Procedural Success and Outcomes With Increasing Use of Enabling Strategies for Chronic Total Occlusion Intervention

Outcomes After Percutaneous Coronary Intervention in Patients With Previous Coronary Artery Bypass Grafting

In patients with previous coronary artery bypass graft surgery (CABG) requiring subsequent percutaneous coronary intervention (PCI), there is uncertainty whether bypass grafts or native coronary arteries should be targeted. We analyzed data from 2,764 patients with previous CABG in the Melbourne Interventional Group registry (2005 to 2018), divided into 2 groups: those who underwent PCI in a native vessel (n = 1,928) and those with PCI in a graft vessel (n = 836). Patients with a graft vessel PCI were older, had more high-risk clinical characteristics (previous myocardial infarction, heart failure, ejection fraction <50%, renal impairment, peripheral and cerebrovascular disease), and had high-risk procedural features (American College of Cardiology and American Heart Association types B2/C lesions). However, patients in the native vessel group were more likely to have PCI in chronic total occlusions. The majority of graft PCI were in saphenous vein grafts (84%), with 10% to radial and 6% in left/right internal mammary artery grafts. Distal embolic protection devices were used in 30% of graft PCI. Patients with graft PCI had higher rates of no reflow (6.3 vs 1.5%, p <0.001), coronary perforation (p = 0.02), and inpatient stent thrombosis (p = 0.03). However, the 30-day mortality and major adverse cardiovascular and cerebrovascular events were similar. The unadjusted long-term mortality (median follow-up of 4.8 years) was higher in patients who underwent a graft PCI (44 vs 32%, p <0.001); however, after Cox proportional hazards modeling, PCI vessel type was not a predictor of long-term mortality (hazard ratio 1.13, 95% confidence interval 0.96 to 1.33, p = 0.14). In conclusion, early clinical outcomes and risk-adjusted long-term mortality are similar for patients with previous CABG who underwent PCI in a native vessel or a bypass graft.

Chronic total occlusion in non-ST elevation myocardial infarction - A multi-centre observational study

OBJECTIVES

To evaluate the characteristics and outcomes of patients with a chronic total occlusion (CTO) in a Non-ST Elevation Myocardial Infarction (NSTEMI) cohort.

BACKGROUND

There is limited data on the clinical characteristics, revascularisation strategies and outcomes of patients presenting with a NSTEMI and a CTO.

METHODS

Retrospective analysis of a six-centre percutaneous coronary intervention (PCI) registry in the UK between January 2015 and December 2020 was performed. Patients with a NSTEMI with and without a CTO were compared for baseline characteristics and outcomes.

RESULTS

There were 17,355 NSTEMI patients in total of whom 1813 patients had a CTO (10.4 %). Patients with a CTO were more likely to be older (CTO: 67.8 (±11.5) years vs. no CTO: 67.2 (±12) years, p = 0.04), male (CTO: 81.1 % vs.71.9 %, p < 0.0001) with a greater prevalence of cardiovascular risk factors. All-cause mortality at 30 days: HR 2.63, 95 % CI 1.42-4.84, p = 0.002 and at 1 year: HR: 1.87, 95 % CI 1.25-2.81, p = 0.003 was higher in the CTO cohort. CTO patients who underwent revascularisation were younger (Revascularisation 66.4 [±11.7] years vs. no revascularisation 68.4 [±11.4] years, p = 0.001). Patients with failed CTO revascularisation had lower survival (HR 0.21, 95 % CI 0.10-0.42, p < 0.0001). The mean time to revascularisation was 13.4 days. There was variation in attempt at CTO revascularisation between the 6 centres for (16 % to 100 %) with success rates ranging from 65 to 100 %.

CONCLUSIONS

In conclusion, the presence of a CTO in NSTEMI patients undergoing PCI was associated with worse in-hospital and long-term outcomes.

Impact of successful antegrade and retrograde CTO PCI on short-term prognosis

BACKGROUND

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) carries risk of complications and should be attempted when the anticipated benefits exceed the potential risks. The primary indication for CTO-PCI is symptom improvement. However, the impact of CTO-PCI on angina and subsequent incidence of major adverse cardiovascular event (MACE) rate remains controversial. Our aim was to study the impact of technically successful elective CTO-PCI on the procedural success rate and short-term MACE. The current study was a prospective cohort study that included a total of 80 patients who were referred to our center (Ain Shams University Hospitals) for elective CTO-PCI and underwent technically successful CTO-PCI. Data were collected on patient arrival to our department, and then, the patients were observed during hospital admission to record any In-Hospital MACE. These patients were then followed up for 6 months to record improvement or worsening of their symptoms and to assess occurrence of any MACE including hospitalization and undergoing symptom-driven coronary angiography.

RESULTS

The mean age of our patients was 56 ± 9.6 years, and 73 patients (91%) were men. Sixty-two patients (77.5%) were done via an antegrade approach, and 18 patients (22.5%) were done via a retrograde approach with an overall procedural success rate of 91.25% (antegrade 93.5%, retrograde 83.3%). The overall mean procedure time was 102 min, the mean contrast volume used was 371 ml, and the mean cumulative air kerma dose was 7.2 Gy. The retrograde group required longer procedure times, larger volumes of contrast and higher exposure to radiation. The overall in-hospital MACE was 8.75%. Sixty-five patients in our study (81.25%) showed an improvement in the grade of their exertional dyspnea or angina within the 6-month follow-up period. Thirteen patients in our study (16.25%) needed re-hospitalization within a 6-month period after PCI. The overall target lesion revascularization rate at 6 months was 8.75%.

