Predictors of long-term adverse outcomes after successful chronic total occlusion intervention: physiology or morphology?

BACKGROUND

Quantitative flow ratio (QFR) and target-vessel SYNTAX score (tvSS) are novel indices used to assess lesion physiology and morphology in percutaneous coronary intervention (PCI). Their prognostic implication after successful recanalization of coronary chronic total occlusion (CTO) is unknown.

OBJECTIVES

To investigate the prognostic value of QFR measured immediately after successful CTO-recanalization in predicting vessel-oriented adverse events, and to compare it with the pre-procedural morphological tvSS.

METHODS

QFR was measured offline after successful CTO-PCIs in a single center. We grouped the patients according to a cut-off value of post-PCI QFR (0.91). The primary outcome was target-vessel failure (TVF) at 2 years.

RESULTS

Among 470 CTO lesions performed during the study period, 324 were eligible for QFR analysis (258 with QFR ≥ 0.91 and 66 with QFR < 0.91). The mean age of the study population was 68.3 ± 10.7 years. The low QFR group had a lower left ventricular ejection fraction (45.8 ± 13.9% vs. 49.8 ± 12.4%, p = 0.025) and a higher rate of atrial fibrillation (19.7% vs. 11.2%, p = 0.020). The mean tvSS was 12.8 ± 4.8, and it showed no significant difference in both groups (13.6 ± 5.1 vs. 12.6 ± 4.6, p = 0.122). Patients with low post-CTO QFR had a trend to develop more TVF at 2 years (21.2% vs. 12.4%, HR 1.74; 95% CI 0.93-3.25, p = 0.086). Low post-CTO QFR failed to predict 2-year TVF (aHR 1.67; 95% CI 0.85-3.29, p = 0.136), while pre-procedural tvSS was an independent predictor for 2-year TVF (aHR 1.06; 95% CI 1.01-1.13, p = 0.030).

CONCLUSION

We found a limited prognostic value of immediate physiological assessment using QFR after successful CTO intervention. Pre-procedure morphological characteristics of CTO lesions using tvSS can play a role in predicting long-term adverse events.

Clinical Outcome of Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stent Implantation for the Treatment of Coronary Drug-Eluting Stent In-Stent Chronic Total Occlusion

AIMS

In-stent chronic total occlusion (IS-CTO) represents a unique challenge for percutaneous coronary intervention. Whether the optimal treatment for IS-CTO is angioplasty with paclitaxel-coated balloons (PCBs) or repeat stenting with drug-eluting stents (DESs) is unclear. We aimed to evaluate the long-term clinical outcome of PCB angioplasty and DES repeat stenting for DES IS-CTO.

METHODS

We retrospectively included patients with DES IS-CTO who underwent successful PCB angioplasty or DES repeat stenting from January 2016 to December 2019. The primary endpoints were major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, and target lesion revascularization (TLR). Cox proportional hazards model was performed to compare the risk of MACEs between PCB angioplasty and DES repeat stenting, and to further explore the prognostic factors of patients with DES IS-CTO.

RESULTS

A total of 214 patients with DES IS-CTO were enrolled: 78 patients (36.4%) treated with PCB and 136 patients (63.6%) treated with DES respectively. The median follow-up was 1160 days, and MACEs were observed in 28.2% of patients with PCB angioplasty versus 26.5% of patients with DES repeat stenting (P = 0.784), mainly driven by TLR (21.8% vs. 19.9%, P = 0.735). There was no significant difference in the risk of MACEs between the PCB group and the DES group (hazard ratio [HR] 1.25, 95% confidence interval [CI] 0.64-2.46, P = 0.512). Multivariate Cox analysis revealed that chronic kidney disease and ≥ 3 stent layers in the lesion were independent predictors of MACEs, while switching to another antiproliferative drug was an independent protective factor (all P < 0.05).

