Presence and Relevance of Myocardial Bridge in LAD-PCI of CTO and Non-CTO Lesions

BACKGROUND

Intravascular ultrasound (IVUS) studies show that one-quarter of left anterior descending (LAD) arteries have a myocardial bridge. An MB may be associated with stent failure when the stent extends into the MB.

OBJECTIVES

The aim of this study was to investigate: 1) the association between an MB and chronic total occlusion (CTO) in any LAD lesions; and 2) the association between an MB and subsequent clinical outcomes after percutaneous coronary intervention in LAD CTOs.

METHODS

A total of 3,342 LAD lesions with IVUS-guided percutaneous coronary intervention (280 CTO and 3,062 non-CTO lesions) were included. The primary outcome was target lesion failure (cardiac death, target vessel myocardial infarction, definite stent thrombosis, and ischemic-driven target lesion revascularization).

RESULTS

An MB by IVUS was significantly more prevalent in LAD CTOs than LAD non-CTOs (40.4% [113/280] vs 25.8% [789/3,062]; P < 0.0001). The discrepancy in CTO length between angiography and IVUS was greater in 113 LAD CTOs with an MB than 167 LAD CTOs without an MB (6.0 [Q1, Q3: 0.1, 12.2] mm vs 0.2 [Q1, Q3: -1.4, 8.4] mm; P < 0.0001). Overall, 48.7% (55/113) of LAD CTOs had a stent that extended into an MB after which target lesion failure was significantly higher compared to a stent that did not extend into an MB (26.3% vs 0%; P = 0.0004) or compared to an LAD CTO without an MB (26.3% vs 9.6%; P = 0.02).

CONCLUSIONS

An MB was more common in LAD CTO than non-CTO LAD lesions. If present, approximately one-half of LAD CTOs had a stent extending into an MB that, in turn, was associated with worse outcomes.

Intraplaque wiring enables drug-coated balloons to be utilized for percutaneous recanalization of chronically occluded coronary arteries

OBJECTIVES

This study aimed to determine whether drug-coated balloon (DCB) angioplasty following intraplaque wiring and the use of modified balloons is safe and effective in the percutaneous treatment of coronary chronic total occlusions (CTOs).

BACKGROUND

DCB is an alternative therapeutic option without the limitations of permanent vascular implants. However, its efficacy in CTOs has yet to be confirmed. The combination of modified balloons and DCB can be effectively applied when the intraplaque passage of the guidewire is achieved in CTOs.

METHODS

Data from 124 consecutive CTO lesions (105 patients) treated at our hospital between February 2016 and December 2020 were screened for inclusion and retrospectively analyzed. Among the 118 lesions successfully recanalized, intraplaque wiring was achieved in 108, and 85 were treated by the DCB-only approach following cutting/scoring balloon dilatation.

RESULTS

Follow-up data were available for 82 lesions (71 patients). The median occlusion length was 18.5 mm, and the J-CTO score was 1.7 ± 0.9. No in-hospital major adverse cardiac events occurred, including abrupt vessel closure. During the median 29-month follow-up period, target lesion revascularization was performed for 10 lesions. Follow-up coronary angiography (8.7 ± 3.9 months after the index procedure) was performed for 64 lesions, demonstrating late lumen loss of -0.15 mm (interquartile range -0.4 to 0.23 mm), binary restenosis (diameter stenosis ≥50%) in 12 lesions (18.8%), and late lumen enlargement in 37 (57.8%).

CONCLUSION

The DCB-only approach following the use of modified balloons is a promising strategy for coronary CTOs when intraplaque wiring is achieved.

Extraplaque versus intraplaque tracking in chronic total occlusion percutaneous coronary intervention

OBJECTIVE

To compare the clinical outcomes after extraplaque (EP) versus intraplaque (IP) tracking in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

The impact of modern dissection and reentry (DR) techniques on the long-term outcomes of CTO PCI remains controversial.

