO lesions according to the J‑CTO score. The MACE rate at 1 year was lower in the post-CTO team group than in the pre-CTO team group (6.4% vs 16.0%; p < 0.01), while it was comparable at 30-day follow-up (0.1% vs 1.7%; p = 0.74). Angina symptoms were significantly reduced at 30-day and 1‑year follow-up, and QoL scores were higher after 1 year.

CONCLUSION

This study demonstrated higher success rates of CTO-PCI and improved clinical outcomes and QoL at 1‑year follow-up after implementation of a dedicated CTO team using the hybrid algorithm.

In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Heart failure patients

In-hospital outcomes of chronic total occlusion Percutaneous Coronary Interventions (CTO PCI) in heart failure patients has not been evaluated on a national base and was the focus of this investigation. We used the Nationwide Inpatient Sample database from 2008 to 2014 to identify adults with single vessel CTO PCI for stable ischemic heart disease (SIHD). Patients were divided into 3 groups: patients without heart failure, heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple logistic regression models were performed to assess in-hospital mortality, acute renal failure, and the use of mechanical support devices. Of 112,061 inpatients with SIHD from 2008 to 2014 undergoing CTO PCI, 21,185 (19%) had HFrEF and 3309 (3%) had HFpEF. Compared to patients without heart failure, HFrEF and HFpEF patients were older (mean age 69.2 vs 66.3, 70.3 vs 66.3 respectively, P < 0.001), had more comorbidities and higher acute in-hospital complications. HFrEF patients had higher adjusted in-hospital mortality [AOR 1.73, 95% CI (1.21-2.48)], acute renal failure [AOR 2.68, 95% CI (2.34-3.06)], and need for mechanical support [AOR 2.76, 95% CI (2.17-3.51)]. Compared to patients without heart failure, HFpEF patients had similar mortality and need for mechanical support, but higher incidence of acute renal failure. Older age was significantly associated with increased in-hospital mortality. chronic total occlusion PCI in patients with heart failure is associated with higher in-hospital morbidity and mortality and warrants further investigation to optimize health care delivery.

Long-Term Outcomes and Duration of Dual Antiplatelet Therapy After Coronary Intervention With Second-Generation Drug-Eluting Stents: The Veterans Affairs Extended DAPT Study

Background Recent guidelines on dual antiplatelet therapy (DAPT) duration after percutaneous coronary intervention (PCI) balance the subsequent risks of major bleeding with ischemic events. Although generally favoring shorter DAPT duration with second-generation drug-eluting stents, the effects on long-term outcomes in the wider population are uncertain. Methods and Results We tracked all patients having PCI with second-generation drug-eluting stents in the Veterans Affairs Healthcare System between 2006 and 2016 for death, myocardial infarction, stroke, and major bleeding up to 13 years. We compared these outcomes with 4 DAPT durations of 1 to 5, 6 to 9, 10 to 12, and 13 to 18 months after the index PCI using hazard ratios (HRs) and 95% CIs from Cox proportional hazards models adjusted by inverse probability weighting. A total of 40 882 subjects with PCI were followed up for a median of 4.3 (25%-75%: 2.4-6.5) years. DAPT discontinuation was rare early after PCI (5.8% at 1-5 months and 6.3% at 6-9 months) but increased (19% and 44%) >9 months. The risk of cardiovascular and noncardiovascular death was higher (HR, 2.03-3.41) with DAPT discontinuation <9 months, likely reflecting premature cessation from factors related to early death. DAPT discontinuation after 9 months following PCI was associated with lower risks of death (HR, 0.93 [95% CI, 0.88-0.99]), cardiac death (HR, 0.79 [95% CI, 0.70-0.90]), myocardial infarction (HR, 0.75 [95% CI, 0.69-0.82]), and major bleeding (HR, 0.82 [95% CI, 0.74-0.91]). Results were similar with an index PCI for an acute coronary syndrome. Conclusions Stopping DAPT after 9 months is associated with lower long-term risks of adverse ischemic and bleeding events and supports recent guidelines of shorter duration DAPT after PCI with second-generation drug-eluting stents.

Rotational atherectomy for chronically and totally occluded coronary lesions: A propensity score-matched outcomes study

Background

Despite advances being made in techniques and devices, certain chronic total occlusion (CTO) lesions remain uncrossable or undilatable. Rotational atherectomy (RA) is usually necessary for such lesions to achieve successful revascularization.

Methods

Information regarding consecutive patients who underwent coronary RA was retrieved from the catheterization laboratory database. Patients who underwent RA for CTO lesion refractory using other conventional devices were recruited, with propensity score-matched cases serving as controls.

