Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part II

A non-interventional cardiologist's guide to coronary chronic total occlusions

Coronary chronic total occlusions (CTO) are present in up to one-third of patients with coronary artery disease (CAD). It is thus essential for all clinical cardiologists to possess a basic awareness and understanding of CTOs, including optimal evaluation and management. While percutaneous coronary intervention (PCI) for CTO lesions has many similarities to non-CTO PCI, there are important considerations pertaining to pre-procedural evaluation, interventional techniques, procedural complications, and post-procedure management and follow-up unique to patients undergoing this highly specialized intervention. Distinct from other existing topical reviews, the current manuscript focuses on key knowledge relevant to non-interventional cardiologists.

The morphology of occlusion stump for endovascular recanalization in non-acute vertebral ostial occlusion

PURPOSE

Non-acute vertebral ostial occlusion (VOO) is a debilitating condition with significant mortality and morbidity rates. However, currently, there is no consensus on the optimal treatment strategy for VOO. This study aims to examine the feasibility, effectiveness, and safety of endovascular recanalization in patients with VOO.

METHODS

We conducted a retrospective review of data from 21 consecutive patients with VOO who underwent endovascular recanalization between May 2018 and August 2023. The patients were divided into two groups based on a new angiographic classification proposed by Gao et al. Type I (tapered stump group) included patients with non-acute extracranial vertebral artery ostial occlusion presenting a tapered occlusion stump. Type II (nontapered stump group) consisted of patients with a nontapered occlusion stump. We collected data on recanalization rates, perioperative complications, and follow-up outcomes.

RESULTS

Our analysis included data from a total of 21 patients (22 lesions) with a mean age of 64.6 ± 10.6 years. The technical success rate was 66.7 % (14/21), and the rate of periprocedural complications was 14.3 % (3/21). The success rate of transitioning from the tapered stump group to the nontapered stump group was 90.9 % (10/11) and 40 % (4/10), respectively (P = 0.024). The perioperative complication rate for type I and type II patients was 18.2 % (2/11) and 10 % (1/10), respectively. Among these patients, 18 cases underwent endovascular recanalization using transfemoral access, while 3 patients underwent transradial access after failed transfemoral access, with successful outcomes for two patients.

CONCLUSIONS

This study suggests that endovascular recanalization may offer a safe, effective, and feasible treatment option for VOO patients. Additionally, the proposed angiographic classification may serve as a useful guide in selecting suitable candidates for surgery.

Percutaneous Coronary Intervention of Chronic Total Occlusion Associated with Higher Inpatient Mortality and Complications Compared With Non-CTO Lesions

BACKGROUND

Percutaneous coronary intervention (PCI) in patients with chronic total occlusion is commonly performed despite unclear long-term benefits. The goal of this study was to evaluate the postprocedural outcome of patients with chronic total occlusion intervention.

METHODS

The National Inpatient Sample database, years 2016-2020, was studied using International Classification of Diseases, Tenth Revision codes. Patients with chronic total occlusion interventions were compared with patients without chronic total occlusion. We evaluated postprocedural mortality and complications.

RESULTS

PCI in patients with chronic total occlusion was associated with higher total inhospital mortality and all postprocedural complications. A weighted total of 10,059,269 patients underwent PCI, with 259,574 having chronic total occlusion. The chronic total occlusion group had a 3.17% mortality rate vs 2.57% of nonchronic total occlusion PCIs (odds ratio [OR] 1.24; 95% confidence interval [CI], 1.18-1.31; P < .001). Using multivariate analysis adjusting for basline charcteristics and high risk features such as age, sex, race, diabetes mellitus, chronic kidney disease, systolic heart failure, 3-vessel PCI, hypertension, chronic obstructive pulmonary disease, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, prior PCI, history of coronary artery bypass graft, history of anemia, smoking status, atrial fibrillation/flutter, valvular heart disease, and , history of stroke, chronic total occlusion PCI remained significantly associated with higher total mortality (OR 1.07; 95% CI, 1.02-1.13; P = .02). Patients with chronic total occlusion compared with nonchronic total occlusion PCI had also higher rates of myocardial infarction (OR 2.85; 95% CI, 2.54-3.21; P < .001), coronary perforation (OR 6.01; 95% CI, 5.25-6.89; P < .001), tamponade (OR 3.36; 95% CI, 2.91-3.88; P < .001), contrast-induced nephropathy (OR 2.05; 95% CI, 1.45-2.90; P < .001), procedural bleeding (OR 3.57; 95% CI, 3.27-3.89; P < .001), and acute postprocedural respiratory failure (OR 2.07; 95% CI, 1.81-2.36; P < .001). All postprocedural complications were more than 3 times the nonchronic total occlusion patients (OR 3.45; 95% CI, 3.24-3.67; P < .001).

CONCLUSION

Using a large national inpatient database, PCI performed in patients with chronic total occlusion was associated with significantly much higher mortality and postprocedural complications compared with PCI in nonchronic total occlusion patients.

Prognostic Value of Different Levels of Uric Acid in Patients with Coronary Chronic Total Occlusion Undergoing Percutaneous Coronary Intervention

Recent data suggest that uric acid (UA) might be an independent predictor of clinical outcomes following percutaneous coronary intervention (PCI). The predictive value of uric acid in patients undergoing PCI for chronic total occlusions (CTO) is unknown. We included patients with CTO who underwent PCI at our center in 2005 and 2012, with available uric acid levels before angiography. Subjects were divided into groups according to uric acid tertiles (<5.5 mg/dL, 5.6-6.9 mg/dL, and >7.0 mg/dL), and outcomes were compared among the groups. Out of the 1963 patients (mean age 65.2 ± 11 years), 34.7% (n = 682) had uric acid concentrations in the first tertile, 34.3% (n = 673) in the second tertile, and 31% (n = 608) in the third tertile. Median follow-up was 3.0 years. Uric acid levels in the first tertile were associated with significantly lower all-cause mortality, as compared to the third tertile, with an adjusted hazard ratio (HR) of 0.67 (95% confidence interval (CI): 0.49 to 0.92; p = 0.012). No significant differences regarding all-cause mortality were found between patients in the first and second tertiles (HR: 0.96 [95% CI: 0.71 to 1.3; p = 0.78]). High levels of uric acid emerged as an independent predictor of all-cause mortality in patients with chronic total occlusion treated with PCI. Hence, uric acid levels should be incorporated into the risk assessment of patients with CTO.

Time correlation of success recanalization for endovascular recanalization of medically refractory non-acute intracranial arterial occlusions

Background and purpose

The management of patients with symptomatic non-acute atherosclerotic intracranial artery occlusion (sNAA-ICAO), which is a special subset with high morbidity and a high probability of recurrent serious ischemic events despite standard medical therapy, has been clinically challenging. A number of small-sample clinical studies have discussed endovascular recanalization for sNAA-ICAO and the lack of a uniform standard of operation time. The purpose of this study was to investigate the time correlation of successful recanalization.

Methods

From January 2013 to August 2021, 69 consecutive patients who underwent endovascular recanalization for sNAA-ICAO were analyzed retrospectively in the First Affiliated Hospital of Harbin Medical University. The technical success rate, periprocedural complications, and rate of TIA/ischemic stroke during follow-up were evaluated.

Results

The overall technical success rate was 73.91% (51/69), and the rate of perioperative complications was 37.68% (26/69). The percentage of patients with perioperative symptoms was 27.53% (19/69). The rate of serious symptomatic perioperative complications was 8.70% (6/69). After adjusting for age, sex, and BMI, the effect of the time from the last symptom to operation on successful recanalization was 0.42 (IQR, 0.20, 0.88, P = 0.021), before the inflection point (51 days).

Conclusions

Endovascular recanalization for sNAA-ICAO is technically feasible in reasonably selected patients. The perioperative safety is within the acceptable range. Before 51 days, the last symptoms to operation time, for every 10 days of delay, the probability of successful recanalization is reduced by 57%.

ULTrasound-guided TRAnsfemoral puncture in COmplex Large bORe PCI: study protocol of the UltraCOLOR trial

INTRODUCTION

Although recently published evidence favours transradial access (TRA) when using large-bore guiding catheters for percutaneous coronary intervention (PCI) of complex coronary lesions, the femoral artery will still be used in a considerate proportion of patients undergoing complex PCI, especially in PCI of chronic total occlusions (CTO). Ultrasound-guided puncture of the femoral artery may reduce clinically relevant access site complications, but robust evidence is lacking up to date.