CONCLUSIONS

Technically successful CTO PCI in a well-equipped center with highly qualified CTO operators resulted in high procedural success rates and low incidence of short-term MACE.

Guide catheter extension use are associated with higher procedural success in chronic total occlusion percutaneous coronary interventions

BACKGROUND

Guide catheter extensions (GCEs) increase support and facilitate equipment delivery, but aggressive instrumentation may be associated with a higher risk of complications.

AIM

Our aim was to assess the impact of GCEs on procedural success and complications in patients submitted to chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

METHODS

We analyzed data from the multicenter LATAM CTO Registry. Procedural success was defined as <30% residual stenosis and TIMI 3 distal flow. Major adverse cardiac and cerebrovascular events (MACCE) was defined as the composite of all-cause death, myocardial infarction, target vessel revascularization, and stroke. Propensity score matching (PSM) was used to compare outcomes with and without GCE use.

RESULTS

From August 2010 to August 2021, 3049 patients were included. GCEs were used in 438 patients (14.5%). In unadjusted analysis, patients in the GCE group were older and had more comorbidities. The median J-CTO score and its components were higher in the GCE group. After PSM, procedural success was higher with GCE use (87.7% vs. 80.5%, p = 0.007). The incidence of coronary perforation (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 0.78-2.71, p = 0.230), bleeding (OR: 1.99, 95% CI: 0.41-2.41, p = 0.986), in-hospital death (OR: 1.39, 95% CI: 0.54-3.62, p = 0.495) and MACCE (OR: 1.07, 95% CI: 0.52-2.19, p = 0.850) were similar in both groups.

CONCLUSION

In a contemporary, multicenter cohort of patients undergoing CTO PCI, GCEs were used in older patients, with more comorbidities and complex anatomy. After PSM, GCE use was associated with higher procedural success, and similar incidence of adverse outcomes.

Contemporary In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the MENATA (Middle East, North Africa, Turkey, and Asia) Chapter of the PROGRESS-CTO Registry

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been rapidly evolving in different parts of the world. We examined the clinical and angiographic characteristics and procedural outcomes of 1,079 consecutive CTO PCIs performed in 1,063 patients at 10 centers in the Middle East, North Africa, Turkey, and Asia regions between 2018 and 2022. The mean age was 61 ± 10 years and 82% of the patients were men. The prevalence of diabetes (49%) and previous PCI (50%) was high. The most common target vessel was the right coronary artery (51%), followed by the left anterior descending artery (33%) and the circumflex artery (15%). The mean Japanese CTO score was 2.1 ± 1.2 and mean PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) score was 1.2 ± 1.0. The technical and procedural success rates were high (91% and 90%, respectively) with a low incidence (1.6%) of in-hospital major adverse cardiac events. The incidence of perforation was 4.6% (n = 50): guidewire exit was the most common mechanism of perforation (48%) and 14 patients required pericardiocentesis (28%). Antegrade wire escalation was the most common crossing strategy used (91%), followed by retrograde approach (24%) and antegrade dissection and re-entry (12%). Median contrast volume, air kerma radiation dose, and fluoroscopy time were 300 (200 to 400) ml, 3.7 (2.0 to 6.3) Gy, and 40 (25 to 65) minutes, respectively. In conclusion, high success and acceptable complication rates are currently achieved at experienced centers in the Middle East, North Africa, Turkey, and Asia regions using a combination of crossing strategies.

Complex high-risk percutaneous coronary intervention types, trends, and outcomes according to vascular access site

BACKGROUND

Radial access is associated with improved outcomes following percutaneous coronary intervention (PCI); however, its role in complex, high-risk percutaneous coronary intervention (CHiP) remains poorly studied.

METHODS

We studied retrospectively all registered patients's records from the British Cardiovascular Intervention Society dataset and compared the baseline characteristics, trends and outcomes of CHiP procedures performed electively between January 2006 and December 2017 according to the access site.

RESULTS

Out of 137,785 CHiP procedures, 61,825 (44.9%) were undertaken via transradial access (TRA). TRA use increased over time (14.6% in 2006 to 67% in 2017). The TRA patients were older, with a greater prevalence of previous stroke, hypertension, peripheral vascular disease, and smokers. TRA was used more frequently in most CHiP procedures (elderly (51.6%), chronic renal failure (52.6%), poor left ventricular (LV) function (47.6%), left main PCI (48.0%), treatment for severe vascular calcification (50.3%); although transfemoral access (TFA) was used more commonly in those with prior history of coronary artery bypass graft surgery, and PCI to a chronic total occlusion and LV support patients. Following adjustment for differences in clinical and procedural characteristics, TFA was independently associated with higher odds for mortality [adjusted odds ratio (aOR): 1.3 (1.1-1.7)], major bleeding [aOR: 2.9 (2.3-3.4)], and MACCE (following propensity score matching) [aOR: 1.2 (1.1-1.4)]. The same was found with multiple accesses: mortality [aOR: 2.1 (1.5-2.8)], major bleeding [aOR: 5.5 (4.3-6.9)], and MACCE [aOR: 1.4 (1.2-1.7)].

CONCLUSION

TRA has become the predominant access site for CHiP procedures and is associated with significantly lower mortality, major bleeding and MACCE odds than TFA.

