Chronic Total Occlusion Coronary Intervention: In Search of a Definitive Benefit

Antegrade Wire Tracking of the Retrograde Tract (ATRT): A Novel Technique for Percutaneous Coronary Intervention for Chronic Total Occlusion

BACKGROUND

Chronic total occlusion (CTO) lesions are the most challenging subset of coronary lesions. For lesions with a failed antegrade approach, the initial retrograde, followed by a combined retrograde and antegrade approach, remains the mainstay of therapy.

OBJECTIVE

The study evaluated a technique of initial retrograde followed by an antegrade approach to treat lesions with a failed antegrade approach.

METHODS

We have adopted this technique to treat 31 CTO lesions with a failed antegrade approach, where a floppy wire was advanced antegrade through the tract created by a retrograde balloon advanced over the retrograde wire (antegrade wire tracking of the retrograde tract (ATRT)), which was advanced into the aorta retrogradely.

RESULT

In 31 patients with failed antegrade approaches, the ATRT technique was tried, which was successful in 25 patients (the success rate was 80.6%). There was a failure to cross the microchannel in four patients, although angiographically, it looked promising. In two patients, it was impossible to advance the microcatheter or the smallest profile balloon retrogradely until the entire length of the CTO body. So, a reverse controlled antegrade and retrograde subintimal tracking (CART) was performed on these two patients excluded from the study.

CONCLUSION

ATRT is a useful technique for CTO percutaneous coronary intervention (PCI) for patients with failed antegrade approaches with acceptable success rates. The procedure is safe in terms of procedural complications.

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.

Comparison of Percutaneous Coronary Intervention-Related Adverse Cardiac Outcomes in Patients With in-stent vs de novo Chronic Total Occlusion: A Systematic Review and Meta-Analysis

Contemporary literature reveals a range of cardiac complications in patients who receive the percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). This study compared the adverse cardiac outcomes and procedural/technical success rates between the patients groups of in-stent (IS) CTO PCI and de novo CTO PCI. This systematic review and meta-analysis compared odds for primary (all-cause mortality, MACE, cardiac death post PCI, stroke) and secondary (bleeding requiring blood transfusion, ischemia-driven target-vessel revascularization, PCI procedural success, PCI technical success, and target-vessel MI) endpoints between 2734 patients who received PCI for IS CTO and 17,808 for de novo CTO. Odds ratios for outcome variables were calculated within 95% confidence intervals (CIs) via the Mantel-Haenszel method. The pooled analysis was undertaken for observational (retrospective/prospective) single- and multicentered studies published between January 2005 and December 2021. We found 57% higher, 166% higher, 129% higher, and 57% lower odds for MACE (OR: 1.57, 95% CI 1.31, 1.89, P < 0.001), ischemia-driven target-vessel revascularization (OR: 2.66, 95% CI 2.01, 3.53, P < 0.001), target-vessel myocardial infarction (MI) (OR: 2.29, 95% CI 1.70, 3.10, P < 0.001), and bleeding requiring blood transfusion (OR: 0.43, 95% CI 0.19, 1.00, P = 0.05), respectively, in patients with IS CTO PCI as compared to that of the de novo CTO PCI. No statistically significant differences between the study groups were recorded for the other primary/secondary outcome variables. The findings from this study indicated a high predisposition for MACE, ischemia-driven target-vessel revascularization, target vessel MI, and a lower incidence of bleeding episodes among IS CTO PCI patients as compared to those with de novo CTO PCI. The prognostic outcomes in CTO PCI cases require further investigation with randomized controlled trials.

Clinical Characteristics and Outcome of Percutaneous Coronary Intervention in Yemeni Patients

Background

Percutaneous coronary intervention (PCI) is increasingly used in the management of acute coronary syndromes (ACSs). PCI has decreased the demand for coronary artery bypass grafting, and more patients with ACS are now undergoing PCI. No previous data about the characteristics and outcome of patients performing PCI in Yemen. This study aimed to assess the patient presentation, characteristics, and outcome among Yemeni patients having PCI in the Military Cardiac Center.

Methods

All patients who underwent PCI either primary or elective in the Military Cardiac Center in Sanaa City were included over 6 months. Clinical, demographic, procedural, and outcome data were extracted and analyzed.

Results

During the study period, 250 patients underwent PCI. The mean ± standard deviation age was 57 ± 11 years, with 84% being male. Of all the patients, 61.6% (156) smoked tobacco, 56% (140) had hypertension, 37% (93) had Type 2 diabetes, 48.4% (121) had hyperlipidemia, and 8% (20) had a family history of ischemic heart disease. Coronary artery presentation was in the form of acute ST-elevation myocardial infarction at 41% (102), non-STEMI at 5.2% (58), stable angina at 31% (77), and unstable angina at 5.2% (13). Coronary artery interventions were elective PCI in 81% (203), emergency in 11% (27), and urgent in 8% (20) with only 3% radial artery access and 97% femoral access. PCI was mainly in the left anterior descending artery in 82% (179), right coronary artery in 41% (89), left circumflex artery in 23% (54), and left main in 1.25% (3). All stents were drug-eluting stents during the registry time. Complication occurred in 17.6% (44) and case fatality was 2% (5).

Conclusions

Despite the current situation in Yemen, PCI was performed with success in a large number of patients with a low incidence of inhospital complications and mortality that is comparable to high- or middle-income settings.

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.

Comparison of successful versus failed percutaneous coronary intervention in patients with chronic total occlusion: A systematic review and meta-analysis

BACKGROUND

The optimal treatment strategy of chronic total occlusion (CTO) is currently debated. This meta-analysis aimed to evaluate the long-term clinical outcomes of successful percutaneous coronary intervention (PCI) of CTO.