METHODS AND ANALYSIS

A total of 542 patients undergoing complex PCI, defined as PCI of CTO, complex bifurcation, heavy calcified lesion or left main, in which the 7-F or 8-F transfemoral access is required, will be randomised to ultrasound-guided puncture or fluoroscopy-guided puncture. The primary outcome is the incidence of the composite end-point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Access site complications and major adverse cardiovascular events up to 1 month will also be compared between both groups.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee ('Medisch Ethische Toetsing Commissie Isala Zwolle') for all Dutch sites, 'Comité Medische Ethiek Ziekenhuis Oost-Limburg' for Hospital Oost-Limburg, 'Comité d'éthique CHU-Charleroi-ISPPC' for Centre Hospilatier Universitaire de Charleroi and 'Ethik Kommission de Ärztekammer Nordrhein' for Elisabeth-Krankenhaus). The trial outcomes will be published in peer-reviewed journals of the concerned literature. The ultrasound guided transfemoral access in complex large bore PCI trial has been administered in the ClinicalTrials.gov database, reference number: NCT03846752.

REGISTRATION DETAILS

ClinicalTrials.gov identifier: NCT03846752.

Why and How Should We Treat Chronic Total Occlusion? Evolution of State-of-the-Art Methods and Future Directions

Chronic total occlusions are considered the most complex coronary lesion in interventional cardiology. The absence of visible lumen on angiography obscures the vessel course and makes vessel wiring unlikely with conventional techniques. Often a source of severe ischemia, chronic occlusions are also markers of advanced atherosclerosis that brings other complex features including lesion length, bifurcations, calcification, adverse vessel remodelling, distal disease, and anatomic distortion from previous bypass grafting. Often advanced atherosclerosis is associated with patient characteristics like left ventricular dysfunction, previous coronary bypass surgery, or multivessel disease that increase procedural demands and hazards. To accommodate these challenges new techniques and dedicated technologies have been developed. When applied to appropriate patients, these advances have improved procedural success, safety, and outcomes. Our aim is to provide the general cardiologist with an overview of these advances that can serve as a basis for counselling patients considered for revascularization.

The Association between Serum Total Bile Acid Level and Long-Term Prognosis in Patients with Coronary Chronic Total Occlusion Undergoing Percutaneous Coronary Intervention

Background and Aims

Bile acids, the key products for elimination of cholesterol, play an important role in coronary artery disease (CAD). However, few studies focused on the roles of more accessible serum total bile acids (TBA) in the prediction of adverse cardiovascular events for coronary chronic artery occlusion (CTO). The aim of this study was to explore the potential relationship between serum TBA and long-term prognosis in patients with CTO undergoing percutaneous coronary intervention (PCI).

Methods

Baseline TBA was determined in 613 patients with CTO after PCI in the present study. All patients were divided into 3 groups according to the median (3.5 μmol/l) and the normal upper limit of the TBA (10 μmol/l). The primary endpoint was all-cause mortality, and the secondary endpoint was major adverse cardiovascular events (MACE).

Results

Average age in this study was 65.44 ± 9.94 years old. The median of TBA was 3.5 (2.1-6.1) μmol/l. Over a median follow-up of 33.5 months, compared to those with below 3.5 μmol/l TBA, 3.5 ~ 10 μmol/l TBA was associated with significantly reduced risk for the MACE (hazard ratio (HR): 0.59, 95% confidence interval (CI): 0.40 to 0.88; p = 0.009) even after adjustment for baseline variables. However, TBA did not predict all-cause mortality and cardiovascular death. Spline analyses showed an L-shaped relationship of the serum TBA with the incidence of MACE.

Conclusions

Moderate fasting serum TBA level has a predictive value for MACE even after adjusting for lifestyle and clinical risk factors in CTO patients undergoing PCI.

Safety and Feasibility of Rotational Atherectomy for Retrograde Recanalization of Chronically Occluded Coronary Arteries

Objective

To evaluate the safety and feasibility of rotational atherectomy (RA) in retrograde chronic total occlusion percutaneous coronary intervention (CTO-PCI) by analyzing immediate and long-term outcomes.

Background

Recent evidence supports the safety and feasibility of RA in CTO-PCI. However, few studies have focused on the use of RA in a retrograde approach to percutaneous revascularization of chronic total occlusion (CTO) lesions and information on long-term outcomes is lacking.

Methods

A total of 329 patients who underwent retrograde CTO-PCI, out of 1496 consecutive CTO-PCI patients from April 2017 to July 2020, were retrospectively recruited from the 2nd Cardiology Department of the Guangdong Provincial People's Hospital. 16 patients underwent RA (RA group) whilst 313 did not (non-RA group).

Results

Technical (87.5% vs. 87.5) and procedural (85.9% vs. 87.5) success rates were similar between both groups. There was no difference concerning major procedural complications between groups (12.5% vs. 19.2%; p &gt; 0.75). No in-hospital MACCEs was recorded in the RA group while there were eight MACCEs in the non-RA group (p &gt; 0.99). In the RA group, 2 cases recorded perforation (1 target vessel perforation case and 1 branch vessel perforation), and 55 cases of vessel perforations/dissections were recorded in non-RA group including 18 target vessel perforations, 2 branch vessel perforations, 35 collateral vessel perforations (one patient died from cardiac tamponade). No difference was found in terms of the perforation rate between the two groups (p &gt; 0.99). Over a mean follow-up period of 26.47 ± 14.46 months, use of RA in retrograde CTO-PCI did not result in an increased mortality rate [hazard ratio (HR) 1.58, 95% confidence interval (CI), 0.31–8.21, p = 0.65], major adverse cardiac and cerebral events (HR 0.99, 95% CI 0.35–2.79, p = 0.99) or overall rehospitalization rate (HR 1.27, 95% CI 0.44–3.67, p = 0.67). Adjusted Kaplan–Meier curves according to Cox regression model suggested several predictors influencing the all-cause mortality, cardiovascular mortality, MACCEs, stroke rate, non-fatal myocardial infarction, target vessel recanalization rate and rehospitalization rate in the comparison.

Conclusions

Our study demonstrates that the in-hospital outcomes and long-term follow up events were the same between RA and non-RA retrograde CTO-PCI patients. RA offered an option for skillful operators in difficult cases when the lesion was severely calcified in retrograde CTO-PCI.

CRP Albumin Ratio May Predict No Reflow in Patients Undergoing Percutaneous Coronary Intervention for Saphenous Vein Graft Stenosis

Many hypotheses have been proposed to explain no-reflow (NR). Some of these hypotheses, state that NR may be caused by damage to the vascular endothelium and an inflammatory process. In a recent study that did not include patients with coronary artery bypass graft (CABG), the ratio of C-reactive protein (CRP) to albumin (CAR) was found to be associated with NR. Our study aims to evaluate the relationship between CAR and NR in patients who underwent percutaneous coronary intervention (PCI) for saphenous vein graft (SVG). In this retrospective study, among the patients with CABG who underwent primary or elective coronary angiography, 242 patients who underwent PCI to the SVG were selected. The incidence of NR was 19.8% (n = 48). Diabetes mellitus, left ventricular ejection fraction (LVEF), stent length, and CAR were found as independent predictors of NR in multivariate logistic regression analysis (P < .05). Using a cut-off level of .930, the CAR predicted NR with a sensitivity of 75% and a specificity of 73% (AUC: .814, 95% CI: .749-.879, P < .001). The CAR was a better predictor than both stent length and LVEF. CAR was found to be the strongest predictor of NR in our study.

