Recanalisation of coronary chronic total occlusions

Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning. The contemporary procedural success rate is 80-90% with a reduction in complications. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. Despite this evidence, CTO recanalisation is grossly underutilised. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology.

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).

Five-year clinical outcomes of zotarolimus-eluting stents in coronary total occlusions

AIMS

Reports of long-term outcomes of patients treated with drug-eluting stents in total coronary occlusions are limited. We analysed clinical outcomes of patients treated with the zotarolimus-eluting Resolute stent (R-ZES) implanted in coronary total occlusions versus non-occluded lesions.

METHODS AND RESULTS

Patients treated with R-ZES and included in four trials (RESOLUTE All Comers, RESOLUTE International, RESOLUTE China RCT, and RESOLUTE China Registry) were pooled and divided into three groups - patients with chronic total occlusions (CTO), patients with total occlusions that had occurred recently (rec-TO), and patients without total occlusions (non-TO). Clinical outcomes at five years were analysed. Of 5,487 patients treated with R-ZES in these trials, 8.0% had CTOs, 8.5% rec-TOs and 83.5% non-TOs. Patients had a mean age of 62.8 years, approximately 25% were female and 30% were diabetics. TLF was similar in the three groups at five years (TLF was 13.2%, 12.5% and 13.3% in the CTO, rec-TO and non-TO groups, respectively, p=0.96). Stent thrombosis tended to occur more frequently for rec-TO compared to CTO and non-TO patients (2.6% vs 1.2% and 1.3%, respectively, p=0.11).

CONCLUSIONS

In this large population of patients who had R-ZES implanted, five-year clinical outcomes were similar whether or not the stents were implanted in total occlusions.

Long-term safety of bioresorbable scaffolds: insights from a network meta-analysis including 91 trials

AIMS

The aim of this study was to investigate the long-term safety and efficacy of biodegradable scaffolds and metallic stents.

METHODS AND RESULTS

We analysed a total of 91 randomised controlled trials with a mean follow-up of 3.7 years in 105,842 patients which compared two or more coronary metallic stents or biodegradable scaffolds and reported the long-term clinical outcomes (≥2 years). Network meta-analysis showed that patients treated with the Absorb bioresorbable vascular scaffold (BVS) had a significantly higher risk of definite or probable scaffold thrombosis (ScT) compared to those treated with metallic DES. The risk of very late ScT was highest with the Absorb BVS among comparators. Pairwise conventional meta-analysis demonstrated that the elevated risk of ScT with Absorb BVS compared to cobalt-chromium everolimus-eluting stents was consistent across the time points of ≤30 days (early), 31 days - 1 year (late) and >1 year (very late) ScT. In addition, target lesion failure rates were significantly higher in the Absorb BVS cohort, driven by both increased risk of target vessel myocardial infarction and ischaemia-driven target lesion revascularisation.

CONCLUSIONS

Absorb BVS implantation was associated with increased risk of long-term and very late ScT compared to current-generation metallic DES. The risk of ScT occurred with a rising trend beyond one year.

Management standards for stable coronary artery disease in India

Coronary artery disease (CAD) is one of the important causes of cardiovascular morbidity and mortality globally, giving rise to more than 7 million deaths annually. An increasing burden of CAD in India is a major cause of concern with angina being the leading manifestation. Stable coronary artery disease (SCAD) is characterised by episodes of transient central chest pain (angina pectoris), often triggered by exercise, emotion or other forms of stress, generally triggered by a reversible mismatch between myocardial oxygen demand and supply resulting in myocardial ischemia or hypoxia. A stabilised, frequently asymptomatic phase following an acute coronary syndrome (ACS) is also classified as SCAD. This definition of SCAD also encompasses vasospastic and microvascular angina under the common umbrella.

Primary Stenting of Totally Occluded Native Coronary Arteries III (PRISON III): a randomised comparison of sirolimus-eluting stent implantation with zotarolimus-eluting stent implantation for the treatment of total coronary occlusions

AIMS

We investigated whether sirolimus-eluting stents (SES) are superior to next-generation zotarolimus-eluting stents (ZES) in treating patients with total coronary occlusions (TCO).