Results

A total of 411 patients underwent coronary RA in the study period. Most patients had high-risk features (65.7% had acute coronary syndrome (ACS), 14.1% ischemic cardiomyopathy, and 5.1% cardiogenic shock), while only 20.2% of the patients had stable angina. Among them, 44 patients underwent RA for CTO lesions (CTO group), whereas the propensity score matched controls consist of 37 patients (non-CTO group). The baseline characteristics, high-risk features, coronary artery disease (CAD) vessel numbers, left ventricular function and biochemistry profiles of both groups were the same except for more patients with diabetes (67.6% vs. 45.5%, p = 0.046) in the non-CTO group and more 1.25 mm burr uses in the CTO group. There were no significant differences in acute procedural outcomes or incidence of acute contrast-induced nephropathy (CIN), and no patient demanded emergent CABG or died during the procedure. There was no significant difference in major adverse cardiovascular events (MACE), CV MACE or individual components between the two groups in the hospital, at 30, 90, and 180 days or at 1 year.

Conclusion

In comparison with the propensity risk factor scores-matched controls, there was no difference in procedural complications, acute CIN or clinical outcomes during various stages of RA for CTO lesions. RA for CTO patients was highly efficient and showed safety and outcome profiles similar to those for non-CTO lesions.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

Coronary Artery Perforation Resulting in a Loculated Extracardiac Hematoma

We describe the case of an 86-year-old man with an extensive cardiac history, including previous coronary artery bypass grafting, who experienced a delayed extracardiac hematoma, 350 mL in volume, after retrograde chronic total occlusion—percutaneous coronary intervention. The patient was successfully treated with resultant liquefaction of the hematoma. (Level of Difficulty: Advanced.)

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

The evolution of the CTO-PCI landscape in Belgium and Luxembourg: a four-year appraisal

BACKGROUND

To chart the evolution of the CTO-PCI landscape in Belgium and Luxembourg, the Belgian Working Group on Chronic Total Occlusions (BWGCTO) was established in 2016.

METHODS

Between May 2016 and December 2019, patients undergoing a CTO-PCI treatment were prospectively and consecutively enrolled. Twenty-one centres in Belgium and one in Luxembourg participated. Individual operators had mixed levels of expertise in treating CTO lesions. Demographic, angiographic, procedural parameters and incidence of major adverse cardiac and cerebrovascular events (MACCE) were systematically registered.

RESULTS

Over a four-year enrolment period, 1832 procedures were performed in 1733 patients achieving technical success in 1474 cases (80%), with an in-hospital MACCE rate of 2.3%. Fifty-nine (3%) cases were re-attempt procedures of which 41 (69%) were successful. High-volume centres treated more complex lesions (mean J-CTO score: 2.15 ± 1.21) as compared to intermediate (mean J-CTO score: 1.72 ± 1.23; p < 0.001) and low-volume centres (mean J-CTO score: 0.99 ± 1.21; p = 0.002). Despite this, success rates did not differ between centres (p = 0.461). Overall success rates did not differ over time (p = 0.810). High-volume centres progressively tackled more complex CTOs while keeping success rates stable. In all centres, the most applied strategy was antegrade wire escalation (83%). High-volume centres more often successfully applied antegrade dissection and re-entry and retrograde techniques in lesions with higher complexity.

CONCLUSION

With variable experience levels, operators treated CTOs with high success and relatively few complications. Although AWE remains the most used technique, it is paramount for operators to be skilled in all contemporary techniques in order to be successful in more complex CTOs.

Outcomes of contemporary versus conventional reverse controlled and antegrade and retrograde subintimal tracking in chronic total occlusion revascularization

BACKGROUND

Chronic total occlusion (CTO) lesions remain technically challenging for percutaneous coronary intervention (PCI). The introduction of a retrograde approach has allowed marked improvement in the success rate of CTO recanalization. Reverse controlled anterograde and retrograde sub-intimal tracking (reverse CART) is the predominant retrograde wire crossing technique and can be broadly classified into three categories: (1) conventional (2) contemporary and (3) extended. The present study aimed to compare the safety and efficacy of conventional and contemporary reverse CART techniques.

METHODS

From March 2015 to May 2020, 303 patients achieving successful retrograde guidewire crossing with conventional or contemporary reverse CART during CTO PCI were included in the study. The patient characteristics, procedural outcomes and in-hospital and 1-year clinical events were compared between the conventional and contemporary groups.