Factors associated with all-cause mortality in patients with coronary artery chronic total occlusions undergoing revascularization (percutaneous coronary intervention or surgery) or medical treatment

Aim    Chronic total occlusion of a coronary artery (CTO) is a predictor of early and late cardiovascular mortality and poor cardiovascular outcomes in patients with coronary artery disease. The purpose of this study was to identify predictors of all-cause mortality in CTO patients that underwent invasive treatment.Material and methods    Patients between 2012 and 2018 with CTO in at least one vessel, as demonstrated by coronary angiography, were included retrospectively in the study. The patients were divided into two groups, an intervention group (percutaneous and surgical revascularization) and a medical group.Results    A total of 543 patients were studied, 152 females (28%) and 391 males (72%). The median follow-up period was 49 (26-72) mos. A total of 186 (34.2%) patients in the medical group and 357 (65.8%) patients in the invasive therapy group were followed. The 5-yr death rate was observed in 50 (26.9%) patients in the medical group and 53 (14.8%) patients in the intervention group, and it was found to be statistically higher in the medical group (p=0.001). In multivariable analysis, heart failure (odds ratio (OR): 1.92, 95% CI: 1.18-3.14; p=0.01), higher glucose levels (OR: 1.05, 95% CI: 1,02-1.08; p=0.04), lower albumin levels (OR: 0.49, 95% Cl: 0.32-0.72; p=0.001), SYNTAX score (OR: 1.03, 95% CI: 1.01-1.05; p=0.001), and CTO (≥2 occluded artery) (OR: 0.42, 95% CI: 0.22-0.72; p=0.01) were independent factors for all-cause mortality.Conclusion    In comparison to the revascularized group, there was an increase in mortality among CTO patients treated medically. Heart failure, SYNTAX score, albumin, glucose, and CTO (≥2 occluded arteries) were independent risk factors for all-cause mortality.

Coronary CT Angiography to Guide Percutaneous Coronary Intervention

Coronary CT angiography (CCTA) has emerged as a powerful noninvasive tool for characterizing the presence, extent, and severity of coronary artery disease (CAD) in patients with stable angina. Recent technological advancements in CT scanner hardware and software have augmented the rich information that can be derived from a single CCTA study. Beyond merely identifying the presence of CAD and assessing stenosis severity, CCTA now allows for the identification and characterization of plaques, lesion length, and fluoroscopic angle optimization, as well as enables the assessment of the physiologic extent of stenosis through CT-derived fractional flow reserve, and may even allow for the prediction of the response to revascularization. These and other features make CCTA capable of not only guiding invasive coronary angiography referral, but also give it the unique ability to help plan coronary intervention. This review summarizes current and future applications of CCTA in procedural planning for percutaneous coronary intervention, provides rationale for wider integration of CCTA in the workflow of the interventional cardiologist, and details how CCTA may help improve patient care and clinical outcomes. Keywords: CT Angiography © RSNA, 2022.

The Comparison of Long-Term Outcome Between Patients with Single and Multiple Coronary Chronic Total Occlusions After Percutaneous Coronary Intervention

Background

Rapid advancements in percutaneous coronary intervention (PCI) have improved the outcome of chronic coronary total occlusions (CTOs); however, data regarding the difference in long-term outcomes in stable coronary artery disease (CAD) patients with single and multiple CTOs who underwent PCI are scarce. This study aimed to compare the long-term outcomes of patients with multiple CTOs and single CTO after PCI.

Methods

This study cohort included stable CAD patients who were diagnosed with CTO and treated with PCI from a single center. The primary endpoint was all-cause death.

Results

We retrospectively reviewed 670 consecutive patients with CTO-PCI. Among them, 539 patients had a single CTO, and 131 (19.7%) patients had multiple (at least two) CTOs. CTO revascularization was achieved in 470 (70.1%) patients. After a median follow-up duration of 33.7 months, the cumulative all-cause mortality (p = 0.037) and cardiac mortality (p = 0.003) were higher in patients with multiple CTOs than in those with a single CTO. In the multivariable model, multiple CTOs and left ventricular ejection fraction (LVEF) less than 40% were independent predictors for cardiac death (adjusted hazard ratio (HR) 2.53; P = 0.013 and adjusted HR 3.95; P < 0.001), while age older than 65 and LVEF less than 40% were independent predictors for all-cause death in CTO-PCI patients (adjusted hazard ratio (HR) 1.84; P = 0.035 and adjusted HR 2.54; P = 0.001).

Conclusion

In CTO-PCI patients, long-term survival was associated with multiple CTOs, age and LVEF, but not with CTO revascularization.

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

AIM

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

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

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

AIM

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

METHODS

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

STRUCTURE

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

rs41291957 controls miR-143 and miR-145 expression and impacts coronary artery disease risk

The role of single nucleotide polymorphisms (SNPs) in the etiopathogenesis of cardiovascular diseases is well known. The effect of SNPs on disease predisposition has been established not only for protein coding genes but also for genes encoding microRNAs (miRNAs). The miR-143/145 cluster is smooth muscle cell-specific and implicated in the pathogenesis of atherosclerosis. Whether SNPs within the genomic sequence of the miR-143/145 cluster are involved in cardiovascular disease development is not known. We thus searched annotated sequence databases for possible SNPs associated with miR-143/145. We identified one SNP, rs41291957 (G > A), located -91 bp from the mature miR-143 sequence, as the nearest genetic variation to this miRNA cluster, with a minor allele frequency > 10%. In silico and in vitro approaches determined that rs41291957 (A) upregulates miR-143 and miR-145, modulating phenotypic switching of vascular smooth cells towards a differentiated/contractile phenotype. Finally, we analysed association between rs41291957 and CAD in two cohorts of patients, finding that the SNP was a protective factor. In conclusion, our study links a genetic variation to a pathological outcome through involvement of miRNAs.

The therapeutic effects of excimer laser coronary atherectomy therapy for in-stent restenosis chronic total occlusions

OBJECTIVES

To evaluate the safety and efficacy of excimer laser coronary atherectomy (ELCA) in patients with in-stent restenosis chronic total occlusions (ISR CTOs).

BACKGROUND

ISR CTOs are a challenge in percutaneous coronary intervention (PCI). Although they can be treated by ELCA, limited data are available on the effects of ELCA treatment in these patients.

METHODS

Fifty-nine consecutive patients underwent PCI for ISR CTOs at Beijing Hospital between December 2017 and September 2020. According to whether or not ELCA was performed, they were divided into two groups. Quantitative coronary angiography (QCA) analyses were performed routinely, including measurement of the minimal lumen diameter and calculation of the percentage diameter stenosis. The procedural success rate, the frequency of peri-procedural complications, and the incidence rates of major adverse cardiac events (MACEs) over nine months were assessed. The primary endpoint in the study was the percentage diameter stenosis.

RESULTS

Procedure success was achieved in most patients in both groups (75.9%). Patients in the ELCA group exhibited a lower percentage diameter stenosis (24.5 ± 9.09 vs. 35.1 ± 18.6, p = 0.048) and a larger minimal lumen diameter (2.36 ± 0.29 mm vs. 1.78 ± 0.64 mm, p < 0.001) than those in the control group and the 9-month incidence rates of MACEs did not differ (9.5% vs 15.8%, p = 0.699).

CONCLUSIONS

This study demonstrated that ELCA may be a safe and effective technique in the treatment of ISR CTOs, and the use of ELCA can achieve good immediate angiographic results, as measured by QCA, without increasing peri-procedural complications or the incidence rates of 9-month MACEs.

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

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

A novel angiographic classification for the endovascular recanalization of symptomatic nonacute extracranial vertebral artery occlusion

BACKGROUND

There remains major uncertainty regarding the optimal therapy for symptomatic nonacute extracranial vertebral artery occlusion (EVAO). Endovascular recanalization for EVAO is technically challenging, and limited data are available. This research aimed to report a multicenter clinical experience of endovascular recanalization for symptomatic nonacute EVAO and establish a novel angiographic classification.

METHODS

From June 2011 to December 2019, 50 symptomatic nonacute EVAO patients treated with endovascular recanalization in three regional referral stroke centers were retrospectively analyzed. All patients were categorized into four groups based on the angiographic classification. The rates of technical success, periprocedural complications, any stroke or death within 1 month, and follow-up data were assessed.

RESULTS

The rates of technical success, periprocedural complications, and any stroke or death within 1 month were 86.0% (43/50), 12.0% (6/50), and 4.0% (2/50), respectively. The recanalization rates gradually decreased from Type A to Type D (100%, 94.7%, 80%, and 63.6%, respectively; P=0.007). The EVAO patients in the Type A group with tapered stump and short-segment occlusions showed excellent recanalization effects, with 100% technical success rates and no complications. Conversely, the lowest recanalization rate of 63.6% (7/11) and the highest periprocedural complication rate of 27.3% (3/11) were observed for the Type D group.

CONCLUSIONS

Endovascular recanalization for symptomatic nonacute EVAO is technically feasible, especially Type A EVAO patients, which can provide an alternative treatment option for recurrent vertebrobasilar ischemia despite optimal medical therapy. The angiographic categorization established in this study is conducive to the selection of suitable patients prior to treatment decision.