CONCLUSIONS

PCB angioplasty was an effective alternative treatment strategy for DES IS-CTO, which had similar long-term outcomes to DES repeat stenting in contemporary practice, but both were accompanied by a high rate of long-term MACEs. Improving the poor prognosis of patients with DES IS-CTO remains a challenge.

Management of in-stent restenosis

In-stent restenosis (ISR) remains the most common cause of stent failure after percutaneous coronary intervention (PCI). Recent data suggest that ISR-PCI accounts for 5-10% of all PCI procedures performed in current clinical practice. This State-of-the-Art review will primarily focus on the management of ISR but will begin by briefly discussing diagnosis and classification. We then move on to detail the evidence base underpinning the various therapeutic strategies for ISR before finishing with a proposed ISR management algorithm based on current scientific data.

Successful percutaneous coronary intervention to the left anterior descending artery in-stent chronic total occlusion via the left internal mammary artery graft: a case report

Background

Percutaneous coronary intervention (PCI) via left internal mammary artery (LIMA) graft is technically challenging, requires special consideration due to association with potential complications and therefore, infrequently performed. Data on in-stent chronic total occlusion (CTO) PCI via the LIMA graft is even rarer.

Case summary

A 59-year-old male with a background history of coronary artery bypass graft surgery and previous PCI, presented with progressive chest pain on mild exertion, in the setting of a chronic coronary syndrome. Transradial coronary angiography revealed significant native three-vessel disease with CTO of right coronary, left anterior descending (LAD) and left circumflex arteries. Left internal mammary artery-LAD was widely patent. The previous LIMA-LAD stent at the anastomosis had a CTO with severe in-stent restenosis (ISR) at the distal end of the stent in the native LAD. The distal LAD was filled from bridging collaterals. Following discussion at the heart team meeting, he underwent successful complex PCI of LAD CTO via the LIMA graft at the site of ISR of previous LIMA-LAD anastomosis stent, which was finally treated with drug-coated balloon (DCB) angioplasty.

Discussion

Recurrent angina post-coronary revascularization can be very challenging to manage by medical therapy alone. Percutaneous intervention of complex coronary lesions in these patients requires experience and skill, especially when approaching lesions using the LIMA as a conduit. The use of DCB for ISR management is a well-known strategy; however, adequate lesion preparation is the key to satisfactory outcome.

Occlusion patterns, strategies and procedural outcomes of percutaneous coronary intervention for in-stent chronic total occlusion

BACKGROUND

In-stent chronic total occlusion (CTO) presents various occlusion patterns, which complicate percutaneous coronary intervention (PCI).

AIMS

The aim of the study was to investigate the initial outcome and strategy of PCI for in-stent CTO according to the angiographic occlusion patterns.

METHODS

This study assessed 791 in-stent CTOs from the Japanese CTO-PCI Expert Registry from 2015 to 2018. They were divided into four patterns: pattern A (n=419), CTO within the stent segment; pattern B (n=196), CTO beyond the distal edge; pattern C (n=85), CTO beyond the proximal edge; and pattern D (n=69) CTO beyond both the proximal and distal edges.

RESULTS

There were significant differences in the technical success rates (96.2%, 86.2%, 92.9%, and 75.4% for patterns A-D, respectively; p<0.001), guidewire crossing times (22 [interquartile range: 10-46], 52 [24-102], 40 [20-78], and 86 [45-127] min, respectively; p<0.001), and the rates of antegrade approach alone (90.9%, 61.2%, 67.1%, and 31.9%, respectively; p<0.001).

CONCLUSIONS

PCI for CTO within the stent segment was associated with excellent initial outcomes with the antegrade approach. However, PCI for CTO beyond both the proximal and distal edges was associated with the poorest outcomes, even with the bidirectional approach.

Procedural Results and Long-Term Outcomes of Percutaneous Coronary Intervention for in-Stent Restenosis Chronic Total Occlusion Compared with de novo Chronic Total Occlusion

Background

In-stent restenosis (ISR) chronic total occlusion (CTO) represents a challenging subgroup for revascularization of CTO by percutaneous coronary intervention (PCI). There are limited data on the treatment and outcomes of PCI for ISR CTO.