METHODS AND RESULTS

In a prospective, randomised trial we compared the SES with the zotarolimus-eluting stent (ZES; Endeavor or Resolute) after successful recanalisation of TCO. During the first phase of the trial, 51 patients were assigned to receive the SES and 46 patients to receive the Endeavor ZES. In the second phase we randomised 103 patients to the SES group and 104 patients to the Resolute ZES group. The primary endpoint was in-segment late lumen loss at eight-month follow-up. At eight months, patients in the SES group had less in-segment and in-stent late loss as compared to the Endeavor group: -0.13±0.3 mm vs. 0.27±0.6 mm (p=0.0002) and -0.13±0.5 mm vs. 0.54±0.5 mm (p<0.0001), respectively. In contrast, the SES and the Resolute ZES showed comparable amounts of in-segment (-0.03±0.7 mm vs. -0.10±0.7 mm, p=0.6) and in-stent (0.03±0.8 mm vs. 0.05±0.8 mm, p=0.9) late loss.

CONCLUSIONS

In the treatment of TCOs, the SES was associated with superior angiographic outcomes compared to the Endeavor ZES. On the other hand, the SES and the Resolute ZES showed comparable angiographic outcomes.

WITHDRAWN: Drug-eluting stents versus bare metal stents for angina or acute coronary syndromes

This review 'topic' has been included in work being carried out as part of a Health Technology Assessment commissioned by the National Institute for Clinical Excellence in England and Wales. Details of this research is available via www.nice.org.uk.

The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HTA programme, NICE, NIHR, NHS or the Department of Health.

The review has been split into 2 reviews that will be published as "Drug‐eluting stents versus bare‐metal stents for stable ischaemic heart disease" and "Drug‐eluting stents versus bare‐metal stents for acute coronary syndrome".

The editorial group responsible for this previously published document have withdrawn it from publication.

The evidence base for revascularisation of chronic total occlusions

When patients with ischaemic heart disease are considered for revascularisation the Heart Team's aim is to choose a therapy that will provide complete relief of angina for an acceptable procedural risk. Complete functional revascularisation of ischaemic myocardium is thus the goal and for this reason the presence of a chronic total occlusion (CTO) - which remain the most technically challenging lesions to revascularise percutaneously - is the most common reason for selecting coronary artery bypass surgery. From the behaviour of Heart Teams it is clear that physicians believe that CTOs are important. Yet when faced with patients with CTOs for whom surgery appears excessive (e.g. nonproximal LAD) or too high risk, there remains a reluctance to undertake CTO PCI, despite significant recent advances in procedural success and safety and a considerable body of evidence supporting a survival benefit following successful CTO PCI. This article reviews the relationship between CTOs, symptoms of angina, ischaemia and left ventricular dysfunction and further explores the evidence relating their treatment to improved quality of life and prognosis in patients with these features.

Drug-eluting stent thrombosis in the treatment of chronic total coronary occlusions: incidence, presentation and related factors. Data from the CIBELES trial

INTRODUCTION AND OBJECTIVES

The aim of this study was to analyze the incidence of drug-eluting stent thrombosis (sirolimus or everolimus) in patients with chronic total coronary occlusions (CTO) and to determine its clinical implications and related factors.

METHODS

Data from the 12-month follow-up of the 207 patients included in the CIBELES trial with CTO were analyzed.

RESULTS

Stent thrombosis occurred in three patients, two definite and one probable (overall thrombosis rate: 1.4%). However, there were no cases of death or Q-wave myocardial infarction. In univariate analysis, patients with a higher incidence of stent thrombosis were those in whom the target vessel was the left anterior descending, who had single-vessel disease, were assigned to treatment with sirolimus-eluting stents, and those with smaller minimum luminal diameter immediately after the procedure. In multivariate analysis, the only independent predictor of stent thrombosis was minimal luminal diameter immediately after the procedure.

CONCLUSIONS

The rate of drug-eluting stent thrombosis in patients with CTO is relatively low (1.4%). The only independent predictor of stent thrombosis in this context was minimal luminal diameter after the procedure and the clinical presentation was in all cases relatively benign.