METHODS

We performed a systematic review and meta-analysis of studies that compared EP versus IP tracking in CTO PCI. Odds ratios (ORs) with 95% confidence intervals (CIs) are calculated using the Der-Simonian and Laird random-effects method.

RESULTS

Our meta-analysis included seven observational studies with 2982 patients. Patients who underwent EP tracking had significantly more complex CTOs with higher J-CTO score, longer lesion length, and more severe calcification and had significantly longer stented segments. During a median follow-up of 12 months (range 9-12 months), EP tracking was associated with a higher risk of major adverse cardiovascular events (MACE) (OR 1.50, 95% CI (1.10-2.06), p = 0.01) and target vessel revascularization (TVR) (OR 1.69, 95% CI (1.15-2.48), p = 0.01) compared with IP tracking. There was no difference in the incidence of all-cause death (OR 1.37, 95% CI (0.67-2.78), p = 0.39), myocardial infarction (MI) (OR 1.48, 95% CI (0.82-2.69), p = 0.20), stent thrombosis (OR 2.09, 95% CI (0.69-6.33), p = 0.19), or cardiac death (OR 1.10, 95% CI (0.39-3.15), p = 0.85) between IP and EP tracking.

CONCLUSION

EP tracking is utilized in more complex CTOs and requires more stents. EP tracking is associated with a higher risk of MACE, driven by a higher risk of TVR at 1 year, but without an increased risk of death or MI compared with IP tracking. EP tracking is critically important for contemporary CTO PCI.

The importance of side branch preservation in the treatment of chronic total occlusions with bifurcation lesions

OBJECTIVES

The aim of this study was to identify the predictive factors for suboptimal result in side branch (SB) in chronic total occlusion (CTO) bifurcation lesions and clinical outcomes of patients with suboptimal result in SB.

BACKGROUND

There is little evidence on the optimal strategy for bifurcation lesions in CTO.

METHODS

We retrospectively reviewed 314 consecutive bifurcation lesions in CTO with SB ≥ 2.5 mm in 3 hospitals from March 2010 to June 2018. Patients were divided into the two groups based on the suboptimal SB treatment (SST) and optimal SB treatment (OST) groups. The baseline characteristics, procedural and clinical outcomes were compared between the two groups. This study also evaluated the predictors of suboptimal result in SB.

RESULTS

Suboptimal result in SB occurred in 47 cases. Presence of stenosis in SB, bifurcations located within the occluded segment and sub-intimal tracking at SB ostium was an independent predictor of suboptimal result in SB. The cumulative incidence of target lesion revascularization (TLR) in all lesions was not significantly different between the two groups, however, TLR in right coronary artery (RCA) was significantly higher in the SST group. In the Cox regression analysis, suboptimal result in SB in RCA and sub-intimal tracking were independent predictors of TLR for MB. In patients with bifurcations located within the occluded segment, usage of two-stent technique was significantly lower in the SST group.

CONCLUSIONS

Meticulous procedures are required for SB preservation to improve not only SB prognosis but also MB, especially in RCA.

Clinical and angiographic outcomes of crossing techniques for coronary chronic total occlusions: the ISAR-CTO registry

BACKGROUND

Clinical and angiographic outcomes following recanalisation of coronary chronic total occlusions (CTO) through contemporary dissection and re-entry techniques (DART) as opposed to intraplaque techniques remain controversial.

AIMS

The aim of this study was to compare clinical and angiographic outcomes following subintimal and intraplaque CTO recanalisation.

METHODS

A total of 454 consecutive patients undergoing successful CTO recanalisation (473 vessels) were included. Intraplaque techniques were used in 403 (85.2%) and DART in 70 (14.8%) vessels. Surveillance angiography was scheduled at 6-9 months and clinical follow-up was performed up to 12 months.