RESULTS

The distributions of the baseline and angiographic characteristics were similar in both study arms, except the CTO lesions of the conventional group were more complex, as reflected by borderline significantly higher mean J-CTO scores (3.4 ± 0.7 vs. 3.3 ± 0.8; p = 0.059). Recanalization using contemporary reverse CART was associated with a short procedure time (189.8 ± 44.4 vs. 181.7 ± 37.3 min; p = 0.044) and decreased procedural complications, particularly target vessel perforation (3.6% vs. 0.6%; p = 0.063) and major side-branch occlusion (36.7% vs. 28.0%; p = 0.051). Technical and procedural success and the in-hospital and 1-year outcomes were not significantly different between the groups.

CONCLUSIONS

Contemporary reverse CART is associated with favorably high efficiency and low-complication rates and carries a comparable success rate and 1-year clinical outcomes as conventional reverse CART.

Trends and outcomes of chronic coronary total occlusion-related ventricular tachyarrhythmias

Our study aims to establish trends and frequencies of ventricular tachyarrhythmia (VTA) among patients with chronic coronary total occlusion (CCTO). We identified CCTO hospitalizations with and without VTA using the National Inpatient Sample. A total of 911,579 CCTO-related hospitalizations were identified, with 92,450 (10.1%) encounters associated with VTA. The CCTO-VTA cohort showed higher all-cause mortality (adjusted odds ratio [aOR] = 4.45, P <  0.001), longer hospital stays (6.8 vs 4.6 days; P <  0.001), and higher hospital charges ($117,382 vs $75,419; P <  0.001) compared to the CCTO non-VTA group. Rates and odds of cardiogenic shock (aOR = 4.19), venous thromboembolism (aOR = 2.09), respiratory failure (aOR = 2.85), and requirement of mechanical ventilation (aOR = 4.23) were higher in the CCTO-VTA group (P <  0.001). Over time, there was an increase in VTA (9.2% in 2010 to 12.1% in 2014) and all-cause mortality (7.5% in 2010 to 12.4% in 2014; P <  0.001). Trends in VTA among patients with CCTO increased by 4.8% for undergoing percutaneous coronary intervention and by 2.5% for undergoing both percutaneous coronary intervention and coronary artery bypass grafting (P <  0.001). Occurrence of VTA among CCTO patients is associated with worse outcomes and higher resource utilization.

Procedural Success Prediction Scoring Systems Used in Percutaneous Coronary Interventions for Chronic Total Occlusions: A Systematic Evaluation

(1) Background: Data suggest that patients with coronary chronic total occlusion (CTO) managed with percutaneous coronary intervention (PCI) could have better outcomes than those treated with optimal medical therapy alone. We aimed to systematically review dedicated scoring systems used to predict successful PCI in patients with CTO. (2) Methods: Electronic databases of MEDLINE (PubMed), Embase, and Cochrane were searched. (3) Results: 32 studies were included. We provided insights into all available predictive models of PCI success in CTO including predictive performance, validations, and comparisons between different scores and models' limitations. Considering the differences in the population included, coronary lesions, and techniques applied across clinical studies, the most used scores displayed a modest to good predictive value, as follows: J-CTO (AUC, 0.55-0.868), PROGRESS-CTO (AUC, 0.557-0.788), CL (AUC, 0.624-0.800), CASTLE (AUC, 0.633-0.68), and KCCT (AUC, 0.703-0.776). As PCI for CTO is one of the most complex interventions, using dedicated scoring systems could ensure an adequate case selection as well as preparation for an appropriate recanalization technique in order to increase chances of successful procedure. (4) Conclusion: Clinical models appear to be valuable tools for the prediction of PCI success in CTO patients. Clinicians should be aware of the limitations of each model and should be able to correctly select the most appropriate score according to real-life case particularities such as lesion complexity and operator experience in order to maximize success and achieve the best patients' outcomes.

Anesthetic Considerations for Percutaneous Coronary Intervention for Chronic Total Occlusions-A Narrative Review

Advancing stent technology has enabled interventional cardiologists to perform percutaneous coronary intervention (PCI) to open chronic total occlusions (CTOs). Because PCI for CTOs improve patient anginal symptoms and quality of life, these procedures have been increasing over the past decade. Compared to standard PCI, these procedures are technically more difficult, with prolonged procedure time and increased risk of complications. Accordingly, anesthesiologists are increasingly being asked to provide sedation for these patients in the cardiac catheterization suite. In CTO PCI, anesthesiologists are more likely to encounter complications such as coronary artery perforation, malignant arrhythmias, non-target vessel ischemia, bleeding and shock. Additionally, CTO PCI may be supported by mechanical circulatory support devices. Understanding the procedural techniques of these complex PCI procedures is important to enable optimal anesthetic care in these patients. This narrative review discusses the pathophysiology, risks, benefits, procedural steps, and main anesthetic considerations for patients undergoing CTO PCI. Despite a growing body of literature, future research is still required to elucidate optimal anesthetic and mechanical support strategies in patients undergoing CTO PCI.