Chronic total occlusions - Current techniques and future directions

Chronic total occlusions (CTOs) of coronary arteries represent a common and significant challenge to interventional cardiology. Medical therapy is often regarded as an adequate long term strategy in the management of these lesions with surgical intervention for refractory symptoms. Extensive collateralisation is used as a marker of distal coronary perfusion, further reinforcing non-invasive strategies. This together with relatively low percutaneous success rates outside of specialised centres has meant that rates of percutaneous intervention have remained low. Increasing evidence suggests that CTOs are not a benign entity. Further, symptom control and quality of life improve significantly with successful percutaneous revascularisation. Both factors have reignited interest in percutaneous modalities. The Japanese have been pioneers in the field of CTO intervention although their success rates have been difficult to replicate. New techniques and equipment developed in North America offer an alternative to the Japanese approach. These techniques focus on time, radiation and contrast minimisation. This review will assess the histopathology of CTO and shifting paradigms in CTO treatment strategies.

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Chronic total occlusions are common and prognostically important.

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Strategies for chronic occlusions are pioneered by Japanese, adapted by North American operators.

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Japanese and North American strategies appear divergent, both add considerable expertise.

Late catch-up in lumen diameter at five-year angiography in MACE-free patients treated with sirolimus-eluting stents in the Primary Stenting of Totally Occluded Native Coronary Arteries: a randomised comparison of bare metal stent implantation with sirolimus-eluting stent implantation for the treatment of total coronary occlusions (PRISON II)

AIMS

The present study was designed to examine the five-year angiographic follow-up of MACE-free patients enrolled in the PRISON II study.

METHODS AND RESULTS

In the PRISON II study a total of 200 patients were randomised to either bare metal stents (BMS) or sirolimus-eluting stents (SES) after successful recanalisation of total coronary occlusions (TCO). Patients free of MACE with available angiography at six months were approached for repeated angiography at five years. The primary endpoint was in-stent very late luminal loss (VLLL) at five years. The secondary endpoint was additional late luminal loss (ALLL) between six months and five years. At five years, repeated angiography was performed in 72 patients, 50/82 (61%) in the SES group and 22/58 (38%) in the BMS group. In-stent VLLL was lower in the SES group (0.19 mm ± 0.72 vs. 0.51 mm ± 0.71, p=0.09) compared to the BMS group and in-segment VLLL was comparable in both groups (0.01 mm±0.58 vs. 0.03 mm ± 0.73, p=0.89). Late catch-up in lumen diameter was observed in the SES group with a trend towards increased ALLL compared to the BMS group (in-stent, 0.35 mm ± 0.88 vs. 0.04 mm ± 0.81, p=0.16; in-segment, 0.20 mm ± 0.74 vs. -0.05 mm ± 0.73, p=0.19).

CONCLUSIONS

At five-year angiographic follow-up, late catch-up was observed after successful recanalisation of TCOs treated with SES. Despite a late catch-up, the angiographic results of SES were superior in-stent and similar in-segment compared to BMS.

Advances in the management of coronary chronic total occlusions

Chronic total occlusions (CTOs) have been called "the last frontier" of percutaneous coronary intervention (PCI) due to traditionally low success rates and high risk for restenosis and re-occlusion. Recent advances in equipment and crossing techniques have significantly increased CTO PCI success rates while maintaining low risk of complications. Specifically, the retrograde approach and controlled antegrade dissection and re-entry in conjunction with advanced guidewires and microcatheters have significantly improved procedural success rates. Moreover, the introduction of the "hybrid" approach has created a unified framework for operators to approach CTOs in a systematic and efficient fashion. Finally, drug-eluting stents, especially second generation, have improved long-term patency after CTO PCI.

Techniques and material used in the percutaneous treatment of chronic coronary occlusions. Data from the CIBELES study

INTRODUCTION

In recent years, various specific techniques and materials have been developed for the treatment of coronary chronic total occlusions (CTO).

OBJECTIVE

To evaluate the current situation in the treatment of CTO (techniques and material) in our setting.

METHODS

We evaluated data on techniques and material used in the CIBELES (ChronIc coronary occlusion treated By EveroLimus Eluting Stent) trial, a randomized comparison of sirolimus- and everolimus-eluting stents in 207 patients with CTO in 13 centers in Spain and Portugal.