Objective

We aimed to evaluate the procedural results and 2-year outcomes of PCI for ISR CTO compared with de novo CTO.

Methods

Patients undergoing attempted CTO PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 2-year major adverse cardiac events (MACE) in patients undergoing ISR CTO and those undergoing de novo CTO PCI.

Results

A total of 426 patients undergoing 484 consecutive CTO PCI (ISR CTO PCI, n=84; de novo CTO, n=400) were enrolled during the study period. Patients undergoing de novo CTO PCI had a significantly greater syntax score than those undergoing ISR CTO PCI [23.0 (17.5, 30.5) vs 21.5 (14.5, 27.0), p=0.039]. Technical (73.8% vs 79.0%, p=0.296) and procedural (73.8% vs 78.0, p=0.405) success rates, as well as the incidence of major procedural complications (1.2% vs 2.3%, p=0.842), were comparable between the two groups. After a median follow-up of 20 months, patients who underwent ISR CTO PCI had a significantly higher incidence of MACE (33.3% vs 10.3%, p<0.001), mainly attributed to the higher TVR rates (24.7% vs 7.6%, p<0.001). ISR CTO was the only independent predictor of MACE (hazard ratio, 4.124; 95% confidence interval, 1.951–8.717; p<0.001) during follow-up in patients who underwent CTO PCI.

Conclusion

ISR CTO PCI shows comparable technical and procedural success, as well as major procedural complications compared with de novo CTO PCI. However, patients who underwent ISR CTO PCI had a significantly worse prognosis than those who underwent de novo CTO PCI, in terms of MACE, driven by TVR. ISR CTO was the only independent predictor of MACE during the follow-up.

Long-term Outcome following Percutaneous Intervention of Intra-stent Coronary Occlusion and Evaluating the Different Treatment Modalities

BACKGROUND

Angioplasty for ISR remains a challenge with relatively high rates of recurrence. Although there is a plethora of data on ISR, there is relatively less data on intra-stent-CTO. In this study, we explore the long-term clinical outcomes following angioplasty to intra-stent CTO and study the differences in clinical outcomes between three treatment-arms: POBA vs. DES vs. DCB.

METHODS AND RESULTS

We evaluated all patients who underwent PCI to intra-stent CTO between 2011 and 2017. The endpoints used were: cardiac-death, TVMI, TLR, TVR, and MACE.During the study period, 403-patients with a mean age of 69.2 years had successful PCI to intra-stent CTO. 50% were diabetic, 38% had CKD and 32% had left ventricular dysfunction. 93% of cases were stable angina. 22% (n = 88) received only POBA, 28% (n = 113) received DCB and 50% (n = 202) received DES. During the median follow-up of 48-months, cardiac-death occurred in 5.8% (n = 23), TVMI in 4% (n = 16), TLR in 45.6% (n = 182), TVR in 48.7% (n = 194) and MACE of 46%. There were no differences in the hard endpoints between the 3treatment arms. However, the TLR and overall MACE were better in DCB and DES-groups as compared to POBA (TLR: 33%vs.42%vs.49%; p = 0.06); MACE (34% vs. 45% vs. 52%; p = 0.05).

CONCLUSION

This is the first study that has focussed on the outcomes following angioplasty to intra-stent CTOs with a very long-term follow-up. The hard endpoints were low, although the TLR rates were high. In regards to treatment strategy, the DCB and DES provide relatively better outcomes than POBA.

In-Stent CTO Percutaneous Coronary Intervention: Individual Patient Data Pooled Analysis of 4 Multicenter Registries

OBJECTIVES

The authors sought to examine the outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusions (CTOs).

BACKGROUND

The outcomes of PCI for ISR CTOs have received limited study.