Endovascular recanalization for non-acute basilar artery occlusions with progressive or recurrent ischemic symptoms: a multicenter clinical experience

BACKGROUND

There is no consensus on the optimal treatment of non-acute basilar artery occlusion (BAO), and endovascular recanalization still poses a therapeutic challenge for these patients. We report a multicenter clinical experience of endovascular recanalization for symptomatic non-acute BAO and propose an angiographic grouping to determine which patient subgroup most benefits from this treatment.

METHODS

Forty-two patients with non-acute BAO with progressive or recurrent vertebrobasilar ischemic symptoms who underwent endovascular recanalization were retrospectively analyzed from January 2015 to December 2019. These patients were classified into three subtypes based on their occlusion length and distal collateral reconstruction on angiograms. The rates of technical success, periprocedural complications and outcome, any stroke or death within 1 month, and follow-up data were examined.

RESULTS

The success rate of endovascular recanalization was 76.2% (32/42). The rate of periprocedural complications was 14.3% (6/42). In the three subgroups (types I-III) the success rates of endovascular recanalization were reduced (90.0%, 71.4% and 50%, respectively, p=0.023), while the overall rates of periprocedural complications were increased (5.0%, 14.3% and 37.5%, respectively, p=0.034). Type I lesions, with short-segment occlusions and good distal BA collateral reconstruction, showed favorable responses to endovascular recanalization. The median follow-up time was 1 year (IQR 11.0-19.5 months), with any stroke or death during follow-up at a rate of 7.9%.

CONCLUSION

Endovascular recanalization can be safe and feasible for reasonably selected patients with non-acute BAO, especially type I lesions, and offers an alternative choice for those with progressive or recurrent vertebrobasilar ischemic symptoms despite aggressive medical therapy.

Prognostic value of malnutrition using geriatric nutritional risk index in patients with coronary chronic total occlusion after percutaneous coronary intervention

BACKGROUND

Malnutrition is associated with poor prognosis in a wide range of chronic illnesses, however, the impact of malnutrition on long-term outcomes of patients at advanced stages of atherosclerosis, coronary chronic artery occlusion (CTO), is not known.

AIMS

This study aims to investigate the relationship between malnutrition and adverse cardiovascular events in patients with CTO after percutaneous coronary intervention (PCI).

METHODS

Baseline malnutrition risk was determined in 669 patients with CTO after PCI in this study. All patients were divided into 3 groups according to 3 categories of the geriatric nutritional risk index (GNRI): moderate to severe, GNRI of <92 (n = 70); low, GNRI of 92-98 (n = 197); and absence of risk, GNRI of ≥98 (n = 402). The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiovascular events (MACE).

RESULTS

Average age in this study was 65.32 ± 9.97 years old. More than one-third of patients were at risk of malnutrition (moderate to severe: 10.5%; low: 29.4%; and absence of risk: 60.1%). Over a median follow-up of 33 months, compared to those with absent risk for malnutrition, moderate to severe risk was associated with significantly increased risk for the all-cause death, cardiovascular death and MACE (hazard ratio [HR]: 2.90, 95% confidence interval [CI]: 1.43 to 5.87, P for trend = 0.002; HR: 3.72, 95% CI: 1.42 to 9.77, P for trend = 0.010; HR: 1.76, 95% CI: 1.02 to 3.03, P for trend = 0.040; respectively) after adjustment for baseline variables. Moreover, addition of the GNRI score significantly raised the predictive value for the all-cause death (0.383, p = 0.004 and 0.022, p = 0.011, NRI and IDI respectively), cardiovascular death (0.488, p < 0.001 and 0.013, p = 0.014, NRI and IDI respectively) and MACE (0.368, p = 0.004 and 0.014, p = 0.008, NRI and IDI respectively) as compared to traditional factors.

CONCLUSIONS

Malnutrition assessed by the GNRI score on admission was an independent predictor for adverse cardiovascular events in CTO patients after PCI. Addition of the GNRI score to the existing risk prediction model significantly increased the predictive ability for cardiovascular events in CTO patients after PCI.

Factors associated with left ventricular reverse remodelling after percutaneous coronary intervention in patients with left ventricular systolic dysfunction

Percutaneous coronary intervention (PCI) is sometimes considered as an alternative therapeutic strategy to surgical revascularization in patients with coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF). However, the types or conditions of patients that receive the clinical benefit of left ventricular reverse remodelling (LVRR) remain unknown. The purpose of this study was to investigate the determinants of LVRR following PCI in CAD patients with reduced LVEF. From 4394 consecutive patients who underwent PCI, a total of 286 patients with reduced LV systolic function (LVEF < 50% at initial left ventriculography) were included in the analysis. LVRR was defined as LV end-systolic volume reduction ≥ 15% and improvement of LVEF ≥ 10% at 6 months follow-up left ventriculography. Patients were divided into LVRR (n = 63) and non-LVRR (n = 223) groups. Multivariate logistic regression analysis revealed that unprotected left main coronary artery (LMCA) intervention was significantly associated with LVRR (P = 0.007, odds ratios [OR] 4.70, 95% confidence interval [CI] 1.54-14.38), while prior PCI (P = 0.001, OR 0.35, 95% CI 0.19-0.66), presence of in-stent restenosis (P = 0.016, OR 0.32, 95% CI 0.12-0.81), and presence of de-novo stenosis (P = 0.038, OR 0.36, 95% CI 0.14-0.95) were negatively associated with LVRR. These data suggest the potential prognostic benefit of unprotected LMCA intervention for LVRR and importance of angiographic follow-up in patients with CAD and LV systolic dysfunction.

Endovascular Recanalization of Symptomatic Nonacute Intracranial Internal Carotid Artery Occlusion: Proposal of a New Angiographic Classification

BACKGROUND AND PURPOSE

The optimal treatment for symptomatic nonacute intracranial ICA occlusion is uncertain, and endovascular recanalization remains a technical challenge. Our purpose was to report multicenter clinical results of endovascular recanalization for medically refractory, nonacute, intracranial ICA occlusion and to propose a new angiographic classification to explore which subgroups of patients are most amenable to this treatment.

MATERIALS AND METHODS

From January 2015 to December 2019, thirty-six consecutive patients who underwent endovascular recanalization for refractory, nonacute, atherosclerotic intracranial ICA occlusion at 3 stroke centers were analyzed retrospectively. The patients were divided into 3 types according to an angiographic classification. Rates of technical success, periprocedural complications, and any stroke or death within 30 days along with follow-up results were evaluated.

RESULTS

The overall technical success rate was 80.6% (29/36), and the rate of any stroke or death within 30 days was 16.7% (6/36). The recanalization success rate gradually decreased from type I to type III in the 3 classification groups (92.9%, 81.3%, and 50%, P = .038), and the opposite was true of the perioperative complication rates (7.1%, 18.8%, and 50%, P = .038). Type I lesions showed favorable recanalization effects, 92.9% technical success rates, and 7.1% perioperative complications.

CONCLUSIONS

Endovascular recanalization for nonacute atherosclerotic intracranial ICA occlusion is technically feasible, especially in patients with type I lesions, and could offer an alternative option for patients with recurrent ischemic symptoms despite aggressive medical therapy. The angiographic classification proposed is conducive to the selection of suitable patients and difficulty in grading.

Cystatin C-Based Renal Function in Predicting the Long-Term Outcomes of Chronic Total Occlusion After Percutaneous Coronary Intervention

Renal function estimated by various biomarkers predicting for adverse cardiovascular events has not been well-identified in received percutaneous coronary intervention (PCI) for chronic total occlusion (CTO), the advanced stages of atherosclerosis. We aim to determine whether the serum cystatin C-based-estimated glomerular filtration rate (eGFR) can have an improved predictive value in patients with CTO lesions undergoing PCI as compared with multiple creatinine-based estimates of kidney function. Six hundred and seventy-one patients received CTO PCI were retrospectively included in the study. The eGFR was calculated by modification of diet in renal disease equation for Chinese (cMDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations at baseline, respectively. Then, the cohort was categorized into three groups according to standard KDIGO kidney stages based on eGFR. The primary endpoint was all-cause mortality, and the secondary endpoint was cardiac death. Strikingly, cystatin C-based eGFR showed a better performance with the greater area being under the receiver operating characteristic (ROC) curve (0.73 for all-cause mortality and 0.73 for cardiac death, separately) and a better assessment for survival free from adverse event across renal levels among four eGFR equations. Compared with eGFR calculated by other formulas, serum cystatin C-based eGFR showed the highest prognostic value for both all-cause mortality (adjusted HR 3.6, 95% CI 1.6-8.1, P = 0.002) and cardiac death (adjusted HR 2.9, 95% CI 1.0-8.1, P = 0.028). Moreover, cystatin C-based eGFR significantly improved the risk reclassification of event with a high value of net reclassification improvement and integrated discrimination improvement. This study may prove that cystatin C-based eGFR is a better predictor of both all-cause mortality and cardiac death than other equations in populations with CTO undergoing PCI.