RESULTS

A radial approach was used in 23% of patients, and retrograde techniques were used in only 5%. A high number of balloons were used (2.2±0.9 per patient). Microcatheters were used in 33% of patients, and post-dilatation balloons in only 25%. The mean number of stents implanted per patient was 2.1±1.0, with a mean total stent length of 49±24 mm. Other devices and techniques used were: Tornus penetration catheter in 4% of patients, rotational atherectomy in 2%, and cutting balloon in 1%. Intracoronary ultrasound was used in only 6% of patients. In 34% of cases, operators used guidewires that were not specifically for CTO. Considerable variability between centers was detected in the use of different techniques, the highest and lowest variability being observed in the use of intracoronary ultrasound and the use of CTO guidewires, respectively.

CONCLUSIONS

In the CIBELES trial, techniques and devices specifically designed for the treatment of CTO were used in a relatively low proportion of patients. Considerable variability between centers was detected.

Randomized comparison of sirolimus-eluting and everolimus-eluting coronary stents in the treatment of total coronary occlusions: results from the chronic coronary occlusion treated by everolimus-eluting stent randomized trial

BACKGROUND

Patients with coronary total occlusions are at especially high risk for restenosis and new revascularizations. Sirolimus-eluting stents dramatically improved the clinical outcome of this subset of patients in randomized trials, but other drug-eluting stents, mainly the everolimus-eluting stent (currently the most frequently used stent), have not yet been evaluated in patients with coronary total occlusions. The objective was to compare the second-generation everolimus-eluting stent with the first-generation sirolimus-eluting stent in patients with coronary total occlusions.

METHODS AND RESULTS

A total of 207 patients with coronary total occlusions and estimated time since occlusion >2 weeks were randomized to everolimus- or sirolimus-eluting stent. The primary end point was in-stent late loss at 9-month angiographic follow-up (noninferiority trial). Clinical follow-up was performed at 1 and 12 months. In-stent late loss at 9 months was 0.29±0.60 versus 0.13±0.69 mm in patients allocated to sirolimus- and everolimus-eluting stent, respectively. The observed difference in in-stent late loss between both groups was -0.16 mm (95% confidence interval, 0.04 to -0.36 mm; P for noninferiority <0.01). The rate of binary angiographic restenosis was 10.8% and 9.1% in patients allocated to sirolimus- and everolimus-eluting stent, respectively (P=0.709), whereas the rate of vessel reocclusion was 3.2% and 1.1%, respectively (P=0.339). At 12 months, the rate of major adverse events was 15.9% versus 11.1% with sirolimus- and everolimus-eluting stent, respectively (P=0.335), and probable or definitive stent thrombosis occurred in 3.0% and 0.0% of patients, respectively (P=0.075).

CONCLUSIONS

In patients with coronary total occlusions, everolimus-eluting stent is as effective as sirolimus-eluting stent.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00793221.

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

Although interventional technology and skills have markedly advanced, percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) lesions remains challenging. Indeed, CTO PCI is technically complex, carries the potential for a relatively high likelihood of failure and acute complications, and requires specifically skilled operators and a demanding use of resources. In addition, controversy persists surrounding appropriate indications for attempting CTO revascularization. Finally, there is a wide uncertainty on the actual benefits achieved with successful CTO recanalization. A growing number of studies have reported procedural results and/or assessed functional effects and long-term clinical outcomes of CTO PCI. We therefore sought to review and critically appraise the evidence base for procedural outcomes and potential clinical benefits of CTO PCI.

Coronary stent thrombosis: current insights into new drug-eluting stent designs

The advances of interventional cardiology have been achieved by new device development, finding appropriate drug regimes, and understanding of pathomechanism. Drug-eluting stents (DES) implantation with dual anti-platelet therapy reduced revascularization without increasing mortality or myocardial infarction compared with bare-metal stenting. However, late-term stent thrombosis (ST) and restenosis limited its value and raised the safety concern. Main mechanisms of this phenomenon are impaired endothelialization and hypersensitivity reaction with polymer. The second generation DES further improved safety and/or efficacy by using thinner stent strut and biocompatible polymer. Recently, new concept DES with biodegradable polymer, polymer-free and bioabsorbable scaffold are under investigation in the quest to minimize the risk of ST.

