Differences in the Clinical and Angiographic Characteristics of Chronic Total Occlusion Lesions in the Three Major Coronary Arteries

The impacts of percutaneous coronary intervention to treat chronic total occlusion of right coronary artery on the 5-year prognosis: A single-centered retrospective study

BACKGROUND

Chronic total occlusions (CTO) occur in about 20% of patients referred for coronary angiography, and right coronary artery (RCA) CTO has been reported in 38-50% of the entire CTO population. Limited data on angiographic and procedural characteristics of RCA-CTO and the risk of adverse cardiac events asks for a detailed study.

METHODS

From 2010 to 2013, patients with attempted revascularization of at least one CTO lesion were included and followed up to 5 years after PCI. Eligible patients are assigned to RCA-CTO and non-RCA-CTO groups based on their target vessels. The primary endpoint was major adverse cardiovascular events (MACEs; a composite of all-cause death, myocardial infarction (MI) or rehospitalization for heart failure), and secondary endpoints were cardiac death, target lesion revascularization (TLR) and target vessel revascularization (TVR).

RESULTS

The present study included 2659 eligible patients, among which 1285 patients were assigned to the RCA-CTO group, whereas 1374 patients were assigned to the non-RCA-CTO group. Lesions in RCA had longer lesion length, higher J-CTO score, higher rates of severe vessel tortuosity, a higher percentage of Rentrop grade 2-3, and more likely to be re-try lesion than those in LAD or LCX (all P < 0.01). CTO lesions in RCA reached less successful recanalization and post-procedural TIMI 3 flow (all <0.01). Multivariate Cox analysis revealed that RCA-CTO was not associated with primary outcome MACEs. Besides MACEs, RCA-CTO was also not associated with cardiac death, but was significantly associated with TLR and TVR (adjusted HR: 1.37 [95% CI:1.07-1.76], P = 0.01; adjusted HR: 1.43 [95% CI:1.13-1.82], P = 0.003).

CONCLUSION

RCA-CTO lesions, which had more complex angiographic features, independently contributed to TLR and TVR but not to MACEs or cardiac death in the 5 years of follow-up.

Determinants of One-Year Outcome After Successful Percutaneous Coronary Intervention for Chronic Total Occlusion; Insight from Japanese CTO-PCI Expert Registry

Although outcomes have improved with new-generation drug-eluting stents, few reports have analyzed the risk factors associated with chronic outcomes of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). This study aimed to investigate the independent risk factors for target lesion revascularization (TLR) and major adverse cardiac and cerebrovascular events (MACCEs) after CTO-PCI using Japanese multicenter data. A total of 3,666 patients, who underwent CTO-PCI and completed a 1-year follow-up, registered at the Japanese CTO-PCI Expert Registry from 2014 to 2019, were examined. The primary outcome was defined as TLR, and the secondary outcome was MACCEs at the 1-year follow-up. TLRs and MACCEs occurred in 175 (4.8%) and 524 (14.3%) patients, respectively. Multivariate logistic regression analysis demonstrated that in-stent occlusion (ISO) (odds ratio [OR] 2.604, 95% confidence interval [CI] 1.695 to 4.001), hemodialysis (OR 1.784, 95% CI 1.062 to 2.997), diabetes mellitus with insulin use (OR 1.741, 95% CI 1.060 to 2.861), moderate-to-severe calcification (OR 1.726, 95% CI 1.197 to 2.487), and the right coronary artery as the target vessel (OR 1.468, 95% CI 1.018 to 2.117) were significantly associated with TLR. Hemodialysis (OR 2.214, 95% CI 1.574 to 3.113), ISO (OR 1.499, 95% CI 1.127 to 1.993), arteriosclerosis obliterans (OR 1.414, 95% CI 1.074 to 1.863), and multivessel disease (OR 1.356, 95% CI 1.117 to 1.647) were significantly associated with MACCEs. One-year outcomes of new-generation drug-eluting stents for CTO-PCI were favorable, and ISO as a lesion factor and hemodialysis as a patient factor were strongly associated with TLR and MACCEs, respectively.

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.