Endovascular recanalization for symptomatic non-acute middle cerebral artery occlusion: proposal of a new angiographic classification

BACKGROUND

Endovascular recanalization for medically refractory non-acute middle cerebral artery (MCA) occlusion remains a clinical dilemma, and limited data are available. We report the multicenter clinical results of endovascular recanalization for symptomatic non-acute MCA occlusion and propose a new angiographic classification to explore which subgroups of patients are most suitable for this treatment.

METHODS

From January 2015 to December 2019, 50 consecutive patients who underwent endovascular recanalization for recurrent symptomatic non-acute MCA occlusion were analyzed retrospectively. All patients were divided into three types according to the angiographic classification. The technical success rate, periprocedural complications, rate of stroke or death within 30 days, and follow-up results were evaluated.

RESULTS

The overall technical success rate was 84.0% (42/50). The perioperative complication rate was 14.0% (7/50), and the rate of stroke or death within 30 days was 12.0% (6/50). The revascularization success rate was higher in patients with type I occlusion than in those with type II or type III occlusion (95.5%, 83.3%, and 60%, respectively; p=0.014), and the opposite was true for the perioperative complication rate (4.5%, 11.1%, and 40.0%, respectively; p=0.013). The median clinical follow-up period was 13.4 months (IQR 12.5-15.6), and the rate of stroke or death beyond 30 days was 8.3%.

CONCLUSIONS

Endovascular recanalization for non-acute MCA occlusion is technically feasible in reasonably selected patients, especially type I patients, and has potential as an alternative option for patients with recurrent stroke or transient ischemic attack in the short term despite optimal medical therapy.

Coronary Angiography Characteristics as Predictor of Successful Chronic Total Occlusion Recanalization

Although remarkable progress in percutaneous coronary intervention (PCI) has been achieved over the last decade, the success rate of chronic total occlusion (CTO) recanalization varies greatly. Coronary angiography characteristics may affect the success rate of CTO recanalization. This study sought to establish a scoring model to predict successful CTO recanalization based on coronary angiography characteristics. We analyze 287 angiography data from patients who underwent elective PCI. Angiography characteristics being measured were lesion location, blunt stump, calcification, ostial lesion, bridging collateral, bending, side branch, tortuosity, previous stent attempt, and lesion length of >20 mm. Data were analyzed using SPSS 25.0. Multivariate analysis shows that side branch lesion ( p  = 0.000), proximal vessels tortuosity ( p  = 0.015), calcified lesion ( p  = 0.000), lesion length of >20 mm ( p  = 0.000), and blunt stump ( p  = 0.000) can predict the successful PCI in the CTO. ROC curve analysis of the score ability to predict successful PCI in the CTO showed area under curve of 0.89 (confidence interval 95%), the cutoff point of ≤2 with a sensitivity of 93.33%, and specificity of 88.23%. We concluded that the five angiography characteristics that strongly associate with successful PCI in the CTO are calcified lesion, blunt stump, lesion length >20 mm, proximal vessel tortuosity, and side branch lesion. This score may help cardiologists to predict the success probability of PCI in the CTO.

Relationship between Coronary Iodine Concentration Determined Using Spectral CT and the Outcome of Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

PURPOSE

To evaluate the feasibility of coronary iodine concentration (CIC) by using spectral CT in the assessment of the outcome of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO).

MATERIALS AND METHODS

In total, 50 consecutive patients underwent preprocedural coronary CT angiography with spectral CT prior to their staged PCI for CTO between June 2017 and July 2018. Iodine density maps, referred to as iodine-no-water maps throughout, with spectral CT provided the CIC at proximal CTO (CTO-CIC). Depending on the outcome of PCI, all CTO lesions were divided into two groups: failed PCI and successful PCI. The receiver operating characteristic curve was used to determine the cutoff values of CTO-CIC in the assessment of the outcome of PCI for CTO.

RESULTS

Of the 50 CTO lesions in 50 patients, 34 (68%) and 16 (32%) were assigned to the successful PCI and failed PCI groups, respectively. The mean CTO-CIC was significantly less in the failed PCI group than in the successful PCI group (1.3 mg/mL ± 0.9 [standard deviation] vs 5.2 mg/mL ± 2.5; P < .001). A low CTO-CIC (≤ 2.5 mg/mL) predicted failed PCI with 87% sensitivity, 79% specificity, 79% positive predictive value, and 90% negative predictive value. At multivariable analysis, the low CTO-CIC was significantly associated with the failed PCI (odds ratio, 27.0; 95% confidence interval: 4.9, 147.6; P < .0001).

CONCLUSION

The CTO-CIC determined by using spectral CT may be useful in the assessment of the outcome of staged PCI for CTO.See also the commentary by Rubinshtein and Blankstein in this issue.© RSNA, 2020.

Complex Large-Bore Radial percutaneous coronary intervention: rationale of the COLOR trial study protocol

INTRODUCTION

The radial artery has become the standard access site for percutaneous coronary intervention (PCI) in stable coronary artery disease and acute coronary syndrome, because of less access site related bleeding complications. Patients with complex coronary lesions are under-represented in randomised trials comparing radial with femoral access with regard to safety and efficacy. The femoral artery is currently the most applied access site in patients with complex coronary lesions, especially when large bore guiding catheters are required. With slender technology, transradial PCI may be increasingly applied in patients with complex coronary lesions when large bore guiding catheters are mandatory and might be a safer alternative as compared with the transfemoral approach.

METHODS AND ANALYSIS

A total of 388 patients undergoing complex PCI will be randomised to radial 7 French access with Terumo Glidesheath Slender (Terumo, Japan) or femoral 7 French access as comparator. The primary outcome is the incidence of the composite end point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Procedural success and major adverse cardiovascular events up to 1 month will also be compared between both groups.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee at each recruiting center ('Medisch Ethische Toetsing Commissie Isala Zwolle', 'Commissie voor medische ethiek ZNA', 'Comité Medische Ethiek Ziekenhuis Oost-Limburg', 'Comité d'éthique CHU-Charleroi-ISPPC', 'Commission cantonale d'éthique de la recherche CCER-Republique et Canton de Geneve', 'Ethik Kommission de Ärztekammer Nordrhein' and 'Riverside Research Ethics Committee'). The trial outcomes will be published in peer-reviewed journals of the concerned literature.

TRIAL REGISTRATION NUMBER

NCT03846752.

The Role of Percutaneous Coronary Intervention in the Treatment of Chronic Total Occlusions: Rationale and Review of the Literature

BACKGROUND

Chronic total occlusion (CTO) of a coronary artery is defined as an occluded segment with no antegrade flow and a known or estimated duration of at least 12 weeks.

OBJECTIVE

We considered the current literature describing the indications and clinical outcomes for denovo CTO- percutaneous coronary intervention (PCI), and discuss the role of CTO-PCI and future directions for this procedure.

METHODS

Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL were searched and relevant studies of CTO-PCI were selected for review.

RESULTS

The prevalence of coronary artery CTO's has been reported to be ~ 20% among patients undergoing diagnostic coronary angiography for suspected coronary artery disease. Revascularization of any CTO can be technically challenging and a time-consuming procedure with relatively low success rates and may be associated with a higher incidence of complications, particularly at non-specialized centers. However, with an increase in experience and technological advances, several centers are now reporting success rates above 80% for these lesions. There is marked variability among studies in reporting outcomes for CTO-PCI with some reporting potential mortality benefit, better quality of life and improved cardiac function parameters. Anecdotally, properly selected patients who undergo a successful CTO-PCI most often have profound relief of ischemic symptoms. Intuitively, it makes sense to revascularize an occluded coronary artery with the goal of improving cardiovascular function and patient quality of life.

CONCLUSION

CTO-PCI is a rapidly expanding specialized procedure in interventional cardiology and is reasonable or indicated if the occluded vessel is responsible for symptoms or in selected patients with silent ischemia in whom there is a large amount of myocardium at risk and PCI is likely to be successful.