Functional recovery after percutaneous revascularization of coronary chronic total occlusions: insights from cardiac magnetic resonance tissue tracking

To evaluate the effect of percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs) on left ventricular (LV) strain assessed using cardiac magnetic resonance (CMR) tissue tracking. In 150 patients with a CTO, longitudinal (LS), radial (RS) and circumferential shortening (CS) were determined using CMR tissue tracking before and 3 months after successful PCI. In patients with impaired LV strain at baseline, global LS (10.9 ± 2.4% vs 11.6 ± 2.8%; P = 0.006), CS (11.3 ± 2.9% vs 12.0 ± 3.5%; P = 0.002) and RS (15.8 ± 4.9% vs 17.4 ± 6.6%; P = 0.001) improved after revascularization of the CTO, albeit to a small, clinically irrelevant, extent. Strain improvement was inversely related to the extent of scar, even after correcting for baseline strain (B =  − 0.05; P = 0.008 for GLS, B =  − 0.06; P = 0.016 for GCS, B =  − 0.13; P = 0.017 for GRS). In the vascular territory of the CTO, dysfunctional segments showed minor improvement in both CS (10.8 [6.9 to 13.3] % vs 11.9 [8.1 to 15.0] %; P < 0.001) and RS (14.2 [8.4 to 18.7] % vs 16.0 [9.9 to 21.8] %; P < 0.001) after PCI. Percutaneous revascularization of CTOs does not lead to a clinically relevant improvement of LV function, even in the subgroup of patients and segments most likely to benefit from revascularization (i.e. LV dysfunction at baseline and no or limited myocardial scar).

Revascularisation of chronic total occlusions and recurrence rate of ventricular arrhythmias

BACKGROUND

The impact of revascularisation of chronic total occlusions (CTO) on the incidence of ventricular arrhythmias (VA) remains to be elucidated.

METHODS

Based on prospectively gathered data, the recurrence rate of VAs following CTO treatment was retrospectively investigated. Patients presenting with VAs as clinical indication for CTO revascularisation were retrospectively selected out of three Belgian CTO registries (i.e. Ziekenhuis Oost-Limburg, UZ Leuven and CHR de la Citadelle). Freedom of VAs was defined as absence of non-sustained or sustained tachycardias (VT), ventricular fibrillations (Vfib) and ventricular extrasystoles (VES; <2500 VES/24 h). Long-term outcome in terms of reoccurrence of VAs was evaluated by reviewing patient records.

RESULTS

Between 2011 and 2019, 912 patients underwent a CTO-PCI across three Belgian centres. In total 43 patients (5%) presented with VAs as clinical indication for CTO revascularisation. Overall follow-up was 723 (391 - 1144) days. Fourteen (33%), 18 (42%), 5 (11%) and 6 (14%) presented with >2500 VES/24 hrs, non-sustained VT, sustained VT and Vfib, respectively. In those patients with a one-year follow-up available (n = 34), overall recurrence rate of VAs was 38% (within VA group: VES: 25%, non-sustained VT: 46%; sustained VT: 25% and Vfib: 60%).

CONCLUSION

Based on this retrospective data analysis, CTO revascularisation, in patients presenting with VAs as the main clinical indication, seems to beneficially impact the incidence of VAs, which ultimately might result in improved patients' outcome.

Cardiac and sudden death after chronic total occlusion percutaneous coronary intervention: Prognostic role of the target vessel

BACKGROUND

The role of the target vessel in percutaneous revascularization of chronic total occlusion (CTO) is unclear.

OBJECTIVE

We sought to assess the long-term results of percutaneous coronary intervention (PCI) for CTO lesions in each coronary artery and to investigate the impact of successful revascularization and previous myocardial infarction (MI) in the territory of the target vessel.

METHODS AND RESULTS

Cohort observational study on 1,124 patients who have undergone CTO PCI attempt: 371 on left anterior descending artery (LAD), 485 right coronary artery, and 268 left circumflex. Patients were further stratified by successfully revascularized and not-revascularized CTO (CTO-NR). Vessels affected by a previous MI were defined as infarct-related artery (IRA). The primary endpoint was cardiac death; the secondary endpoint was the combined rate of sudden cardiac-death and sustained ventricular-arrhythmias (SCD/SVAs). Propensity score-matching was performed to evaluate LAD versus NON-LAD CTO. Up to 12-year follow-up, the clinical benefit associated with successful PCI was consistent across the three groups. CTO-NR had the greatest association with cardiac death and SCD/SVAs in each coronary artery and in IRA-CTO patients.