METHODS

The authors examined the clinical and angiographic characteristics and procedural outcomes of 11,961 CTO PCIs performed in 11,728 patients at 107 centers in Europe, North America, Latin America, and Asia between 2012 and 2020, pooling patient-level data from 4 multicenter registries. In-hospital major adverse cardiovascular events (MACE) included death, myocardial infarction, stroke, and tamponade. Long-term MACE were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization.

RESULTS

ISR represented 15% of the CTOs (n = 1,755). Patients with ISR CTOs had higher prevalence of diabetes (44% vs. 38%; p < 0.0001) and prior coronary artery bypass graft surgery (27% vs. 24%; p = 0.03). Mean J-CTO (Multicenter CTO Registry in Japan) score was 2.32 ± 1.27 in the ISR group and 2.22 ± 1.27 in the de novo group (p = 0.01). Technical (85% vs. 85%; p = 0.75) and procedural (84% vs. 84%; p = 0.82) success was similar for ISR and de novo CTOs, as was the incidence of in-hospital MACE (1.7% vs. 2.2%; p = 0.25). Antegrade wiring was the most common successful strategy, in 70% of ISR and 60% of de novo CTOs, followed by retrograde crossing (16% vs. 23%) and antegrade dissection and re-entry (15% vs. 16%; p < 0.0001). At 12 months, patients with ISR CTOs had a higher incidence of MACE (hazard ratio: 1.31; 95% confidence interval: 1.01 to 1.70; p = 0.04).

CONCLUSIONS

ISR CTOs represent 15% of all CTO PCIs and can be recanalized with similar success and in-hospital MACE as de novo CTOs.

Thirty-day and 5-year results of percutaneous coronary intervention for in-stent restenotic chronic total occlusion lesions: Data from 2,659 consecutive patients

OBJECTIVES

To investigate the procedure success rate and clinical outcomes of in-stent restenotic chronic total occlusion (ISR-CTO) percutaneous coronary intervention (PCI).

BACKGROUND

Few studies have reported the short- and long-term clinical outcomes of ISR-CTO PCI.

METHOD

Patients who underwent ISR-CTO (n = 212) or de-novo CTO (n = 2,447) PCI at Fuwai Hospital from 2010 to 2013 were enrolled. Thirty-day and 5-year clinical outcomes were analyzed. The primary outcome was the incidence of all-cause death, myocardial infarction (MI), and heart failure at follow-up. The secondary outcome was the recanalization result (reasonable, suboptimal, or failed recanalization).

RESULTS

ISR-CTO PCI had a higher rate of suboptimal recanalization than de-novo CTO PCI (p < .01). The syntax score before PCI (odds ratio (OR): 1.06; 95% confidence interval (CI): 1.02-1.10; p = .002) and occlusion length ≥ 20 mm (OR: 2.70:95% CI: 1.46-4.98; p = .001) were predictors of suboptimal recanalization in ISR-CTO PCI. Cardiac death (p = .03) and 30-day all-cause mortality (p = .05) were higher among patients who underwent ISR-CTO PCI. The ISR-CTO group had a higher rate of MI (p = .07) at 5 years. Suboptimal recanalization (hazard ratio: 2.56; 95% CI: 1.13-5.83; p = .025) was an independent predictor of long-term major adverse events in ISR-CTO.

CONCLUSIONS

Suboptimal recanalization, 30-day cardiac death, and long-term MI rates are higher for ISR-CTO PCI than de-novo CTO PCI. Suboptimal recanalization is an independent predictor of long-term major adverse events after ISR-CTO PCI.