Outcomes of late endovascular recanalization for symptomatic non-acute atherosclerotic intracranial large artery occlusion

OBJECTIVES

The optimal treatment of symptomatic non-acute atherosclerotic intracranial large artery occlusion (ILAO) beyond 24 h from onset remains uncertain. We investigate the outcomes of late endovascular recanalization for symptomatic non-acute atherosclerotic ILAO.

PATIENTS AND METHODS

From September 2013 to July 2018, with safety as the first principle, late endovascular recanalization for symptomatic non-acute atherosclerotic ILAO beyond 24 h from onset was attempted in 32 consecutive patients. Primary safety outcome was any stroke or death within 30 days. Primary efficacy outcome were functional independence at 90 days.

RESULTS

The median time from imaging-documented occlusion to treatment was 25.5 days (interquartile range: 10.5-36.5) for all patients. Technical success in recanalization was achieved in 17 patients (53.1%, 17/32). The 30-day rate of any stroke or death was 5.9% (1/17) in the recanalized group versus 6.7% (1/15) in the failure group (P = 0.927). The rate of functional independence at 90 days (70.5%, 12/17) was increased significantly as compared with that before operation (23.5%, 4/17) in the recanalized group (P = 0.015). The rate of functional independence at 90 days (66.7%, 10/15) was not different from that before operation (66.7%,10/15) in the failure group (P = 1.00). The median score reduction in mRS from baseline at 90 days was 1.0 (interquartile range: 1.0-2.0) in the recanalized group versus 0 (interquartile range: 0.0-0.0) in the failure group (P＜0.001).

CONCLUSION

For carefully selected patients with symptomatic non-acute atherosclerotic ILAO beyond 24 h from onset, late endovascular recanalization is technically feasible. The periprocedural safety of late endovascular recanalization is acceptable. Successful recanalization may effectively improve the degree of disability in such patients. However, it should be emphasized that revascularization of non-acute ILAO is a high risk procedure, which should only be performed by experienced operators with safety as the first principle.

A novel real-time intravascular ultrasound double-lumen microcatheter for recanalization of chronic total occlusion: a case report

Background

Chronic total occlusion revascularization remains a challenging problem because of its complexity. We present a case of a patient with chronic total occlusion who was successfully revascularized with the use of a new device called a real-time intravascular ultrasound double-lumen microcatheter.

Case presentation

A 58-year-old East Asians woman presented to our hospital with a complaint of recurrent chest pain of 5 months’ duration. Angiography revealed chronic total occlusion of the right coronary artery from the right coronary artery ostium to the ostia of the posterolateral and posterior descending branches. A guidewire was passed to the distal right coronary artery but went into the false lumens at the posterior descending and posterolateral ostia after use of the antegrade and retrograde approaches. Hence, we used the new device to pass through the subintimal right coronary artery space with reentry into the true lumen before the posterior descending and posterolateral ostia. A stent was successfully deployed at the posterior descending and posterolateral ostia, and the final result was excellent.

Conclusions

This device was useful for finding the entry point and for reentry into the true lumen of a chronic total occlusion. It may be a valuable tool for recanalization of complex chronic total occlusion lesions.

A comparison of procedural success rate and long-term clinical outcomes between in-stent restenosis chronic total occlusion and de novo chronic total occlusion using multicenter registry data

Background

There have been little data about outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusion (CTO) in the drug eluting stent (DES) era. This study aimed to compare the procedural success rate and long-term clinical outcomes of ISR CTO and de novo CTO.

Methods and results

Patients who underwent PCI for ISR CTO (n = 164) versus de novo CTO (n = 1208) were enrolled from three centers in Korea between January 2008 and December 2014. Among a total of ISR CTO, a proportion of DES ISR CTO was 79.3% (n = 130). The primary outcome was major adverse cardiac events (MACEs); a composite of all-cause death, non-fatal myocardial infarction (MI), or target lesion revascularization (TLR). Following propensity score-matching (1:3), the ISR CTO group (n = 156) had a higher success rate (84.6% vs. 76.0%, p = 0.035), mainly driven by high success rate of PCI for DES ISR CTO (88.6%), but showed a higher incidence of MACEs [hazard ratio (HR): 2.06; 95% confidence interval (CI) 1.37–3.09; p < 0.001], mainly driven by higher prevalence of MI [HR: 9.71; 95% CI 2.06–45.81; p = 0.004] and TLR [HR: 3.04; 95% CI 1.59–5.81; p = 0.001], during 5 years of follow-up after successful revascularization, as compared to the de novo CTO group (n = 408).

Conclusion

The procedural success rate was higher in the ISR CTO than the de novo CTO, especially in DES ISR CTO. However, irrespective of successful revascularization, the long-term clinical outcomes for the ISR CTO were significantly worse than those for the de novo CTO, in terms of MI and TLR.

Graphic abstract

Improvement of left ventricular function assessment by global longitudinal strain after successful percutaneous coronary intervention for chronic total occlusion

The benefit of revascularization of chronic total occlusion (CTO) in percutaneous coronary intervention (PCI) is controversial. On the other hand, left ventricular (LV) global longitudinal strain (GLS) is a more sensitive marker of LV myocardial ischemia and LV function than LV ejection fraction (EF). The purpose of this study was to investigate the impact of revascularization of CTO on LV function using LV GLS. A total of 70 consecutive patients (65.1±8.9 years, 59 males, LVEF 51.0±12.0%) with CTO who had a positive functional ischemia and underwent PCI, were included in this study. Echocardiography was performed before and 9 months after the procedure with conventional assessment including LV end-diastolic and end-systolic volume (LVEDV, LVESV), LVEF, and with 2DSTE analysis of GLS. Successful PCI was obtained in 60 patients (86%). There were no stent thromboses during follow-up. GLS showed a significant improvement 9 months after successful PCI (pre-PCI -12.4±4.1% vs. post-PCI -14.5±4.1%, P< 0.01), whereas in failed PCI group that did not change significantly (pre-PCI -13.2±4.2% vs. post-PCI -14.0±4.7%, P = 0.64). LVEF, LVEDV and LVESV did not change significantly during follow-up in both successful and failed groups. Successful PCI for CTO improved LV function, assessed by LV GLS.

Risk of cardiac and sudden death with and without revascularisation of a coronary chronic total occlusion

Objective

The aim of this study is to evaluate the long-term risk of cardiac death and sudden cardiac death (SCD) and/or sustained ventricular arrhythmias (SVAs) in patients with coronary chronic total occlusions (CTO) revascularised versus those with CTO not revascularised by percutaneous coronary intervention (PCI).

Methods

From a cohort of 1357 CTO-PCI patients, 1162 patients who underwent CTO PCI attempt were included in this long-term analysis: 837 patients were revascularised by PCI (CTO-R group) and 325 were not revascularised (CTO-NR group). Primary adverse endpoint was the incidence of cardiac death; secondary endpoint was the cumulative incidence of SCD/SVAs.

Results

Up to 12-year follow-up (median 6 year), compared with CTO-R patients, those with CTO-NR had significantly higher rate of cardiac death (13%[43/325]vs6%[48/837]; p<0.001) and SCD/SVAs (7.5%[24/325]vs2.5%[20/837]; p<0.001). The risk of cardiac death and SCD/SVAs was mainly driven by the subgroup of infarct-related artery (IRA) CTO patients and was significantly higher only in IRA CTO-NR patients (18%vs7%, p<0.001, 14%vs5%, p=0.001; IRA CTO-NR vs IRA CTO-R, respectively). At multivariable Cox hazards regression analysis, CTO-NR remains one of the strongest independent predictors of higher risk of cardiac death and of SCD/SVAs in the overall population and in IRA CTO patients.

Conclusions

At long-term follow-up, patients with CTO not revascularised by PCI had worse outcomes compared with those with CTO revascularised, with >2-fold risk of cardiac death and threefold risk of SCD/SVAs. The presence of an infarct-related artery (IRA CTO) not revascularised identified the category of patients with the highest rate of adverse events .

Procedural and follow-up clinical outcomes after chronic total occlusion revascularization: Data from an Indian public hospital

BACKGROUND

Chronic total occlusion (CTO) continues to be challenging lesion subset for percutaneous intervention. Last decade has seen tremendous increase in percutaneous coronary intervention (PCI) in this subset owing to improved understanding of the anatomy and enhanced skillset with availability of dedicated hardware. We sought to study the outcomes of CTO PCI in an Indian public hospital.