An Interventional Odyssey: The Importance of Planning and Prompt Recognition and Treatment of Complications During a Complex Chronic Total Occlusion Intervention

Despite significant progress, chronic total occlusion (CTO) percutaneous coronary interventions (PCI) are often challenging and carry increased risk of complications. We present a highly complex CTO PCI case that was successfully completed despite numerous complications (perforation, donor vessel closure, stent loss, guide extension tip fracture, access site bleeding and cardiac arrest) to highlight the importance of appropriate patient selection, pre-procedural planning, comprehensive patient-centered risk/benefit discussion, and prompt recognition and treatment of intra-procedural complications.

Overview of Percutaneous Coronary Interventions for Chronic Total Occlusions Treated at Brazilian Centers Participating in the LATAM CTO Registry

BACKGROUND

Major advances have been seen in techniques and devices for performing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), but there are limited real-world practice data from developing countries.

OBJECTIVES

To report clinical and angiographic characteristics, procedural aspects, and clinical outcomes of CTO PCI performed at dedicated centers in Brazil.

METHODS

Included patients underwent CTO PCI at centers participating in the LATAM CTO Registry, a Latin American multicenter registry dedicated to prospective collection of these data. Inclusion criteria were procedures performed in Brazil, age 18 years or over, and presence of CTO with PCI attempt. CTO was defined as a 100% lesion in an epicardial coronary artery, known or estimated to have lasted at least 3 months.

RESULTS

Data on 1196 CTO PCIs were included. Procedures were performed primarily for angina control (85%) and/or treatment of moderate/severe ischemia (24%). Technical success rate was 84%, being achieved with antegrade wire approaches in 81% of procedures, antegrade dissection and re-entry in 9%, and retrograde approaches in 10%. In-hospital adverse cardiovascular events occurred in 2.3% of cases, with a mortality rate of 0.75%.

CONCLUSIONS

CTOs can be treated effectively in Brazil by using PCI, with low complication rates. The scientific and technological development observed in this area in the past decade is reflected in the clinical practice of dedicated Brazilian centers.

Comparative Analysis of Patient Characteristics in Chronic Total Occlusion Revascularization Studies: Trials vs Real-World Registries

BACKGROUND

The few randomized controlled trials (RCTs) on chronic total occlusion (CTO) percutaneous coronary intervention (PCI) are subject to selection bias.

OBJECTIVES

The purpose of this study was to evaluate the differences between real-world CTO patients and those enrolled in RCTs.

METHODS

This study performed a meta-analysis of national and dedicated CTO PCI registries and compared patient characteristics and outcomes with those of RCTs that randomized patients to CTO PCI versus medical therapy. Given the large sample size differences between RCTs and registries, the study focused on the absolute numbers and their clinical significance. The study considered a 5% relative difference between groups to be potentially clinically relevant.

RESULTS

From 2012 to 2022, 6 RCTs compared CTO PCI versus medical therapy (n = 1,047) and were compared with 15 registries (5 national and 10 dedicated CTO PCI registries). Compared with registry patients, RCT patients had fewer comorbidities, including diabetes, hypertension, previous myocardial infarction, and prior coronary artery bypass graft surgery. RCT patients had shorter CTO length (29.6 ± 19.7 mm vs 32.6 ± 23.0 mm, a relative difference of 9.2%) and lower Japan-Chronic Total Occlusion Score scores (2.0 ± 1.1 vs 2.3 ± 1.2, a relative difference of 13%) compared with those enrolled in dedicated CTO registries. Procedural success was similar between RCTs (84.5%) and dedicated CTO registries (81.4%) but was lower in national registries (63.9%).

CONCLUSIONS

There is a paucity of randomized data on CTO PCI outcomes (6 RCTs, n = 1,047). These patients have lower risk profiles and less complex CTOs than those in real-world registries. Current evidence from RCTs may not be representative of real-world patients and should be interpreted within its limitation.

Risk Burden of Coronary Perforation in Chronic Total Occlusion Recanalization: Latin American CTO Registry Analysis

Background

Coronary perforation is a life‐threatening complication of acute percutaneous coronary intervention (PCI) for chronic total occlusions (CTO), but data on midterm outcomes are limited.

Methods and Results

Data from LATAM (Latin American)‐CTO Registry (57 centers; 9 countries) were analyzed. We assessed the risk of 30‐day, 1‐year major adverse cardiac events of coronary perforation using time‐to‐event and weighted composite end point analysis having CTO PCI without perforation as comparators. Additionally, we studied the independent predictors of perforation in these patients. Of 2054 patients who underwent CTO PCI between 2015 and 2018, the median Multicenter CTO Registry in Japan and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention‐Chronic total occlusions scores were 2.0 (1.0–3.0) and 1.0 (0.0–2.0), respectively. The perforation rate was 3.7%, of which 55% were Ellis class 1. After 1‐year coronary perforation had higher major adverse cardiac events rates (24.9% versus 13.3%; P<0.01). Using weighted composite end point, perforation was associated with increased bleeding and ischemic events at 6 months (P=0.04) and 1 year (P<0.01). We found as independent predictors associated with coronary perforation during CTO PCI: maximum activated clotting time (P<0.01), Multicenter CTO Registry in Japan score ≥2 (P=0.05), antegrade knuckle wire (P=0.04), and right coronary artery CTO PCI (P=0.05).

Conclusions

Coronary perforation was infrequent and associated with anatomical and procedural complexity, resulting in higher risk of hemorrhagic and ischemic events. Landmark and weighted analysis showed a sustained burden of major events between 6 months and 1 year follow‐up.