CONCLUSIONS

Unsuccessful percutaneous CTO revascularization was associated with lower cardiac survival and freedom from SCD/SVAs, irrespective of the vessel treated. This result was mainly driven by patients with an IRA CTO.

Reattempt Percutaneous Coronary Intervention of Chronic Total Occlusions after Prior Failures: A Single-Center Analysis of Strategies and Outcomes

OBJECTIVE

The initial recanalization rate of coronary chronic total occlusions (CTOs) is >85% when performed by experienced operators, but only 10% of prior failed CTO patients receive reattempted recanalization. This retrospective study analyzed the success rate and strategies used in reattempt percutaneous coronary intervention (PCI) of CTOs after prior failures.

METHODS

Overall, 206 patients with 212 CTOs were enrolled. All patients with prior recanalization failures received reattempt PCIs from January 2015 to March 2019 at Zhongshan Hospital, Fudan University. Data on clinical factors (age, sex, comorbidities, left ventricular ejection fraction, history of cigarette usage, and revascularization), angiographic characteristics of CTOs (target lesion, Japanese Chronic Total Occlusion (J-CTO) score, the morphology of CTO lesions, and collateral channel scale), strategies (procedural approach and use of devices), and major adverse events were obtained and analyzed.

RESULTS

The mean age of enrolled patients was 60.96 ± 12.36 years, with a male predominance of 90.3%. Of the patients, 47.1% had a prior myocardial infarction and 70.4% underwent stent implantation previously, while the in-stent occlusion rate was 6.6%. CTOs were primarily localized in the left anterior descending artery (43.9%) and the right coronary artery (43.9%). 80.7% of lesions were classified as very difficult (J-CTO score ≥3), and the overall success rate was 81.1%. In multivariable regression analysis, J-CTO score, collateral channel scale, application of coronary multispiral computed tomography angiography, dual injection, intravascular ultrasound, active greeting technique, parallel wiring, and CTO morphology were predictors of recanalization success. There were no significant differences in rates of procedural complications between the final recanalization success and failure groups.

CONCLUSIONS

Recanalization of complex CTOs is associated with high success rate and low complication rates when performed by high-volume CTO operators and after multiple reattempts.

Comparison of Clinical Outcomes Between Second-and First-Generation Drug-Eluting Stents in Patients With Chronic Total Occlusion Lesion: A Meta-Analysis

Background and Objectives: The second-generation drug-eluting stents have been used to treat chronic total occlusion lesion. However, there is limited evidence of the clinical outcomes that whether the second-generation drug-eluting stents is superior to first-generation ones in patients with chronic total occlusion lesion undergoing percutaneous coronary intervention. The study aimed to compare the differences in clinical outcomes between the two generations drug-eluting stents in patients with those by a meta-analysis.

Methods: PubMed, Embase, the Cochrane library and Web of science databases were systemically searched before March, 2021. Randomized controlled trials and observational studies were included to compare the second-generation drug-eluting stents with the first-generation ones in patients with chronic total occlusion lesion undergoing percutaneous coronary intervention. The clinical outcomes were major adverse cardiac events (MACE), target vessel revascularization, myocardial infarction, all-cause death. Fixed effects models were used to calculate the odds ratio (OR) and 95% confidence interval (CI) of each clinical outcome. Sensitivity analysis was performed to detect potential sources of heterogeneity. Subgroup analyses were used to assess the differential effects.

Results: The meta-analysis included eight studies involving 4,583 patients with chronic total occlusion lesion undergoing percutaneous coronary intervention. Pooled analysis showed that the incidence of MACE (OR = 0.68, 95%CI 0.54–0.85, P = 0.0008), target vessel revascularization (OR = 0.70, 95%CI 0.54–0.91, P = 0.007), and myocardial infarction (OR = 0.58, 95%CI 0.37–0.93, P = 0.02) were lower in the second-generation drug-eluting stents compared with the first-generation ones. However, there was not difference in all-cause deaths between two drug-eluting stents (OR = 0.67, 95%CI 0.45–1.01, P = 0.05).

Conclusions: The second-generation drug-eluting stents are associated with lower MACE, target vessel revascularization, and myocardial infarction compared with the first-generation ones in patients with chronic total occlusion lesion undergoing percutaneous coronary intervention. The results of this study can provide a reference for the selection of stents in patients with chronic total occlusion lesion. Further randomized controlled trials are needed to verify that the second-generation drug-eluting stents is superior to the first-generation ones in patients with chronic total occlusion (Registered by PROSPERO, CRD42020158406).