Paclitaxel-coated balloon with bare-metal stenting in patients with chronic total occlusions in native coronary arteries

OBJECTIVES

We sought to evaluate the efficacy and safety of paclitaxel-coated balloon plus bare-metal stenting (BMS) in chronic total occlusions (CTOs).

BACKGROUND

Drug-eluting stent implantation after recanalization of CTOs is limited by the occurrence of restenosis and risk for late stent thromboses.

METHODS

In this prospective, bicenter trial we treated 48 patients after successful chronic total occlusion (CTO) recanalization in a native coronary artery with paclitaxel-coated balloon plus BMS. Patients were matched according to stent length, reference diameter, and diabetes mellitus with 48 patients treated with Taxus stent implantation. Dual antiplatelet therapy was prescribed for 6 months. Angiographic (clinical) follow-up was obtained after 6 (12) months. Primary endpoint was in-stent late lumen loss.

RESULTS

There was no difference in patient baseline characteristics or procedural results. Stent length was 59.7 ± 32.4 mm (16-151 mm) for paclitaxel-coated balloon plus BMS versus 56.2 ± 25.9 mm (16-132 mm) for Taxus stent. Late loss was statistically not different within the stent with 0.64 ± 0.69 mm versus 0.43 ± 0.64 mm (difference 0.20 mm, 95% confidence interval -0.07 to 0.47, P = 0.14) and at the occlusion site with 0.33 ± 0.69 mm versus 0.26 ± 0.70 mm, respectively. Restenosis rate was 27.7% compared with 20.8% (P = 0.44) and the combined clinical endpoint (cardiac death, myocardial infarction attributed to the target vessel, target lesion revascularization) was 14.6% versus 18.8% (P = 0.58), respectively.

CONCLUSIONS

In conclusion, for patients with complex CTOs in native coronary arteries the use of paclitaxel-coated balloon after bare-metal stenting was associated with similar clinical results and a nonsignificantly higher in-stent late loss compared with a matched population with paclitaxel-eluting stent implantation.

Chronic total occlusions: successful recanalization of very old lesions

PURPOSE

The treatment of chronic total occlusion is thought to be the final frontier in treating coronary artery disease nonsurgically. In the past, an old occlusion was not likely to be treated successfully percutaneous. We have had success in revascularizing some very old 20 plus year old occlusions percutaneously.

METHODS

Six patients were treated who had >20-year-old occlusions. Five patients were male; mean age of patients was 72.2 years (range 63-86). Mean age of the occlusion was 24.8 years. All patients had ischemia in the corresponding territory. Four of the patients had right coronary artery occlusions; one had a left circumflex occlusion and one had left anterior descending artery occlusion.

RESULTS

Using a combination of radial and/or femoral approach, we successfully recanalized all of these old occlusions. No patients had major adverse cardiac events. Two patients developed restenosis at follow-up that was subsequently treated uneventfully. All the patients had a complete relief of angina.

CONCLUSION

In a small single center experience, even very old occlusions >20-year old can be effectively treated with dedicated systems, excellent guiding catheter support and experienced physicians.

Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: a mixed-treatment comparison analysis of 117 762 patient-years of follow-up from randomized trials

BACKGROUND

Drug-eluting stents (DES) have been in clinical use for nearly a decade; however, the relative short- and long-term efficacy and safety of DES compared with bare-metal stents (BMS) and among the DES types are less well defined.

METHODS AND RESULTS

PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials, until March 2012, that compared any of the Food and Drug Administration-approved durable stent and polymer DES (sirolimus-eluting stent [SES], paclitaxel-eluting stent [PES], everolimus-eluting stent [EES], zotarolimus-eluting stent [ZES], and ZES-Resolute [ZES-R]) with each other or against BMS for de novo coronary lesions, enrolling at least 100 patients and with follow-up of at least 6 months. Short-term (≤ 1 year) and long-term efficacy (target-vessel revascularization, target-lesion revascularization) and safety (death, myocardial infarction, stent thrombosis) outcomes were evaluated and trial-level data pooled by both mixed-treatment comparison and direct comparison analyses. From 76 randomized clinical trials with 117 762 patient-years of follow-up, compared with BMS, each DES reduced long-term target-vessel revascularization (39%-61%), but the magnitude varied by DES type (EES~SES~ZES-R>PES~ZES>BMS), with a >42% probability that EES had the lowest target-vessel revascularization rate. There was no increase in the risk of any long-term safety outcomes, including stent thrombosis, with any DES (versus BMS). In addition, there was reduction in myocardial infarction (all DES except PES versus BMS) and stent thrombosis (with EES versus BMS: Rate ratio, 0.51; 95% credibility interval, 0.35-0.73). The safest DES appeared to be EES (>86% probability), with reduction in myocardial infarction and stent thrombosis compared with BMS. Short-term outcomes were similar to long-term outcomes, with SES, ZES-R, and everolimus-eluting stent being the most efficacious and EES being the safest stent.