The comparison of efficacy and safety between transradial and transfemoral approach for chronic total occlusions intervention: a meta-analysis

This meta-analysis compared the outcomes of transradial access (TRA) and transfemoral access (TFA) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in recent decades. We searched multiple databases for articles published between January 1, 2015, and December 31, 2020. Six observational studies with 11,736 patients were analyzed. Data included baseline demographics, Japan-chronic total occlusion (J-CTO) score, sheath size, PCI vessel, retrograde method, procedural time, fluoroscopy time, and contrast volume. The more prevalent target CTO vessel was the left coronary artery in the TRA group and the right coronary artery in the TFA group. Higher J-CTO score, longer procedural time, and more contrast volume were seen in the TFA group. In comparison, the TRA group had better procedural success rate (odds ratio (OR), 0.846; 95% confidence interval (CI) 0.749-0.956) and less vascular complications (OR, 0.323; 95% CI 0.203-0.515), but similar retrograde success rate (OR, 0.965; 95% CI 0.382-2.435). In-hospital death (OR, 0.527; 95% CI 0.187-1.489) and major adverse cardiovascular events (OR, 0.729; 95% CI 0.504-1.054) did not differ between the groups. Overall, fewer vascular complications and higher procedural success rates were noted in the TRA CTO PCI population. However, similar retrograde success rates and clinical outcomes were noted between the groups.

Crossing Total Occlusions Using a Hydraulic Pressure Wave: Development of the Wave Catheter

With the ongoing miniaturization of surgical instruments, the ability to apply large forces on tissues for resection becomes challenging and the risk of buckling becomes more real. In an effort to allow for high force application in slender instruments, in this study, we have investigated using a hydraulic pressure wave (COMSOL model) and developed an innovative 5F cardiac catheter (L = 1,000 mm) that allows for applying high forces up to 9.0 ± 0.2 N on target tissues without buckling. The catheter uses high-speed pressure waves to transfer high-force impulses through a slender flexible shaft consisted of a flat wire coil, a double braid, and a nylon outer coating. The handle allows for single-handed operation of the catheter with easy adjusting of the input impulse characteristic, including frequency (1–10 Hz), time and number of strokes using a solenoid actuator, and easy connection of an off-the-shelf inflator for catheter filling. In a proof-of-principle experiment, we illustrated that the Wave catheter was able to penetrate a phantom model of a coronary Chronic Total Occlusion (CTO) manufactured out of hydroxyapatite and gelatin. It was found that the time until puncture decreased from 80 ± 5.4 s to 7.8 ± 0.4 s, for a stroke frequency of 1–10 Hz, respectively. The number of strikes until puncture was approximately constant at 80 ± 5.4, 76.7 ± 2.6, and 77.7 ± 3.9 for the different stroke frequencies. With the development of the Wave catheter, first steps have been made toward high force application through slender shafts.

Contemporary Issues in Chronic Total Occlusion Percutaneous Coronary Intervention

Remarkable progress has been achieved in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in recent years, with refinement of the indications and technical aspects of the procedure, imaging, and complication management. Randomized controlled trials and rigorous prospective registries have provided high-quality data on the benefits and risks of CTO PCI. Global collaboration has led to an agreement on nomenclature, indications, endpoint definition, and principles of clinical trial design that have been distilled in global consensus documents such as the CTO Academic Research Consortium. Increased use of preprocedural coronary computed tomography angiography and intraprocedural intravascular imaging, as well as development of novel techniques and structured CTO crossing and complication management algorithms, allow a systematic, stepwise approach to this difficult lesion subset. This state-of-the-art review provides a comprehensive discussion about the most recent developments in the indications, preprocedural planning, technical aspects, complication management, and future directions of CTO PCI.

CTO in Contemporary PCI

Percutaneous Coronary Intervention (PCI) of Chronic Total Occlusions (CTO) represents the most challenging procedure in modern endovascular treatments. In recent years, the success rate of CTO PCI has substantially improved, owing to increasing operator expertise and advancements in CTO equipment and algorithms as well as the development of expert consensus documents. In this review, we summarize existing evidence for CTO PCI, its success/ risk prediction scoring tools, procedural principles and complications and provide an insight into the future role of CTO PCI.

Lesion characteristics and procedural complications of chronic total occlusion percutaneous coronary intervention in patients with prior bypass surgery: A meta-analysis