METHODS

This was a single-center non-randomized descriptive follow-up study on CTO PCI. The end-points were procedural success, immediate, and late adverse cardiovascular events [major adverse cardiac event (MACE)] and change in angina and left ventricular function at follow-up.

RESULTS

A total 389 CTO lesions were treated with a success rate of 87% (339/389). The mean Japanese chronic total occlusion (J-CTO) score was 1.78 ± 0.12 (mean ± standard deviation). Multivariate analysis of different angiographic components of J-CTO score identified tortuosity (p = 0.001), calcifications (p ≤ 0.001), and blunt stump (p = 0.007) as independent predictors of procedural failure. The periprocedural mortality was less than 1%, and the non-life threatening complications were about 4%. The MACE rate was significantly higher in the procedural failure group (60%) than in the procedural success group (5.3%, p < 0.001). An increase in left ventricular ejection fraction (LVEF) was noted following successful CTO PCI after complete revascularization.

CONCLUSIONS

The success rates for CTO PCI in this registry were about 87%. Immediate and long-term clinical outcomes were better with lower MACE (5%) after a successful procedure. A key outcome variable included an increase in LVEF among patients after a successful CTO PCI. The overall periprocedural complications were about 5.5%, but majority were non-life threatening.

Internal mammary artery graft failure: Clinical features, management, and long-term outcomes

Objective

Data on long-term outcomes after internal mammary artery (IMA) coronary graft failure are scarce. Our objective was to describe the clinical characteristics, management, and prognosis after angiographically confirmed IMA graft failure following coronary revascularization.

Methods

A three-hospital retrospective registry, observational and descriptive, with prospective follow-up of all consecutive cases of IMA graft failure between 2004 and 2014 was conducted. After treatment, clinical and procedural features were compared between those with and without cardiovascular events.

Results

Fifty-seven patients were included (89% male, mean age: 62 years, at surgery) in the registry. Most patients underwent an IMA angioplasty (percutaneous coronary intervention [PCI], 74%). In nine cases, the PCI failed at the graft level, and seven underwent a native vessel revascularization. Native vessel treatment was performed in 20% of the study subjects, all with stents. Finally, medical management was decided in three cases. Events after treatment for IMA graft failure were frequent (50.8%), during a median follow-up of 7.5 years. Acute presentation (hazard ratio_MACE = 1.35; 95% confidence interval (CI): 1.12–3.00, p < 0.01), age of the patient (hazard ratio_MACE = 1.85, 95% CI: 1.17–2.11, p < 0.01), presence of diabetes mellitus (hazard ratio_MACE = 2.75, 95% CI: 1.13–6.69, p = 0.02), and the management modality used (IMA-simple angioplasty VS IMA-stenting: hazard ratio_MACE = 5.5, 95% CI: 1.40–21.15, p = 0.01) displayed prognostic relevance on multivariate analysis. All-cause mortality occurred in 21.1% and presentation as infarction (hazard ratio_DEATH = 1.05, 95% CI: 1.01–2.17, p = 0.01), age (hazard ratio_DEATH = 9.08, 95% CI: 2.52–32.69, p < 0.01), and left ventricular ejection fraction (hazard ratio_DEATH = 3.68, 95% CI: 1.65–8.18, p < 0.01) were independent predictors of the same.

Conclusions

In this long-term registry, most patients presented with an acute condition (myocardial infarction, progressive angina) within 12 months after surgery. Acute presentation, age, diabetes mellitus, reduced left ventricular ejection fraction, IMA graft failure segment affected, and the management strategy were related with long-term prognosis.

Impact of Coronary Artery Chronic Total Occlusion on Arrhythmic and Mortality Outcomes: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aimed to examine the relationship between chronic coronary artery total occlusion (CTO) status and the occurrence of ventricular tachycardia (VT)/ventricular fibrillation (VF) or appropriate implantable cardioverter-defibrillator (ICD) therapy.

BACKGROUND

CTO is a significant problem in patients with ischemic heart disease. However, the extent to which it predisposes affected individuals to VT/VF and whether these arrhythmic events could be prevented by revascularization are unclear. Therefore, a systematic review and meta-analysis were conducted to examine the relationship between CTO status and the occurrence of VT/VF or appropriate ICD therapy.

METHODS

PubMed and Embase databases were searched until November 16, 2017, identifying 137 studies.

RESULTS

Seventeen studies involving 54,594 subjects (mean age, 61 ± 21 years of age, 81% male) with a mean follow-up of 43 ± 31 months were included. The presence of CTO was associated with higher risk of VT/VF or appropriate ICD therapy (adjusted hazard ratio [aHR]: 1.99; 95% confidence interval (CI): 1.53 to 2.59; p < 0.0001, I² = 3%) but not in cardiac mortality (aHR: 2.59; 95% CI: 0.64 to 10.59; p = 0.18, I² = 86%) or in all-cause mortality (aHR: 1.70; 95% CI: 0.84 to 3.46; p = 0.14; I² = 64%). Compared to patients with non-infarct-related CTOs, those with infarct-related CTOs have a higher risk of VT/VF or appropriate ICD therapy (aHR: 2.47; 95% CI: 1.76 to 3.46; p < 0.0001; I² = 14%), cardiac mortality (aHR: 2.73; 95% CI: 1.02 to 7.30; p < 0.05; I² = 79%) and higher all-cause mortality (aHR: 1.69; 95% CI: 1.19 to 2.40; p < 0.01; I² = 40%). Nonrevascularization of CTOs tended to be associated with an increased risk of all-cause mortality compared to successful revascularization (unadjusted HR: 1.52; 95% CI: 0.96 to 2.43; p = 0.08; I² = 76).

CONCLUSIONS

CTOs, especially infarct-related, are associated with high risk of VT/VF or appropriate ICD therapy and mortality. ICD implantation could be beneficial. However, it is not clear that revascularization has an impact on the outcome of patients with CTOs.

Incidence and in-hospital outcomes of single-vessel coronary chronic total occlusion treated with percutaneous coronary intervention

BACKGROUND

Coronary chronic total occlusion (CTO) using percutaneous coronary intervention (PCI) presents a distinct challenge in the field of cardiology owing to multiple reasons including the increased risk of peri-procedural complications. We sought to explore rates of hospitalization, outcomes, use of mechanical circulatory support devices, and economic burden associated with single-vessel coronary CTO undergoing PCI for stable coronary artery disease (CAD).

METHODS

The National Inpatient Sample spanning from 2008 through 2014 was queried to identify hospitalizations associated with single-vessel coronary CTO-PCI for stable CAD by excluding hospitalizations with ST-elevation and non-ST elevation myocardial infarction. Survey-Specific logistic regression was used to analyze adjusted incidence of in-hospital mortality and acute renal failure.

RESULTS

A total of 109,094 hospitalizations were identified as having single-vessel coronary CTO-PCI for stable CAD from 2008 to 2014. An increasing number of coronary CTO-PCI hospitalizations (2465 to 2688 per 100,000 PCI procedures, P_trend < 0.001) with an overall in-hospital mortality of 0.5% was observed. The rate of in-hospital mortality remained unchanged (P_trend = 0.13), but an increasing rate of acute renal failure was observed in the multivariate-adjusted analysis (P_trend < 0.001). Furthermore, a rise in the utilization of intra-aortic balloon pumps and percutaneous left ventricular assist devices during single-vessel coronary CTO-PCI was noted. Taken together, these may account for increasing costs of hospitalization for single-vessel coronary CTO-PCI ($13,909 in 2008 to $17,729 in 2014, P_trend < 0.001).

CONCLUSION

In a large retrospective study, slightly increased rates of single-vessel coronary CTO-PCI for stable CAD were observed. This is accompanied by a rise in morbidity and growing healthcare costs.

Sparse Ultrasound Image Reconstruction From a Shape-Sensing Single-Element Forward-Looking Catheter

OBJECTIVE

Minimally invasive procedures, such as intravascular and intracardiac interventions, may benefit from guidance with forward-looking (FL) ultrasound. In this work, we investigate FL ultrasound imaging using a single-element transducer integrated in a steerable catheter, together with an optical shape sensing (OSS) system.