Angiographic Scoring System for Predicting Successful Percutaneous Coronary Intervention of In-Stent Chronic Total Occlusion

The purpose of this study was to develop a scoring model to predict the technical success of recanalizing via antegrade approach in-stent chronic total occlusion (IS-CTO) by percutaneous coronary intervention (PCI). We retrospectively collected data from 474 patients who underwent an uneasy IS-CTO PCI via antegrade approach from January 2015 to December 2018, consecutively. We selected clinical and angiographic factors and utilized a derivation and validation cohort (4:1 sampling ratio) analysis. Factors with strong correlations with technical failure, according to multivariable analysis, were assigned 1 point, and a scoring system with a 4-point maximum was established. The model was then validated with a validation cohort. The overall procedural success rate was 77.4%. On multivariable analysis, the factors that correlated with technical failure were proximal bending (beta coefficient [β] = 2.142), tortuosity (β = 2.622), stent under expansion (β = 3.052), and poor distal landing zone (β = 2.004). The IS-CTO score demonstrated good calibration and excellent predicting capacity in the derivation (receiver-operator characteristic [ROC] area = 0.973 and Hosmer-Lemeshow chi-squared = 5.252; p = 0.072) and validation (ROC area = 0.976 and Hosmer-Lemeshow chi-squared = 0.916; p = 0.632) cohorts. In the validation subset, the IS-CTO score demonstrated superior performance to the Japanese chronic total occlusion score (J-CTO) and PROGRESS CTO scores for predicting technical success (area under the a curve [AUC] 0.976 vs. 0.642 vs. 0.579, respectively; difference in AUC between the IS-CTO score and J-CTO score = 0.334, p < 0.01; difference in AUC between the IS-CTO score and PROGRESS score = 0.397, p < 0.01). Our results suggest that the IS-CTO score system is a helpful tool to predict the technical success of IS-CTO PCI via antegrade approach in china. Graphical Abstract.

Successful revascularization versus medical therapy in diabetic patients with stable right coronary artery chronic total occlusion: a retrospective cohort study

Background

The territory of the right coronary artery (RCA) is smaller than that of the left anterior descending artery. Previous studies have reported conflicting results when considering whether stable RCA-chronic total occlusion (CTO) should be reopened. The coexistence of diabetic and coronary artery diseases represents a severe situation. Therefore, we aimed to determine if stable RCA-CTO in diabetic patients was necessary to be reopened. To our knowledge, no studies have focused on this topic to date.

Methods

We enrolled diabetic patients with RCA-CTO who had clinical presentations of symptomatic stable angina or silent ischemia. RCA-CTO was treated with either successful revascularization (the CTO-SR group) or medical therapy (the CTO-MT group). The primary endpoint was all-cause death. Both Cox regression and propensity score matching analyses were used. Sensitivity analysis was performed based on subgroup populations and relevant baseline variables.

Results

A total of 943 patients were included: 443 (46.98%) patients in the CTO-MT group and 500 (53.02%) patients in the CTO-SR group. After a mid-term follow-up (CTO-SR: 48 months; CTO-MT: 42 months), we found that CTO-SR was superior to CTO-MT in terms of all-cause death (adjusted hazard ratio [HR] [model 1]: 0.429, 95% conference interval [CI] 0.269–0.682; adjusted HR [model 2]: 0.445, 95% CI 0.278–0.714). The superiority of CTO-SR was consistent for cardiac death, possible/definite cardiac death, repeat revascularization, target vessel revascularization (TVR) and repeat nonfatal myocardial infarction. Subgroup analysis confirmed the mortality benefit of CTO-SR by percutaneous coronary intervention (the successful CTO-PCI subgroup, 309 patients in total). While CTO-SR by coronary artery bypass grafting (the CTO-CABG subgroup, 191 patients in total) offered patients more benefit from repeat revascularization and TVR than that offered by successful CTO-PCI.

Conclusions

For stable RCA-CTO patients with diabetes, successful revascularization offered patients more clinical benefits than medical therapy. CTO-CABG might be a more recommended way to accomplish revascularization.

Trial registration This study was not registered in an open access database

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0911-4) contains supplementary material, which is available to authorized users.

A weighted angiographic scoring model (W-CTO score) to predict success of antegrade wire crossing in chronic total occlusion: analysis from a single centre