Coronary artery bypass graft (CABG) accelerates the prevalence of native coronary chronic total occlusion (CTO), and this kind of CTO shows extensive challenging and complex atherosclerotic pathology. As a result, the procedural success rate of percutaneous coronary intervention (PCI) is inferior to another kind of lesions. The present meta-analysis aims to compare the lesion characteristics and procedural complications of CTO-PCI in patients with or without prior CABG. A total of 8 studies, comprising of 13439 patients, published from inception to August 2021 were included in this meta-analysis. Results were pooled using random effects model and are presented as odds ratio (OR) with 95% confidence intervals (95% CIs). From the 13439 patients enrolled, 3349 (24.9%) patients had previous CABG and 10090 (75.1%) formed the control group in our analysis. For the clinical characteristic, compared to the non-CABG patients, prior CABG patients were older (OR, 3.98; 95% CI, 3.19-4.78; p < .001; I2  = 72%), had more male (OR, 1.30; 95% CI, 1.14-1.49; p < .001; I2  = 6%), diabetes mellitus (OR, 1.54; 95% CI, 1.36-1.73; p < .001; I2  = 37%), dyslipidemia (OR, 1.89; 95% CI, 1.33-2.69; p < .001; I2  = 81%), hypertension (OR, 1.88; 95% CI, 1.46-2.41; p < .001; I2  = 71%), previous myocardial infarction (OR, 1.94; 95% CI, 1.48-2.56; p < .001; I2  = 85%), and previous PCI (OR, 1.74; 95% CI, 1.52-1.98; p < .001; I2  = 22%). Non-CABG patents had more current smoker (OR, .45; 95% CI, 0.27-0.74; p < .001; I2  = 91%). BMI (OR, -0.01; 95% CI, -0.07-0.06; p = .85; I2  = 36%) were similar in both groups. For lesions location, the right coronary artery (RCA) was predominant target vessel in both groups (50.5% vs 48.7%; p＝.49), although, the left circumflex (LCX) was more frequently CTO in the prior CABG group (27.3% vs 18.9%; p＜.01), while left anterior descending artery (LAD) in non-CABG ones (16.0% vs 29.1%; p＜0.01). For lesions characteristics, prior CABG patients had more blunt stump (OR, 1.71; 95% CI, 1.46-2.00; p < .001; I2  = 40%), proximal cap ambiguity (OR, 1.45; 95% CI, 1.28-1.64; p < .001; I2  = 0.0%), severe calcifications (OR, 2.91; 95% CI, 2.19-3.86; p < .001; I2  = 83%), more bending (OR, 3.07; 95% CI, 2.61-3.62; p < .001; I2  = 0%), lesion length > 20 mm (OR, 1.59; 95% CI, 1.10-2.29; p = .01; I2  = 83%), inadequate distal landing zone (OR, 1.95; 95% CI, 1.75-2.18; p＜.001; I2  = 0.0%), distal cap at bifurcation (OR, 1.65; 95% CI, 1.46-1.88; p < .001; I2  = 0.0%), and higher J-CTO score (SMD, 0.52; 95% CI, 0.42-0.63; p < .001; I2  = 65%). But side branch at proximal entry (OR, 0.88; 95% CI, 0.72-1.07; p = .21; I2  = 45%), in-stent CTO (OR, 0.99; 95% CI, 0.86-1.14; p = .88; I2  = 0.0%), lack of interventional collaterals (OR, 0.80; 95% CI, 0.55-1.15; p = .23; I2  = 78%), and previously failed attempt (OR, 0.73; 95% CI, 0.48-1.11; p = .14; I2  = 89%) were similar in both groups. For complication, prior CABG patients had more perforation with need for intervention (OR, 1.91; 95% CI, 1.36-2.69; p < 0.001; I2  = 34%), contrast-induced nephropathy (OR, 3.40; 95% CI, 1.31-8.78; p = .01; I2  = 0.0%). Non-CABG patents had more tamponade (OR, 0.25; 95% CI, 0.09-0.72; p = .01; I2  = 0.0%), and the major bleeding complication (OR, 1.18; 95% CI, 0.57-2.44; p = .65; I2  = 0%) were no significant difference in both groups. In conclusion, Patients with prior CABG undergoing CTO-PCI have more complex lesion characteristics, though procedural complication rates were comparable.

Angiographic Characteristics and Outcomes of Percutaneous Coronary Intervention of Reattempted Chronic Total Occlusion: Potential Contributing Factors to Procedural Success

This study aimed to analyze angiographic characteristics of new attempted percutaneous coronary intervention (PCI) on chronic total occlusion (CTO) compared to first attempt group. The cohort of 527 CTO-PCIs was divided into first-attempt and re-attempt groups, and angiographic characteristics, level of complexity, and contributing factors to failure were analyzed. Between-group success rate difference and potential angiographic and technical aspects contributing to the success in new attempts were scrutinized. A total of 47 new PCIs in 39 patients were performed. The reattempt group showed higher J-CTO score compared to the first-attempt group (2.4 ± 1.06 vs. 1.2 ± 1.06; p < 0.001). The use of more complex techniques and devices such as retrograde approach (29.8% vs. 12.9%) and IVUS (48.9 vs. 27.3%; p: 0.002) were more frequent in the reattempt group. Both procedural and fluoroscopy time were higher in the reattempt group (197 ± 83.9 vs. 150.1 ± 72.3 and 97.7 ± 55.4 vs. 68.7 ± 43, respectively; p < 0.001). There was no between-group difference in terms of technical success (79.8 vs. 76.6% for first attempt vs. reattempt group, respectively; p: 0.6). The overall success rate increased by 6.1%, achieving 85.9% in the entire cohort. Reattempted CTO-PCIs required more complex techniques and had comparable technical success rate with regard to the first-attempt group.

Update on chronic total occlusion percutaneous coronary intervention

Chronic total occlusion (CTO) percutaneous coronary interventions (PCI) can be challenging to perform. The main indication for CTO PCI is to improve symptoms. Several contemporary studies have reported high CTO PCI success rates at experienced centers but success rates in all-comer registries remain low. Several scores can estimate the difficulty and the likelihood of success of CTO PCI. Dual arterial access and use of CTO crossing algorithms can improve the success and safety of CTO PCI. Intracoronary imaging can optimize stent expansion and minimize adverse cardiovascular events. While complications are more common in CTO PCI, careful planning and prompt diagnosis and treatment can prevent them or minimize their adverse consequences. In this article, we review contemporary data on the indications, safety and efficacy of CTO PCI.

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion by treated segment length

BACKGROUND

Long lesions are known to have worse outcomes following percutaneous coronary intervention (PCI), but there are limited data assessing the association between lesion length and clinical outcomes in PCI procedures undertaken in chronic total occlusions (CTO).