Impact of chronic total occlusion lesions on clinical outcomes in patients receiving rotational atherectomy: results from the ROCK registry

The aim of this study was to investigate the impact of chronic total occlusion (CTO) on clinical outcomes in patients with calcified coronary lesions receiving rotational atherectomy (RA). This multi-center registry enrolled consecutive patients with calcified coronary artery disease who underwent RA during percutaneous coronary intervention (PCI) from 9 tertiary centers in Korea between January 2010 and October 2019. The primary outcome was target-vessel failure (TVF) which included the composite of cardiac death, target-vessel myocardial infarction (TVMI), and target-vessel revascularization (TVR). A total of 583 lesions were enrolled in this registry and classified as CTO (n = 42 lesions, 7.2%) and non-CTO (n = 541 lesions, 92.8%). The CTO group consisted of younger patients who were more likely to have a history of previous percutaneous coronary intervention or coronary artery bypass graft surgery. The incidence of the primary outcome was 14.1% and 16.7% for the non-CTO group and CTO group, respectively. The primary outcomes observed in the two groups were not significantly different (log-rank p = 0.736). The 18-month clinical outcomes of the CTO group were comparable to those of the non-CTO group in multivariate analysis. About 7% of patients requiring RA have CTO lesions and these patients experience similar clinical outcomes compared with those having non-CTO lesions. Use of RA for CTO lesions was safe despite higher procedural complexity.

A clinical study on the effect of open chronic total occlusion on hemodynamics of collateral circulation donor

OBJECTIVE

This study applied pressure measurement to measure the hemodynamic changes in right coronary artery (RCA) donor vessels before and after the opening of the vessel in patients with left anterior descending chronic total occlusion (LAD-CTO) interventional therapy.

METHODS

A total of 45 patients with LAD-CTO were divided into two groups of percutaneous coronary intervention (PCI) to observe the hemodynamic changes (fractional flow reserve [FFR] and instantaneous wave-free ratio [iFR]) before and after opening the chronic total occlusion (CTO), in order to provide collateral circulating donor vessels to the CTO, and observe the changes in iFR and FFR. The results of these two measures were compared to determine the significance of the donor vascular function.

RESULTS

A total of 45 patients with LAD-CTO successfully underwent LAD-CTO interventional therapy, and were immediately measured for FFR and iFR of the donor vessels. The FFR changes before right coronary artery flow reserve (RCAFR) was 0.73±0.083, and after the operation, this was 0.77±0.073. The iFR changes before RCAFR was 0.90±0.048, and after the operation, this was 0.93±0.034. Before and after the opening of the RCA, the FFR change (ΔFFR) and iFR change (ΔiFR) were also correlated with r = 0.033 (0.041-0.568: P < 0.05). A total of 19 cases had a FFR value of <0.75 before the operation, and the average FFR before and after the PCI was 0.65±0.048 and 0.72±0.057, respectively. Furthermore, the ΔFFR was 0.076±0.057 (n = 19), and FFR was >0.75 in 26 cases. The ΔFFR was 0.017±0.0088 (n = 26). These two groups were compared, P = 0.0032 (P < 0.05).

CONCLUSION

The FFR and iFR results were the same in terms of RCA hemodynamic changes, after the LAD-CTO was opened. For the RCA with a preoperative FFR of <0.75, the increase in RCAFR after LAD-CTO PCI was more obvious.

Mortality 10 Years After Percutaneous or Surgical Revascularization in Patients With Total Coronary Artery Occlusions

BACKGROUND

The long-term clinical benefit after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with total occlusions (TOs) and complex coronary artery disease has not yet been clarified.

OBJECTIVES

The objective of this analysis was to assess 10-year all-cause mortality in patients with TOs undergoing PCI or CABG.

METHODS

This is a subanalysis of patients with at least 1 TO in the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which investigated 10-year all-cause mortality in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial, beyond its original 5-year follow-up. Patients with TOs were further stratified according to the status of TO recanalization or revascularization.

RESULTS

Of 1,800 randomized patients to the PCI or CABG arm, 460 patients had at least 1 lesion of TO. In patients with TOs, the status of TO recanalization or revascularization was not associated with 10-year all-cause mortality, irrespective of the assigned treatment (PCI arm: 29.9% vs. 29.4%; adjusted hazard ratio [HR]: 0.992; 95% confidence interval [CI]: 0.474 to 2.075; p = 0.982; and CABG arm: 28.0% vs. 21.4%; adjusted HR: 0.656; 95% CI: 0.281 to 1.533; p = 0.330). When TOs existed in left main and/or left anterior descending artery, the status of TO recanalization or revascularization did not have an impact on the mortality (34.5% vs. 26.9%; adjusted HR: 0.896; 95% CI: 0.314 to 2.555; p = 0.837).