Long-Term Outcomes of Percutaneous Coronary Intervention for Patients With In-Stent Chronic Total Occlusion Versus De Novo Chronic Total Occlusion

Limited data are available on long-term outcomes and health status in the treatment of in-stent coronary chronic total occlusion (IS-CTO) and de novo coronary chronic total occlusion (de novo CTO). This study compared the long-term clinical outcomes and health status of percutaneous coronary intervention (PCI) for patients with IS-CTO versus patients with de novo CTO in the drug-eluting stent era. We screened 483 consecutive patients with 1 CTO lesion, including 81 patients with IS-CTO and 402 patients with de novo CTO. Propensity score matching was used to balance baseline characteristics between the 2 groups. The clinical end point was major adverse cardiac events (MACE). The success rates of CTO lesion revascularization were similar in both groups. In the propensity score-matched patients, after a median follow-up of 36 months, MACE was observed in 32.8% of patients with IS-CTO versus 13.5% of the patients with de novo CTO (P < .001), mainly driven by target-vessel revascularization (21.9% vs 6.7%; P < .01). Moreover, patients with IS-CTO had significantly worse Seattle Angina Questionnaire anginal stability scores than the patients with de novo CTO. In conclusion, patients with IS-CTO after PCI had a worse clinical outcome, mainly MACE, and a poorer anginal stability in the long term than patients with de novo CTO.

Long-term outcomes of percutaneous coronary intervention for in-stent chronic total occlusion

BACKGROUND

The development of the technique has improved the success rate of percutaneous coronary intervention (PCI) for in-stent chronic total occlusion (IS-CTO). However, long-term outcomes remain unclear. The present study sought to investigate long-term outcomes of PCI for IS-CTO.

METHODS

A total of 474 IS-CTO patients were enrolled at two cardiac centers from 2015 to 2018 retrospectively. These patients were allocated into either successful or failed IS-CTO PCI groups. The primary endpoint (major adverse cardiac events [MACE]) consisted of recurrent angina pectoris (RAP), target-vessel myocardial infarction (MI), heart failure, cardiac death, or ischemia-driven target-vessel revascularization (TVR) at follow-up. Multivariable Cox regression analysis was used to investigate the association between treatment appropriateness and clinical outcomes.

RESULTS

A total of 367 patients were successfully treated with IS-CTO PCI while 107 patients had failed recanalization. After a median follow-up of 30 months (interquartile range: 17-42 months), no significant difference was observed between the two groups for the following parameters: cardiac death (successful PCI vs. failed PCI: 0.9% vs. 2.7%; adjusted hazard ratio [HR]: 1.442; 95% confidence interval [CI]: 0.21-9.887; P = 0.709), RAP (successful PCI vs. failed PCI: 40.8% vs. 40.0%; adjusted HR: 1.025; 95% CI: 0.683-1.538; P = 0.905), heart failure (successful PCI vs. failed PCI: 6.1% vs. 2.7%; adjusted HR: 0.281; 95% CI: 0.065-1.206; P = 0.088), target-vessel related MI (successful PCI vs. failed PCI: 1.5% vs. 2.7%; adjusted HR: 1.150; 95% CI: 0.221-5.995; P = 0.868), MACE (successful PCI vs. failed PCI: 44.2% vs. 45.3%; adjusted HR: 1.052; 95% CI: 0.717-1.543; P = 0.797). More patients were free of angina in the successful IS-CTO PCI group compared with failed PCI in the first (80.4% vs. 60%, P < 0.01) and second years (73.3% vs. 60.0%, P = 0.02) following up. Successful IS-CTO PCI had a lower incidence of MACE in the first and second years (20.2% vs. 40.0%, P < 0.01; 27.9% vs. 41.3%, P = 0.023) compared with failed PCI. After a median follow-up of 30 months, the reocclusion rate was 28.5% and TVR was 26.1% in the successful IS-CTO PCI group. Receiving >18 months of dual antiplatelet therapy (DAPT) was an independent predictor of decreased risk of TVR (HR: 2.682; 95% CI: 1.295-5.578; P = 0.008) or MACE (without TVR) (HR: 1.898; 95% CI: 1.036-3.479; P = 0.038) in successful IS-CTO PCI.

CONCLUSIONS

After a median follow-up of 30 months, the successful IS-CTO PCI group had MACE similar to that of the failed PCI group. However, the successful IS-CTO PCI group had improved angina symptoms and were free from requiring coronary artery bypass grafting in the first or second years. To decrease MACE, DAPT was found to be essential and recommended for at least 18 months for IS-CTO PCI.