METHODS AND RESULTS

We formed a longitudinal cohort (2006-2018, n = 27,205) of stable angina patients who underwent PCI to CTO in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographical, procedural, and outcome data were analyzed in three groups by treated segment length, < 30 mm (n = 11,782), 30-59 mm (n = 10,415), ≥ 60 mm (n = 5008). Prevalence of previous myocardial infarction and PCI were higher in patients in 30-59 mm group or ≥ 60 mm group compared with < 30 mm group. Following multivariable analysis, no significant difference was observed in in-patient death (OR = 30-59 mm group = 1.10, CI:0.55-2.19, p = 0.78) (OR ≥ 60 mm group = 0.82, CI: 0.33-2.05, p = 0.67), and 1-year death (OR = 30-59 mm group = 1.06, CI: 0.81-1.37, p = 0.69) (OR ≥ 60 mm group =1.01, CI: 0.70-1.43, p = 0.99) (< 30 mm group = reference) but in-patient MACE was higher in > = 60 mm group (OR: 1.52, CI: 1.15-2.01, p = 0.06) but similar in 30-59 mm group (OR: 1.16, CI: 0.91-1.48, p = 0.22) compared with < 30 mm group. The adjusted rates of procedural complications were higher in ≥ 60 mm group (OR: 1.61, CI: 1.40-1.85, p < 0.001) but were similar in 30-59 mm group (OR: 1.06, CI: 0.94-1.20, p < 0.31) compared with < 30 mm group. For every 10 mm increase, there was an increased adjusted risk of in-patient procedural complications and coronary perforation but not in-patient MACE or death.

CONCLUSION

Patients with very long CTO lesions have higher risk of procedural complications and in-patient MACE but similar risk of short or long-term mortality compared with short CTO lesions.

Safety and efficacy of dedicated guidewire, microcatheter, and guide catheter extension technologies for chronic total coronary occlusion revascularization: Primary results of the Teleflex Chronic Total Occlusion Study

BACKGROUND

Description of procedural outcomes using contemporary techniques that apply specialized coronary guidewires, microcatheters, and guide catheter extensions designed for chronic total occlusion (CTO) percutaneous revascularization is limited.

METHODS

A prospective, multicenter, single-arm study was conducted to evaluate procedural and in-hospital outcomes among 150 patients undergoing attempted CTO revascularization utilizing specialized guidewires, microcatheters and guide extensions. The primary endpoint was defined as successful guidewire recanalization and absence of in-hospital cardiac death, myocardial infarction (MI), or repeat target lesion revascularization (major adverse cardiac events, MACE).

RESULTS

The prevalence of diabetes was 32.7%; prior MI, 48.0%; and previous bypass surgery, 32.7%. Average (mean ± standard deviation) CTO length was 46.9 ± 20.5 mm, and mean J-CTO score was 1.9 ± 0.9. Combined radial and femoral arterial access was performed in 50.0% of cases. Device utilization included: support microcatheter, 100%; guide catheter extension, 64.0%; and mean number of study guidewires/procedure was 4.8 ± 2.6. Overall, procedural success was achieved in 75.3% of patients. The rate of successful guidewire recanalization was 94.7%, and in-hospital MACE was 19.3%. Achievement of TIMI grade 2 or 3 flow was observed in 93.3% of patients. Crossing strategies included antegrade (54.0%), retrograde (1.3%) and combined antegrade/retrograde techniques (44.7%). Clinically significant perforation resulting in hemodynamic instability and/or requiring intervention occurred in 16 (10.7%) patients.

CONCLUSIONS

In a multicenter, prospective registration study, favorable procedural success was achieved despite high lesion complexity using antegrade and retrograde guidewire maneuvers and with acceptable safety, yet with comparably higher risk than conventional non-CTO PCI.

Should Interventional Cardiologists Super-Subspecialize?: Moving From Patient Selection to Operator Selection

The field of interventional cardiology has expanded rapidly. As a result, four evolving areas have evolved - peripheral vascular interventions, structural heart interventions, adult congenital heart intervention, and chronic total occlusion. The complexity of these procedures and the number of devices available has grown rapidly. In addition, the professional and public expectations of procedural success and of minimizing case-avoidance have also grown. Specific issues include volume-outcome relationships, maintaining currency and proficiency, accessibility to specialized procedures, and the need to maintain a fundamental level of expertise in acute coronary interventions.

Vascular complications associated with intraaortic balloon pump supported percutaneous coronary intervention (PCI) and clinical outcomes from the British Cardiovascular Intervention Society National PCI Database

INTRODUCTION

The impact of a vascular complication (VC) in the setting of intraaortic balloon pump (IABP) supported PCI on clinical outcomes is unclear.

METHODS

Using data from the BCIS National PCI Database, multivariate logistic regression was used to identify independent predictors of a VC. Propensity scoring was used to quantify the association between a VC and outcomes.

RESULTS

Between 2007 and 2014, 9,970 PCIs in England and Wales were supported by IABP (1.6% of total PCI), with 224 femoral VCs (2.3%). Annualized rates of a VC reduced as the use of radial access for PCI increased. The independent predictors of a VC included a procedural complication (odds ratio [OR] 2.9, p < .001), female sex (OR 2.3, p < .001), PCI for stable angina (OR 3.47, p = .028), and use of a glycoprotein inhibitor (OR 1.46 [1.1:2.5], p = .04), with a lower likelihood of a VC when radial access was used for PCI (OR 0.48, p = .008). A VC was associated with a higher likelihood of transfusion (OR 5.7 [3.5:9.2], p < .0001), acute kidney injury (OR 2.6 [1.2:6.1], p = .027), and periprocedural MI (OR 3.2 [1.5:6.7], p = .002) but not with adjusted mortality at discharge (OR 1.2 [0.8:1.7], p = .394) or 12-months (OR 1.1 [0.76:1.56], p = .639). In sensitivity analyses, there was a trend towards higher mortality in patients experiencing a VC who underwent PCI for stable angina (OR 4.1 [1.0:16.4], p value for interaction .069). Discussion and Conclusions Although in-hospital morbidity was observed to be adversely affected by occurrence of a VC during IABP-supported PCI, in-hospital and 1-year survival were similar between groups.