RESULTS

There were no significant differences in terms of the cumulative incidence of MACE (p=0.908) or binary restenosis (p=0.320) between the two groups. There was no independent correlation between recanalisation technique and MACE occurrence or in-segment binary restenosis. Target lesion revascularisation (TLR) was performed in 60 (17.5%) and 12 (18.1%) (p=0.719) lesions, respectively. The occurrence of occlusive restenosis was low (7 [2.3%] vs 1 [1.6%]; p=0.824) and comparable between groups.

CONCLUSIONS

Contemporary DART are associated with similar midterm clinical and angiographic outcomes compared to intraplaque recanalisation. The rate of occlusive restenosis was low and comparable in both groups. Regardless of recanalisation technique, the overall incidences of binary restenosis and TLR following CTO recanalisation remain higher than those reported for non-CTO PCI.

A case of right coronary artery chronic total occlusion with difficulty in retrograde system establishment

Advances in microcatheters (MCs) enables the establishment of retrograde systems for the treatment of chronic total occlusion (CTO). However, there are still cases in which establishing a retrograde system is difficult because the guidewire or MC cannot pass through due to calcification, stenosis, or tortuosity. We present a case of a 56-year-old man with angina. Coronary angiography revealed a CTO of the right coronary artery (RCA). Although we started an antegrade approach at first, the guidewire went to subintimal lumen. We switched to a retrograde approach. Although the guidewire passed through posterolateral (PL) channel, the MC could not pass due to a stenosis at the junction of the main RCA trunk. Therefore, we negotiated the septal channel; however, it could only be guided in the peripheral direction. When the guidewire was more advanced in the peripheral direction, it crossed the guidewire that had previously passed through the PL channel. Then, when a balloon was delivered via the septal channel and trapped the guidewire from the PL channel, the MC was successfully delivered via the PL channel. After establishing the retrograde system, revascularization succeeded smoothly. In conclusion, this technique can be one option for the treatment of CTO patients. <Learning objective: Even if a guidewire passes retrogradely, the establishment of the retrograde system may be difficult in some cases since the microcatheter cannot pass retrogradely. This technique can be one of the effective options for the treatment of patients with chronic total occlusion when establishing a retrograde system is difficult.>.

Procedural outcomes of chronic total occlusion percutaneous coronary intervention in patients with dissection and reentry versus wire escalation techniques: a meta-analysis

BACKGROUND

The procedural safety of dissection and reentry (DR) techniques in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains controversial, when compared with conventional wire escalation (WE) techniques. The meta-analysis was performed to evaluate the impact of DR techniques vs. WE techniques on periprocedural outcomes in patients with CTO undergoing PCI.

METHODS

Studies were searched in electronic database from inception to December 2018. Results were pooled using random effects model and fixed effects model.

RESULTS

The pooled analyses revealed that DR techniques increased risks of periprocedural complications in patients with CTO PCI, including higher coronary perforation rate [risk ratio (RR) = 2.10, 95% confidence interval (CI) 1.24-3.55], periprocedural myocardial infarction (RR = 1.85, 95% CI 1.23-2.78), branch occlusion (RR = 2.69; 95% CI 1.92-3.77) and coronary hematoma (RR = 3.06; 95% CI 2.45-3.82) detected by intravascular ultrasound, when compared to those with WE techniques. However, DR techniques were more applied in patients with higher complexity CTO lesions, which was evidenced by higher J-CTO score [standard mean differences (SMD) = 0.71, 95% CI 0.51-0.91] and longer fluoroscopy time (SMD = 0.93, 95% CI 0.70-1.16), that may explain the higher complications rates in the DR techniques group as compared with WE techniques.

CONCLUSION

The present meta-analysis suggests that the DR technique is relatively frequently used during contemporary CTO PCI, especially for challenging more complex CTO lesions. However, it is associated with higher, yet acceptable, rates of periprocedural adverse events as compared with a conventional WE strategy. Further refinement of DR techniques and evidence from large RCTs is needed to define the optimal role of DR in hybrid CTO PCI.