METHODS

Electronic databases were searched for studies comparing long-term outcomes between successful PCI in patients with CTO using drug-eluting stents and failed procedures. Meta-analysis was conducted with major adverse cardiac events (MACE) and all-cause mortality during the longest follow-up as endpoints. The combined hazard ratios (HRs) were applied to assess the correlation between successful CTO PCI and MACE/all-cause mortality.

RESULTS

Eight studies consisting of 6,211 patients published between 2012 and 2020 met our inclusion criteria, and the CTO PCI success rate was 81.2%. Patients in the failed group were much older, and more likely to have morbidities (hypertension and prior myocardial infarction), reduced left ventricular ejection fraction, and severe lesion characteristics (multivessel disease and moderate/severe calcification). Pooled results indicated that successful CTO PCI was significantly associated with prognosis. Compared to failed recanalization, patients receiving successful procedures had an improved MACE (HR: 0.50, 95% CI: 0.40-0.61, p < 0.001). Subgroup analyses further revealed the prognostic value of successful CTO PCI. However, no difference was observed regarding all-cause mortality (HR: 0.79, 95% CI: 0.61-1.02, p = 0.074).

CONCLUSIONS

The present study showed that CTO recanalization was associated with improved long-term outcomes. However, randomized trials are needed to confirm the results due to the mismatch of baseline characteristics.

Contradictory Effect of Coronary Collateral Circulation on Regional Myocardial Perfusion That Assessed by Quantitative Myocardial Perfusion Scintigraphy

Background

Previous studies showed conflicting results about the contribution of coronary collateral circulation (CCC) to myocardial perfusion and function. The aim of this study was to investigate these contradictory problems by gated myocardial perfusion scintigraphy (gated MPS) for the first time.

Methods

The current cohort was retrospectively selected among patients who underwent gated MPS and coronary angiography within 2 months. Two different groups including 96 patients were assessed by gated MPS to detect the understanding of the miscellaneous effect of CCC on myocardial perfusion. Group 1 consisted of those who had collateral arteries that were not-well-developed (Rentrop grade 0 - 1) (n = 58), while group 2 consisted of those who had collateral arteries that were well-developed (Rentrop grade 2 - 3) (n = 38).

Results

There was no statistically significant difference between groups 1 and 2 in terms of perfusion and functional parameters obtained from gated MPS. Furthermore, no statistically significant difference was found in the phase analysis parameters which is a novel technique to evaluate left ventricular synchronization. On the other hand the left ventricular mass index values were high and quite close to the statistically significant value (P = 0.059) in group 2.

Conclusions

The current results that obtained by using the gated MPS technique for the first time in the evaluation of CCC showed that the well-developed collateral circulation has a positive effect on myocardial perfusion and function, but this effect was not statistically significant. Results need to be supported by large scale of patients’ size.

Progressive Collateral Stenosis Leading to Symptomatic Chronic Total Occlusion

We present a case of chronic total occlusion (CTO) in a functional 79-year-old female with no past history of coronary artery disease, who was previously asymptomatic due to robust collateral circulation. A 79-year-old Caucasian female presented to the emergency department complaining of chest pain radiating to the neck, jaw, left arm with associated numbness in the left fingers, that had started earlier in the day. She has no previous cardiac history and never had similar symptoms before. Troponin levels were negative. Nuclear stress test showed findings worrisome for ischemia and was a high-risk exam. The patient underwent diagnostic angiography. There was complete total occlusion of the mid right coronary artery, with collateral circulation supplying the distal right coronary artery territory. Ultimately, it found that progressive stenosis of the left anterior descending (LAD) artery led to inadequate collateral circulation and completely occluded the right coronary artery's territory, causing the patient's new-onset angina. Afterwards, the patient underwent percutaneous coronary intervention (PCI). Successful implantation of two drug-eluting stents occurred. The final angiographic result was 0% residual stenosis and Thrombolysis in Myocardial Infarction (TIMI)-3 flow. CTO affecting one or more coronary arteries is not uncommon in patients taken to the catheterization laboratory. However, despite recent advancements in PCI outcomes, treatment of CTO by PCI remains relatively low, due to fear of adverse outcomes such as cardiac perforations. Recent research has supported the safety of performing PCIs on patients with CTO. This case report further reinforces the need to approach treating CTO via angioplasty.

Percutaneous coronary intervention for chronic total occlusion in patients aged <75 years versus ≥75 years: a systematic review

Objective: To examine the effect of age on procedural and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions. Methods: Literature search was conducted across PubMed, Google Scholar and Web of science, databases till March 2019. Results: Seven studies including 7671 patients with an overall follow-up period of 1.5 to 5 years were included in our review. A total of 6299/1372 patients were included in non-elderly and elderly groups, respectively, with mean age and 67%/61% male patients. CTO-PCI was similarly successful in younger and older patients (82.8%, n = 5070 vs. 78.1%, n = 1010). The incidence of short-term outcomes was low across the studies and comparable between the two groups (all-cause mortality: 0.4% younger vs. 0.85% elderly, cerebrovascular accidents: 0.3% vs. 0.4%, major adverse cardiovascular events (MACE): 1.53% vs. 3.72% and major bleeding: 0.57% vs. 2.18%). Long-term outcomes including all-cause mortality (8.89% vs. 29.5%), cardiac mortality (3.72% vs. 15%) and MACE (24.9% vs. 40%) occurred with a higher incidence in elderly patients. When results were segregated according to the success of CTO-PCI, reduced clinical events were noted with successful revascularization in either age group. Conclusion: Compared with the younger age group, CTO-PCI in elderly patients is safe and feasible with a comparable incidence of short-term outcomes. In either population, the incidence of long-term outcomes including survival remains a concern but when successful, CTO-PCI may be associated with improvement in terms of multiple patient-important clinical end-points.