Combined use of rotational and excimer lASER coronary atherectomy (RASER) during complex coronary angioplasty-An analysis of cases (2006-2016) from the British Cardiovascular Intervention Society database

INTRODUCTION

Combining rotational (RA) and excimer laser coronary atherectomy (ELCA)-RASER atherectomy-is technique utilized in the percutaneous management of calcific coronary disease. The evidence base examining its safety and utility is sparse and limited to small case-series. This study examines the patterns and outcomes of RASER atherectomy use in the largest cohort to date.

METHODS

Using the British Cardiac Intervention Society database, data were analyzed on all PCI procedures in the UK between 2006 and 2016. Descriptive statistics and multivariate logistic regressions were used to examine baseline, procedural, and outcome associations with RASER.

RESULTS

We identified 153 (0.02%) RASER atherectomy cases out of 686,358 PCI procedures. Baseline covariates associated with RASER use were age, BMI, diabetes, stable coronary disease, and previous CABG. Procedural co-variates associated with RASER were CTO-PCI, the use of more/longer stents, intravascular imaging, cutting balloons, and microcatheters. Adjusted rates of in-hospital major adverse cardiac/cerebrovascular events (MACCE) were not significantly different with RASER. However, there were higher odds of arterial complications (OR 3.23, 95% CI: 1.58-6.61), slow flow (OR 3.50, 95% CI: 1.29-9.55), and shock induction (OR 9.66, 95% CI: 3.44-27.06).

CONCLUSIONS

RASER atherectomy use in complex PCI is associated with higher risk baseline and procedural characteristics. Although increased rates of shock induction, slow flow, and arterial complications were observed, RASER does not increase the likelihood of in-hospital MACCE, major bleeding, or death.

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion in prior coronary artery bypass grafting patients

OBJECTIVE

To compare the clinical characteristics and outcomes in patients with stable angina who have undergone chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in native arteries with or without prior coronary artery bypass grafting (CABG) surgery in a national cohort.

BACKGROUND

There are limited data on outcomes of patients presenting with stable angina undergoing CTO PCI with previous CABG.

METHODS

We identified 20,081 patients with stable angina who underwent CTO PCI between 2007-2014 in the British Cardiovascular Intervention Society database. Clinical, demographical, procedural and outcome data were analyzed in two groups; group 1-CTO PCI in native arteries without prior CABG (n = 16,848), group 2-CTO PCI in native arteries with prior CABG (n = 3,233).

RESULTS

Patients in group 2 were older, had more comorbidities and higher prevalence of severe left ventricular systolic dysfunction. Following multivariable analysis, no significant difference in mortality was observed during index hospital admission (OR:1.33, CI 0.64-2.78, p = .44), at 30-days (OR: 1.28, CI 0.79-2.06, p = .31) and 1 year (OR:1.02, CI 0.87-1.29, p = .87). Odds of in-hospital major adverse cardiovascular events (MACE) (OR:1.01, CI 0.69-1.49, p = .95) and procedural complications (OR:1.02, CI 0.88-1.18, p = .81) were similar between two groups but procedural success rate was lower in group 2 (OR: 0.34, CI 0.31-0.39, p < .001). The adjusted risk of target vessel revascularization (TVR) remained similar between the two groups at 30-days (OR:0.68, CI 0.40-1.16, P-0.16) and at 1 year (OR:1.01, CI 0.83-1.22, P-0.95).

CONCLUSION

Patients with prior CABG presenting with stable angina and treated with CTO PCI in native arteries had more co-morbid illnesses but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality, MACE or TVR.

Chronic total occlusion percutaneous coronary intervention in everyday clinical practice - an expert opinion of the Association of Cardiovascular Interventions of the Polish Cardiac Society

Coronary chronic total occlusions (CTO) are increasingly encountered during invasive and non-invasive coronary angiography and remain the most challenging lesions for percutaneous revascularization. During recent years success rates and safety outcomes of CTO percutaneous coronary intervention (PCI) have substantially improved, particularly due to the introduction of new techniques and dedicated equipment as well as specialized training programs of CTO operators. Significantly, the steady advances in CTO PCI techniques have coincided with the new data from randomized clinical trials supporting the role of percutaneous recanalization of CTO in relieving angina and improving the quality of life. The current expert consensus document outlines the rationale, clinical outcomes as well as technical, safety and reimbursement issues of CTO PCI. In addition, the requirements for achieving and maintaining competency in CTO PCI among interventional cardiologists are discussed. Finally, we present the modified hybrid algorithm (the so-called Polish hybrid algorithm) providing some unique refinements to the contemporary CTO PCI strategies. Continuous efforts (including active engagement with the payer) are urgently needed to increase guideline-recommended referrals to CTO PCI, and thus improve the quality of life of CTO patients in Poland.