CONCLUSIONS

At 10-year follow-up, the status of TO recanalization or revascularization did not affect mortality, irrespective of the assigned treatment and location of TOs. The present study might support contemporary practice among high-volume chronic TO-PCI centers where recanalization is primarily offered to patients for the management of angina refractory to medical therapy when myocardial viability is confirmed. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).

Two-year left ventricular systolic function of percutaneous coronary intervention vs optimal medical therapy for patients with single coronary chronic total occlusion

In this study, two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (RT-3DE) were applied to compare the changes of left ventricular systolic function associated with percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with single chronic total occlusion (CTO). 63 single CTO patients (age 61.88 ± 8.86 years) were examined by echocardiography and were divided into the PCI group (n = 27) and OMT group (n = 36) according to the initial treatment strategy. Two-dimensional left ventricular ejection fraction (2D-LVEF), two-dimensional indexed left ventricular end-systolic volume (2D-LVESVI), and two-dimensional indexed left ventricular end-diastolic volume (2D-LVEDVI) were measured using two-dimensional echocardiography (2DE). Three-dimensional left ventricular ejection fraction (3D-LVEF), three-dimensional indexed left ventricular end-systolic volume (3D-LVESVI), and three-dimensional indexed left ventricular end-diastolic volume (3D-LVEDVI) were measured using RT-3DE. Global circumferential strain (GCS) and global longitudinal strain (GLS) were measured using 2D-STE. After 2 years of follow-up, there were no significant differences in the 2D-LVEF, 2D-LVESVI, 3D-LVEF, 3D-LVESVI, 3D-LVEDVI, and GCS, except for GLS (P = .001) between the CTO-PCI and CTO-OMT groups. GLS decreased significantly in OMT group (P = .016) in contrast with PCI group in which GLS increased significantly (P = .007). Left ventricular systolic function assessment using 2D-STE showed a significant difference in GLS between CTO-PCI and CTO-OMT. And the patients who chose PCI revascularization at the 2-year follow-up had better left ventricular systolic function improvement than those who were conservatively treated with OMT.

Chronic total occlusion percutaneous coronary intervention: managing perforation complications

INTRODUCTION

Coronary artery perforation (CAP) is an infrequent (<1%) complication of percutaneous coronary intervention (PCI), that can lead to dramatic consequences, including tamponade and death. The incidence of CAP is higher (4-9%) in chronic total occlusion (CTO) PCI due higher complexity of these lesions and the techniques used to recanalized them.

AREAS COVERED

In this Expert Review, we discuss the specific features of CTO PCI predisposing to CAP. We also describe the typical procedural scenarios in which CAP can occur and provide a universal management algorithm. Currently available devices and techniques for CAP treatment are presented in detail. Finally, we discuss imaging support for diagnosis of pericardial effusion in CAP as well as medical and surgical management.

EXPERT OPINION

With increasing volumes and complexity of CTO PCI, the incidence of CAP is likely to rise. Adherence to good catheterization laboratory practices, availability of dedicated equipment to seal CAP, perform pericardiocentesis, and provide hemodynamic support, as well as adequate training, are pillars for the prevention and optimal management of CAP during CTO PCI.

Management of Chronic Total Occlusion of Coronary Artery

Chronic total occlusion (CTO) of a coronary artery is typically defined as a completely occluded artery without any antegrade flow and a duration of at least 3 months. We reviewed the current literature describing the optimal management of CTO including the role of revascularization and choice of modality, i.e., percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery. Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL) were searched and relevant studies of patients with CTO were selected for review. The prevalence of coronary artery CTOs is approximately 25% among patients undergoing coronary angiography for angina. Available data suggests that PCI of CTO can be a technically complex procedure with relatively lower success rates compared with non-CTO PCI and typically associated with a higher complication rate especially at nonspecialized centers. Furthermore, successful CTO-PCI is associated with symptomatic improvement but does not appear to improve mortality, myocardial infarction, stroke, and repeat revascularization rates. Based on contemporary data, PCI of CTO lesions may be considered in patients with incapacitating angina despite treatment with optimal guideline-directed medical therapy and in whom based on coronary anatomy there is a reasonable chance of technical success with an acceptable risk.

Incidence and outcomes of chronic total occlusion percutaneous coronary intervention in the Netherlands: data from a nationwide registry

Background

Patients with chronic total coronary occlusions (CTO) are at increased risk for poor clinical outcomes. We aimed to determine the incidence of CTO percutaneous coronary intervention (PCI) and to identify CTO patients at risk for cardiac events in the nationwide Netherlands Heart Registration (NHR).