CONCLUSIONS

DES are highly efficacious at reducing the risk of target-vessel revascularization without an increase in any safety outcomes, including stent thrombosis. However, among the DES types, there were considerable differences, such that EES, SES, and ZES-R were the most efficacious and EES was the safest stent.

Midterm Outcomes of Simultaneous Hybrid Coronary Artery Revascularization for Left Main Coronary Artery Disease

<p><b>Background:</b> The purpose of this study was to evaluate the feasibility, safety, and midterm outcomes of a simultaneous hybrid revascularization strategy for left main coronary artery disease (LMCAD), compared with conventional off-pump coronary artery bypass grafting (OPCAB).</p><p><b>Methods:</b> We compared the in-hospital and midterm outcomes of a simultaneous hybrid revascularization strategy (minimally invasive direct coronary bypass grafting of the left anterior descending coronary artery [LAD] and percutaneous intervention to non-LAD lesions) in 20 patients with LMCAD in an enhanced operating room. These patients were matched by propensity score to a group of 20 control patients who underwent standard OPCAB between September 2007 and December 2009.</p><p><b>Results:</b> All baseline clinical characteristics of the 2 groups were similar. All of the patients in the 2 groups underwent surgery uneventfully without conversion to on-pump coronary artery bypass grafting. Compared with OPCAB, the patients in the hybrid group had shorter lengths of stay in the intensive care unit (34.8 � 37.6 hours versus 50.7 � 34.5 hours, <i>P</i> = .01). Transfusion requirements were reduced in the hybrid patients compared with the OPCAB patients (5% versus 40%, <i>P</i> = .01). The 2 groups did not differ with respect to the occurrence of other important morbidities. During the mean (�SD) follow-up of 18.5 � 9.8 months, the group of patients who underwent the simultaneous hybrid procedure experienced an incidence of major adverse cardiac or cerebrovascular events that was similar to that of the OPCAB control group (100% versus 90%, respectively; <i>P</i> = .31).</p><p><b>Conclusions:</b> The midterm follow-up indicated that the simultaneous hybrid revascularization procedure for LMCAD is feasible, safe, and effective. These promising early findings warrant further prospective investigations.</p>

Long-term outcome of percutaneous coronary intervention for chronic total occlusions

OBJECTIVES

The aim of this study was to evaluate long-term clinical outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO).

BACKGROUND

Despite technical advancements, there is a paucity of data on long-term outcomes after PCI of CTO.

METHODS

We evaluated long-term clinical outcomes in 1,791 patients who underwent PCI of 1,852 CTO at 3 tertiary care centers in the United States, South Korea, and Italy between 1998 and 2007. Median follow-up was 2.9 years (interquartile range: 1.5 to 4.6 years).

RESULTS

Procedural success was obtained in 1,226 (68%) patients. Stents were implanted in 1,160 patients (95%); 396 patients (34%) received bare-metal stents (BMS), and 764 patients (66%) received drug-eluting stents (DES). After multivariable analysis, successful CTO PCI was an independent predictor of a lower cardiac mortality (hazard ratio [HR]: 0.40, 95% confidence interval [CI]: 0.21 to 0.75, p < 0.01) and reduced need for coronary artery bypass graft surgery (HR: 0.21, 95% CI: 0.13 to 0.40, p < 0.01); it also correlated with a strong trend toward lower all-cause mortality (HR: 0.63, 95% CI: 0.40 to 1.00, p = 0.05) at 5-year follow-up. Among patients who underwent stent implantation, treatment with DES rather than BMS resulted in less target vessel revascularization at long-term follow-up (17.2% vs. 31.1%, p < 0.01); definite/probable stent thrombosis rates were similar (DES 1.7%, BMS 2.3%, p = 0.58). Within the DES subgroup, patients treated with paclitaxel-eluting stents and sirolimus-eluting stents had similar clinical outcomes.