Rational guidewire use in the coronary chronic total occlusion interventions

Background

Procedures for coronary chronic total occlusion (CTO) are still a clinical challenge with relatively lower success rates. Recent advances in the biotechnology and introduction of CTO-dedicated guidewires have increased the procedural success rate of CTO interventions. Herein, we aimed to reveal the clinical and angiographic predictors of the crossability of the initial guidewire choice and rational guidewire usage in CTO interventions. A total of 177 patients with an indication for a coronary CTO procedure were included in this study. The use of 1–3 guidewires and crossing of the CTO lesion with the initial guidewire choice was defined as rational guidewire usage. The CTO lesions were classified according to the Japanese chronic total occlusion registry (J-CTO) and EuroCTO scores for evaluating the difficulty of the procedures. Then, a statistical analysis was performed to assess the initial guidewire choice, crossability, and contributors to rational guidewire usage.

Results

The mean J-CTO score was 1.42 ± 1.16, and the mean EuroCTO score was 1.44 ± 1.18. The success rate of the procedures was 90.4%. The initial guidewire choice crossed the lesion in 44.1% of the cases, in which 1–3 guidewires were used (82.1%). The crossability of the polymeric and moderate stiff tip guidewires was higher (82.1% and 64.1%, respectively), and the Pilot series was the most successful brand (36.2%). Logistic regression analysis confirmed that J-CTO score, procedural technique, guidewire type, and stiffness of the tip were the major predictors of rational guidewire usage.

Conclusion

Our analysis showed that the use of polymeric and moderate stiff tip guidewires, particularly the Pilot brand, were associated with rational guidewire usage in easy and intermediate difficulty CTO cases.

Association of Operator and Hospital Experience With Procedural Success Rates and Outcomes in Patients Undergoing Percutaneous Coronary Interventions for Chronic Total Occlusions

Background:

An inverse relationship has been described between procedural success and outcomes of all major cardiovascular procedures. However, this relationship has not been studied for percutaneous coronary intervention (PCI) of chronic total occlusion (CTO).

Methods:

We analyzed the data on patients enrolled in Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry in Michigan (January 1, 2010 to March 31, 2018) to evaluate the association of operator and hospital experience with procedural success and outcomes of patients undergoing CTO-PCI. CTO-PCI was defined as intervention of a 100% occluded coronary artery presumed to be ≥3 months old.

Results:

Among 210 172 patients enrolled in the registry, 7389 (3.5%) CTO-PCIs were attempted with a success rate of 53%. CTO-PCI success increased with operator experience (45% and 65% in the lowest and highest experience tertiles) and was the highest for highly experienced operators at higher experience centers and the lowest for inexperienced operators at low experience hospitals. Multivariable logistic regression models (with spline transformed prior operator and institutional experience) demonstrated a positive relationship between prior operator and site experience and procedural success rates (likelihood ratio test=141.12, df=15, P <0.001) but no relationship between operator and site experience and major adverse cardiac event (likelihood ratio test=19.12, df=15, P =0.208).

Conclusions:

Operator and hospital CTO-PCI experiences were directly related to procedural success but were not related to major adverse cardiac event among patients undergoing CTO-PCIs. Inexperienced operators at high experience centers had significantly higher success but not major adverse cardiac event rates compared with inexperienced operators at low experience centers. These data suggested that CTO-PCI safety and success could potentially be improved by selective referral of these procedures to experienced operators working at highly experienced centers.

Latest developments in chronic total occlusion percutaneous coronary intervention

INTRODUCTION

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.

AREAS COVERED

We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.

EXPERT OPINION

After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.

Chronic total occlusion percutaneous coronary intervention in Latin America

OBJECTIVES

To report clinical, angiographic characteristics, outcomes, and predictors of unsuccessful procedures in patients who underwent chronic total occlusion (CTO) percutaneous coronary interventions (PCI) in Latin America.

BACKGROUND

CTO PCI has been increasingly performed worldwide, but there is a lack of information in this region.

METHODS

An international multicenter registry was developed to collect data on CTO PCI performed in centers in Latin America. Patient, angiographic, procedural and outcome data were evaluated. Predictors of unsuccessful procedures were assessed by multivariable analysis.

RESULTS

We have included data related to 1,040 CTO PCIs performed in seven countries in Latin America (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, and Puerto Rico). The mean age was 64 ± 10 years, and CTO PCI was performed mainly for angina control (81%) or treatment of a large ischemic area (30%). Overall technical success rate was 82.5%, and it was achieved with antegrade wire escalation in 81%, antegrade dissection/re-entry in 8% and with retrograde techniques in 11% of the successful procedures. Multivariable analysis identified moderate/severe calcification, a blunt proximal cap and a previous attempt as independent predictors of unsuccessful procedures. In-hospital major adverse cardiovascular events (MACE) occurred in 3.1% of the cases, death in 1% and cardiac tamponade in 0.9% CONCLUSIONS: CTO PCI in Latin America has been performed mainly for ischemia relief. Procedures were associated with a success rate above 80% and low incidence of MACE. Predictors of unsuccessful procedures were similar to those previously reported in the literature.

Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Hope for the best, prepare for the worst: How to manage coronary perforations

The incidence of coronary perforation in a contemporary cohort of 13,339 PCI procedures was 0.51%. The majority (75%) were large-vessel perforations Although only 1 patient required emergency cardiac surgery, in-hospital mortality was high (10%) Given the infrequent occurrence of coronary perforations, uniform recommendations for its management are lacking. Nonetheless, the present study suggests that avoiding oversized balloons or stents might potentially reduce the incidence of perforations.