Methods

We included all PCI procedures with ≥1 CTO registered in the NHR from January 2015 to December 2018, excluding acute interventions. We used multivariable logistic regression of baseline characteristics to calculate the risk for events as odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the PCIs performed during the study period, 6.3% (8,343/133,042) were for CTOs, with the percentage increasing significantly over time from 5.9% in 2015 to 6.6% in 2018 (p < 0.001). Coronary artery bypass grafting <24 h was carried out in 0.3%, and the only significant predictor was diabetes mellitus (OR 2.97, 95% CI 1.04–8.49, p = 0.042). Myocardial infarction (MI) <30 days occurred in 0.5%, and renal insufficiency (i.e. estimated glomerular filtration rate <30 ml/min per 1.73 m²) was identified as an independent predictor (OR 4.70, 95% CI 1.07–20.61, p = 0.040). Among patients undergoing CTO-PCI, 1‑year mortality was 3.7%, and independent predictors included renal insufficiency (OR 5.59, 95% CI 3.25–9.59, p < 0.001), left ventricular ejection fraction <30% (OR 3.43, 95% CI 2.00–5.90, p < 0.001), previous MI (OR 1.62, 95% CI 1.14–2.31, p = 0.007) and age (OR 1.06 per year increment, 95% CI 1.04–1.07, p < 0.001). Target-vessel revascularisation <1 year occurred in 11.3%.

Conclusion

CTO-PCI is still infrequently performed in the Netherlands. The most important predictor of mortality after CTO-PCI was renal insufficiency. Identification of patients at risk may help improve the prognosis of CTO patients in the future.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01521-y) contains supplementary material, which is available to authorized users.

Technical Feasibility and Safety of Percutaneous Coronary Intervention for True Ostial Left Anterior Descending Artery-Chronic Total Occlusion

BACKGROUND

Percutaneous coronary intervention (PCI) for true ostial left anterior descending artery (LAD)-chronic total occlusion (CTO) lesions poses technical challenges owing to its inherent anatomic features.

METHODS

In total, 270 consecutive patients who underwent PCI for ostial LAD-CTO at 13 major cardiac centers in South Korea were included. Ostial LAD-CTO was strictly defined as a LAD-CTO lesion whose proximal cap was within 1 mm from the carina of the distal left main coronary artery (LMCA) bifurcation.

RESULTS

Ostial LAD-CTOs were frequently accompanied by stumpless lesion entry (43.4%), whereas significant bending within the occluded segment was less frequent (14.4%). The overall technical success rate was 85.9%, and serious in-hospital adverse events occurred in 5.6%. The retrograde approach tended to contribute more frequently to success in patients with concomitant LMCA disease, stumpless CTO, interventional collaterals, and higher Japanese-CTO scores. Apparent dissection or hematoma requiring rescue procedure at the LMCA or left circumflex artery occurred in 14 patients (5.2%), with a higher tendency in patients who had LMCA disease (12.1% vs 4.2%) and stumpless entry (9.4% vs 2.0%) than in those without. Among patients who were successfully treated, with an average of 1.7 stents, target-vessel failure occurred in 23 patients (9.9%) during a median 3.3 years of follow-up.

CONCLUSIONS

In this first large-scale analysis of true ostial LAD-CTO, PCI was feasible with a high technical success rate and favourable mid-term outcomes. Clinically relevant inflow vessel injury can occur during PCI and should be an important technical consideration regarding safety.

Procedural and In-hospital Outcomes of Rotational Atherectomy in Retrograde Coronary Chronic Total Occlusion Intervention

Coronary chronic total occlusions (CTOs) are characterized by a high incidence of severe plaque calcifications, which are associated with a high use of the retrograde approach and a low success rate of percutaneous coronary intervention (PCI). However, the feasibility of rotational atherectomy (RA) in retrograde CTO-PCI remains unknown. The aim of the present study is to examine the safety and efficacy of RA in retrograde CTO-PCI. Consecutive patients (n = 129) who underwent RA during CTO-PCI were categorized into anterograde and retrograde groups according to the CTO crossing approach. The distributions of the baseline characteristics were similar in the 2 groups, but the lesion type was more complex (P = .001), and the starting burr size was smaller (P = .003) in the retrograde group than in the anterograde group. There was a trend of a higher incidence of procedural complications in the retrograde group than in the anterograde group (P = .054). Technical and procedural success and in-hospital outcomes were not significantly different between the 2 groups. In conclusion, RA was feasible in retrograde CTO PCI, but some specific precautions are required before and during the procedure. In addition, further investigation of the long-term outcomes of RA in retrograde CTO PCI is necessary.