AIMS

The aim of this study was to derive a weighted score model predicting success/failure of antegrade wire crossing in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Four hundred and four consecutive CTO cases (408 lesions) undergoing CTO-PCI between January 2009 and March 2015 were included. Data were divided into two sets, namely "derivation" and "validation", in a 70:30 ratio. The score was derived using multivariate analysis to identify independent predictors of wire crossing failure from the derivation set (n=285 lesions) and validated on the remaining 123 lesions (validation set). The overall procedural success rate was 83.6%. Independent predictors of CTO-PCI failure and their contribution to the weighted score were a blunt stump (beta coefficient 2.12), length of occlusion >20 mm (beta coefficient 1.71), presence of calcification (beta coefficient 0.72), presence of tortuosity (beta coefficient 1.06) and collateral with Rentrop grade <2 (beta coefficient 1.06). The respective scores allotted were +2.0, +1.5, +1, +1, +1 (total 6.5), rounding the coefficient to the nearest 0.5. Score values of 0-2, >2-4 and >4 were classified as low, intermediate and high levels of difficulty for CTO-PCI success and were associated with 98%, 74.2%, and 42.5% (p<0.0001), respectively, of antegrade wire crossing success in the derivation set. This was also validated on the validation set with CTO success in the three derived difficulty levels being 100%, 82.4% and 48.4%, respectively.

CONCLUSIONS

Our weighted angiographic CTO score is a strong predictor of final antegrade wire crossing success and could be used in day-to-day clinical practice of CTO interventions.

Lesion characteristics and procedural outcomes of re-attempted percutaneous coronary interventions for chronic total occlusion

This study was performed to investigate lesion characteristics and procedural outcomes of re-attempted percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Prior failure of percutaneous revascularization of CTO has been identified as an independent predictor of failure at subsequent attempts. However, procedural outcomes of re-attempted PCI for CTO have not been elucidated. We evaluated lesion characteristics and procedural outcomes in 310 consecutive patients undergoing CTO-PCI, and compared the results between re-attempted (n = 59) and initial procedures (n = 251). Overall, 266 CTO lesions (85.8%) were treated successfully. In addition, the technical success rate in the re-attempted CTO lesions was 69.5% (41 of 59), although this was lower than for initially attempted lesions (89.6%, 225 of 251; P = 0.0021). In the details of reasons of previous failures, treatment devices failed to cross even after guidewire cross and procedure discontinuation due to management of complications achieved higher rates of technical success compared to those with the inability of guidewire crossing in re-attempted CTO-PCI (87.5 and 85.7 vs. 65.9%, respectively). CTO lesions in which PCI was re-attempted had more complex features, including calcification, tortuous morphology, and long lesion length, whereas patient demographics were similar. Re-attempted CTO lesions required complex procedures, including the retrograde approach (55.9 vs. 13.9%, P < 0.001), longer fluoroscopic time, and larger radiation dose. Meanwhile, rates of complications and in-hospital MACCE were similarly low in both groups. The technical success rates of re-attempted CTO-PCI lesions were acceptable. Furthermore, CTO-PCIs in re-attempted lesions were as safe as initially attempted CTO-PCI. However, re-attempted CTO-PCI lesions showed features of high anatomical complexity that required more complex and longer procedures, including the retrograde approach, for successful interventional revascularization. Re-attempted CTO-PCI due to treatment devices failed to cross even after guidewire cross and procedure discontinuation due to management of complications in previous attempt had higher success rates that those with the inability of guidewire crossing.

Influence about the flow of distal branch after intervention of the right coronary artery chronic total occlusion

OBJECTIVE

Limited data are available for the clinical outcomes after the recanalization of right coronary artery (RCA) chronic total occlusion (CTO). The study aims to assess the clinical outcomes in the antegrade flow of the distal branch after successful RCA CTO percutaneous coronary intervention (PCI).

METHODS

Between January 2002 and December 2012, 538 patients who underwent RCA CTO PCI were enrolled. The clinical outcomes as myocardial infarction (MI), target vessel revascularization, cardiac death, major adverse cardiac events, and all-cause mortality, were compared to the antegrade flow of distal branch after successful RCA CTO PCI.

RESULTS

The CTOs were located in proximal segments (57.6%), mid segments (27.5%) and distal segments (14.9%). The average Syntax score was 18.4±9.6 and 47.8% patients had a Syntax score greater than 27.5. A total of 62.8% patients had final thrombolysis of myocardial infarction (TIMI)-3 flow of distal branch, 16.9% patients had final TIMI-3 flow of only one major branch, 11.3% patients had TIMI-1-2 flow, and 8.9% patients had no antegrade flow. The incidence of periprocedural MI was lower in both side branches were preserved (13.9% vs. 23.0% and 18.8%, p=0.01). The clinical outcomes were similar between the groups with and without good antegrade flow of distal side branch. End stage renal disease (ESRD) and left ventricular ejection fraction (LVEF) <40% predicted three-year cardiac death.

CONCLUSIONS

There is no significant difference of clinical outcomes when distal side branches of RCA are recanalized successfully. ESRD and LVEF <40% were the predictors for three-year cardiac death.