Effects of Altered Levels of Pro- and Anti-Inflammatory Mediators on Locations of In-Stent Reocclusions in Elderly Patients

Imbalances of proatherogenic inflammatory and antiatherogenic inflammatory mediators were involved in the pathogenesis of atherosclerosis. This study sought to investigate the effects of proatherogenic inflammatory and antiatherogenic inflammatory mediators on the proximal, middle, and distal coronary artery reocclusions in elderly patients after coronary stent implantations. We measured the expression levels of proatherogenic inflammatory/antiatherogenic inflammatory cytokines. This included interleukin-1 β (IL-1 β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor-α (TNF-α), high-sensitivity C-reactive protein (hs-CRP), interleukin-10 (IL-10), interleukin-17 (IL-17), interleukin-13 (IL-13), and interleukin-37 (IL-37) in the elderly patients with the proximal, middle, and distal coronary artery reocclusions after coronary stent implantations. Levels of IL-1 β, IL-6, IL-8, TNF-α, and hs-CRP were remarkably increased (P < 0.001), and levels of IL-10, IL-17, IL-13, and IL-37 were remarkably lowered (P < 0.001) in the elderly patients with the proximal, middle, and distal coronary artery reocclusions. Imbalances of proatherogenic inflammatory and antiatherogenic inflammatory mediators may be involved in the formation and progression of proximal, middle, and distal coronary artery reocclusions in elderly patients after coronary stent implantations.

Acute, in-Hospital Outcome of Percutaneous Coronary Intervention for In-Stent Chronic Total Occlusion

BACKGROUND

Percutaneous coronary intervention (PCI) of total chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. Recanalization of in-stent CTO (IS-CTO) is associated with inferior success rates. This present study aims to comparatively evaluate the acute outcome of patients with IS-CTO and de novo CTO.

METHODS

Between 2012 and 2018 we included 600 patients. Antegrade and retrograde CTO-PCI techniques were used and the primary endpoint was a composite safety endpoint comprising in-hospital death, vascular complications, cardiac tamponade, stroke and acute myocardial infarction.

RESULTS

IS-CTO predominantly occurred in the right coronary artery (71.2%). The success (p = 0.495) and complication rates (p = 0.255) were independent of the target vessel. The lesion lengths of IS-CTO were longer than in de-novo CTO (40 mm vs. 30 mm, statistical trend p = 0.081) alongside with the implanted stent lengths (76 mm vs. 63 mm, statistical trend p = 0.070) and their diameter (3.5 mm vs. 3.0 mm, p < 0.001). We determined that procedural and fluoroscopy time were longer in patients with IS-CTO (115.0 min vs. 93.0 min, p = 0.018 and 40.0 min vs. 30.0 min, p = 0.040) and that in this group of patients the amount of contrast medium was higher (250 ml vs. 200 ml, p = 0.015). Overall success rates were comparable between the two group of patients (87.9% vs. 84.4%, p = 0.586). In-hospital, acute procedural complications regarding the composite safety were rare and showed no statistically significant difference (3.0% vs. 5.6%; p = 0.563).

CONCLUSIONS

Recanalization of in-stent CTO lesions go along with long procedural and high fluoroscopy times as well as an increased amount of contrast medium. Compared to de novo CTO they can be performed safe in experienced hands with similar success rates.

Chronic Total Occlusion Interventions: Update on Current Tips and Tricks

PURPOSE OF REVIEW

To summarize novel techniques and developments in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

RECENT FINDINGS

Using an algorithmic, step-by-step approach can help overcome several complex CTO lesions subsets, such as proximal cap ambiguity, ostial location, in-stent occlusion, bifurcations, balloon uncrossable and undilatable lesions. Similarly, an algorithmic approach can help prevent and optimally treat CTO PCI-related complication, such as perforation, radiation, and contrast-induced nephropathy. Continual update and reassessment of each operator's algorithm for performing CTO PCI can lead to improved outcomes.