CONCLUSIONS

Successful CTO PCI is associated with reduced long-term cardiac mortality and need for coronary artery bypass graft surgery. Treatment of CTO with DES rather than BMS is associated with a significant reduction in target vessel revascularization with similar rates of stent thrombosis. Paclitaxel-eluting stents and sirolimus-eluting stents had similar long-term safety and efficacy outcomes.

Everolimus-eluting stents for treatment of chronic total coronary occlusions

BACKGROUND

After successful recanalization of a coronary chronic total occlusion (CTO) the risk for restenosis and subsequent need for repeat intervention is high. Everolimus-eluting stents (EESs) were associated with low rates of restenosis, reintervention and stent thrombosis in non-occluded lesions. We sought to determine the antiproliferative impact of the everolimus-eluting Xience V stent in CTOs.

METHODS

Fifty-three patients with a CTO in a native coronary artery were included. CTO was defined as a duration of occlusion ≥3 months and thrombolysis in myocardial infarction 0 flow. EESs were exclusively implanted to completely cover the occluded and adjacent stenotic segments. Dual antiplatelet therapy was prescribed for 6 months. Follow-up angiography was scheduled at 6 months. Clinical follow-up was done at 12 months. The primary endpoint was late loss at the initial occlusion site. Secondary clinical endpoint was a composite of cardiac death, myocardial infarction not clearly attributable to a non-target vessel and target lesion revascularization.

RESULTS

Mean occlusion length was 24 ± 17 mm, ranging from 4 to 74 mm. Mean stent length was 79 ± 36 mm, ranging from 18 to 158 mm. Reference diameter was 3.27 ± 0.58 mm. Late loss at the initial occlusion site was 0.22 ± 0.69 mm. There were six (11%) binary restenosis with a target lesion reintervention in three (6%) patients. There was no death, myocardial infarction or stent thrombosis within 12 months.

CONCLUSION

In patients with successful recanalization of complex CTOs the use of EESs results in a low angiographic late loss and restenosis rate without stent thrombosis throughout 12 months follow-up.

Drug-eluting coronary stents - focus on improved patient outcomes

The development of stent has been a major advance in the treatment of obstructive coronary artery disease since the introduction of balloon angioplasty. Subsequently, neointimal hyperplasia within the stent leading to in-stent restenosis emerged as a major obstacle in long-term success of percutaneous coronary intervention. Recent introduction of drug-eluting stents is a major breakthrough to tackle this problem. This review article summarizes stent technology, reviews progress of drug-eluting stents and discusses quality of life, patient satisfaction, and acceptability of percutaneous coronary intervention.

[Treatment strategies for chronic total occlusion: current status and outlook]

The present article discusses the current status of treatment strategies for chronic total occlusion (CTO) and the prospects offered by new therapies. The indication for revascularisation recognized in the current European guidelines includes the presence of typical symptoms and evidence of ischemia of over 10% of the total myocardium, while in patients with multiple vascular diseases the aim is complete revascularisation. Although the vast majority of patients with CTO fulfil these criteria, they are currently not receiving interventional treatment as frequently as expected. The reasons often given for this include the low success rates and high recurrence rates. However, both problems have been improved by drug-eluting stents (DES) on the one hand and by wire techniques and strategies on the other, such that results almost comparable with non-occluded coronary lesions can be achieved. While more advanced approaches like retrograde recanalization should be restricted to specialized centres, marked improvements can be achieved even without these special techniques by means of consistent further training and the application of modern techniques. Despite the aggressiveness of these approaches to pass through an occluded artery, the complication rate is not higher than with non-occluded lesions when the specific complications of recanalization are avoided in a careful approach. Further technical improvements are expected with the use of modern imaging techniques such as intravascular ultrasound and high-resolution CT imaging of coronary arteries.