METHODS

We tested the feasibility of the proposed device by imaging the surface of a tissue-mimicking (TM) phantom and an ex vivo human carotid plaque. While manually steering the catheter tip, ultrasound A-lines are acquired at 60 Hz together with the catheter shape from the OSS system, resulting in a two-dimensional sparse and irregularly sampled data set. We implemented an adaptive Normalized Convolution (NC) algorithm to interpolate the sparse data set by applying an anisotropic Gaussian kernel that is rotated according to the local direction of the catheter scanning pattern. To choose the Gaussian widths tangential ( ${\sigma _t}$) and normal ( ${\sigma _n}$) to the scanning pattern, an exhaustive search was implemented based on RMSE computation on simulated data.

RESULTS

Simulations showed that the sparse data set contains only 5% of the original information. The chosen widths, ${\sigma _n} = \text{250}\;\mu {\textrm{m}}$ and ${\sigma _t} = \text{100}\;\mu{\textrm{m}}$, are used to successfully reconstruct the surface of the phantom with a contrast ratio of 0.9. The same kernel is applied successfully to the carotid plaque data.

CONCLUSION

The proposed approach enables FL imaging with a single ultrasound element, mounted on a steerable device.

SIGNIFICANCE

This principle may find application in a variety of image-guided interventions, such as chronic total occlusion (CTO) recanalization.

Revascularization vs. Medical Therapy for Coronary Chronic Total Occlusions in Patients With Chronic Kidney Disease

BACKGROUND

We investigated whether the outcome of revascularization differed from the outcome of medical therapy in chronic kidney disease (CKD) and non-CKD patients with chronic total occlusion (CTO).Methods and Results:A total of 2,010 patients with CTO who underwent revascularization (n=1,355), including percutaneous coronary intervention (n=878) and coronary artery bypass grafting (n=477), or had medical therapy alone (n=655) were examined. The primary outcome was all-cause death during follow-up. Among the non-CKD patients (n=1,679), revascularization had a lower incidence of all-cause death (adjusted hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.41-0.72, P<0.001) compared with medical therapy. Among the CKD patients (n=331), the difference in the incidence of all-cause death was not as marked between the 2 treatments (adjusted HR 0.71, 95% CI 0.48-1.06, P=0.09). There was a significant interaction between kidney function and treatment strategy (revascularization vs. medical therapy) on all-cause death (P for interaction=0.014).

CONCLUSIONS

Based on the clinical outcomes, in CTO patients with preexisting CKD, revascularization via PCI or bypass surgery might not be as effective as in non-CKD patients.

Diagnostic accuracy of multi-slice computed tomography in identifying lesion characteristics in coronary total occlusion

We performed this study to compare the sensitivity and specificity of multi-slice computed tomography (MSCT) to coronary angiography (CA) in detecting coronary total occlusion (CTO) lesion characteristics. Moreover, we analyzed the association between these characteristics and the risk of revascularization failure. Fifty patients with confirmed CTO diagnosis were tried for revascularization using the antegrade (all 50) or retrograde (in failed nine antegrade interventions) approaches. Each patient underwent CA and MSCT before the intervention and data from both modalities were compared using the SPSS software. Successful revascularization occurred in 36 (72%) and 6 (66.7%) patients of the antegrade and retrograde groups, respectively. Compared to CA, MSCT exhibited high sensitivity in detecting CTO segment calcification (100%), size of the affected vessel (100%, area under the curve [AUC] = 0.82), distal filling of the affected segment (97.7%) and side-branching at the CTO segment (93.3%). However, it had lower sensitivity in detecting collaterals (75%) and the length of the affected segment (87.5%, AUC = 0.77). According to MSCT data, increased occlusion length > 18 mm (p = 0.01), atherosclerotic vessel wall (p = 0.02), small distal vessel size ≤ 2.75 mm (p = 0.002), proximal side-branching (p = 0.01) and calcification of the proximal cap (p = 0.007) or distal stump (p = 0.01) were associated with an increased risk of revascularization failure. MSCT exhibited high sensitivity in identifying several CTO lesion characteristics, such as lesional calcification and size of the affected vessel. However, further research is needed to improve the diagnostic accuracy of this modality and define the predictors of revascularization failure in CTO patients.

Long-term Survival Benefit of Statin in Patients with Coronary Chronic Total Occlusion without Revascularization

BACKGROUND

Limited data are available on the efficacy of statin therapy in stable ischemic heart disease with chronic total occlusion (CTO) without revascularization. We investigated whether statin therapy could be beneficial in stable patients with CTO without revascularization.

METHODS

From March 2003 to February 2012, 2,024 patients with at least one CTO were enrolled in a retrospective, single-center registry; 664 of these patients were managed conservatively without an initial revascularization strategy. Among them, we excluded CTO cases involving acute coronary syndrome, in-hospital death or incomplete data and classified 551 patients into statin (n = 369) and non-statin (n = 182) groups according to use of statin at discharge. Propensity score matching analysis was also performed in 148 pairs. The primary outcome was cardiac death.

RESULTS

The median overall follow-up duration was 45.7 months (interquartile range: 19.9-70.5 months). Cardiac death occurred in 22 patients (6.0%) in the statin group vs. 24 patients (13.2%) in the non-statin group (P < 0.001). In propensity score matching analysis, statin therapy was associated with a low risk of cardiac death (adjusted hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.18-0.85; P = 0.022) and major adverse cardiac events (adjusted HR, 0.66; 95% CI, 0.43-0.98; P = 0.043). On multivariate analysis, independent predictors for cardiac death were age > 70 years, renal insufficiency, prior myocardial infarction, left ventricular ejection fraction < 40%, proximal-to-mid CTO location, and no use of statin in CTO patients.

CONCLUSION

Statin therapy at discharge may be associated with a reduction in long-term cardiac mortality in stable CTO patients without revascularization.

Staged Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With ST-Segment-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis

Background

Studies have shown that chronic total occlusion (CTO) in a noninfarct‐related artery in patients with ST‐segment–elevation myocardial infarction is linked to increased mortality. It remains unclear whether staged revascularization of a noninfarct‐related artery CTO in patients with ST‐segment–elevation myocardial infarction translates to improved outcomes. We performed a meta‐analysis to compare outcomes between patients presenting with ST‐segment–elevation myocardial infarction with concurrent CTO who underwent percutaneous coronary intervention of noninfarct‐related artery CTO versus those who did not.

Method and Results

We conducted an electronic database search of all published data. The primary end point was major adverse cardiovascular events. Secondary end points were all‐cause mortality, cardiovascular mortality, myocardial infarction, repeat revascularization with either percutaneous coronary intervention or coronary artery bypass grafting, stroke, and heart failure readmission. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed. Random effects model was used and heterogeneity was considered if I² >25. Six studies (n=1253 patients) were included in the analysis. There was a significant difference in major adverse cardiovascular events (OR, 0.54; 95% CI, 0.32–0.91), cardiovascular mortality (OR, 0.43; 95% CI, 0.20–0.95), and heart failure readmissions (OR, 0.57; 95% CI, 0.36–0.89), favoring the patients in the CTO percutaneous coronary intervention group. No significant differences were observed between the 2 groups for all‐cause mortality (OR, 0.47; 95% CI, 0.22–1.00), myocardial infarction (OR, 0.78; 95% CI, 0.41–1.46), repeat revascularization (OR, 1.13; 95% CI, 0.56–2.27), and stroke (OR, 0.51; 95% CI, 0.20–1.33).

Conclusions

In this meta‐analysis, CTO percutaneous coronary intervention of the noninfarct‐related artery in patients presenting with ST‐segment–elevation myocardial infarction was associated with a significant reduction in major adverse cardiovascular events, cardiovascular mortality, and heart failure readmissions.

Interventional Management of "Balloon-Uncrossable" Coronary Chronic Total Occlusion: Is There Any Way Out?

It has been estimated that coronary chronic total occlusion (CTO) is encountered in 15 to 20% patients referred for coronary angiography (CAG). The success of percutaneous coronary intervention (PCI) of CTO can be attributed to the vast array of hardware that has now become available and also to the vastly enhanced operator expertise. It is however realistic to state that despite the tremendous increase in the rate of success, there then comes a subset of CTO where PCI attempts fail. The reason for such failures given that other variables remain constant is the inability to cross the CTO lesion. This can be due to a failure to cross the lesion with a guide wire (despite guide wire escalation). The second cause of failure is the inability to cross the lesion with a balloon (balloon-uncrossable [BU] CTO). This can occur despite the successful placement of a guidewire in the distal true lumen. The BU lesions contribute 2% to 10% of CTO PCI failure cases. The author attempts to present a creative solution to assist crossing such lesions.