The impact of dissection and re-entry versus wire escalation techniques on long-term clinical outcomes in patients with chronic total occlusion lesions following percutaneous coronary intervention: An updated meta-analysis

BACKGROUND

The meta-analysis was performed to evaluate the effect of dissection and re-entry (DR) vs. wire escalation (WE) techniques on long-term clinical outcomes in patients with chronic total occlusion (CTO) lesions undergoing percutaneous coronary intervention.

METHODS

Studies were searched in electronic databases from inception to September, 2019. Results were pooled using random effects model and fixed effects model and are presented as risk ratios (RR) with 95% confidence intervals (CI).

RESULTS

Pooled analyses revealed that patients with DR techniques had overall higher complexity CTO lesions than patients with WE techniques and required a greater number of stents and a greater mean stent length. The "extensive" DR techniques may have a higher incidence of target vessel revascularization (TVR) (RR = 2.30, 95% CI: 1.77-2.98), in-stent restenosis (RR = 1.71, 95% CI: 1.30-2.23), in-stent reocclusion (RR = 1.86, 95% CI: 1.03-3.3) and death/myocardial infarction/TVR (RR = 2.10, 95% CI: 1.71-2.58), when compared with WE techniques, during the long-term follow-up. However, "limited" DR techniques result in more promising outcomes, and are comparable to conventional WE techniques.

CONCLUSIONS

Dissection and re-entry techniques were associated with increased risk of long-term negative clinical events, especially "extensive" DR techniques. However, "limited" DR techniques resulted in good long-term outcomes, comparable to WE techniques.

Subintimal Versus Intraplaque Recanalization of Coronary Chronic Total Occlusions: Mid-Term Angiographic and OCT Findings From the ISAR-OCT-CTO Registry

OBJECTIVES

The aim of this study was to compare angiographic and optical coherence tomography findings following subintimal as opposed to intraplaque recanalization of chronic total occlusions (CTOs).

BACKGROUND

There is ongoing controversy regarding outcomes of intraplaque versus subintimal CTO recanalization.

METHODS

Consecutive patients undergoing angiography and intravascular optical coherence tomography following CTO recanalization were included in the ISAR-OCT-CTO (Intracoronary Stenting and Angiographic Results - Optical Coherence Tomography for Chronic Total Occlusions) registry. The study endpoints were percent diameter stenosis and late lumen loss as well as rate of uncovered and malapposed struts. Independent correlates of uncovered and malapposed struts were assessed by multivariate analysis.

RESULTS

The study included 75 patients. Intraplaque and dissection and re-entry techniques (DART) were used in 46 and 29 patients, respectively. There were no differences in terms of in-segment percent diameter stenosis (median 36.9 [interquartile range (IQR): 26.4 to 43.1] vs. 31.2 [IQR: 23.2 to 49.5]; p = 0.656), in-stent late lumen loss (0.215 mm [IQR: 0.063 to 0.495 mm] vs. 0.230 mm [IQR: 0.060 to 0.645 mm]; p = 0.837), or in-segment late lumen loss (0.030 mm [IQR: -0.278 to 0.510 mm] vs. 0.130 mm [IQR: -0.120 to 0.500 mm]; p = 0.395) at follow-up between the 2 techniques. Optical coherence tomography analysis showed comparable strut coverage (79.9% vs. 71.3%; p = 0.255) but significantly higher strut malapposition (6.6% vs. 13.6%; p < 0.001) following DART. Use of DART independently correlated with presence of strut malapposition (odds ratio: 3.41; 95% confidence interval: 1.24 to 9.36; p = 0.017) but not of strut coverage (odds ratio: 0.65; 95% confidence interval: 0.28 to 1.49; p = 0.314).

CONCLUSIONS

Intraplaque and subintimal recanalization techniques are associated with comparable mid-term angiographic results. Although the rate of uncovered struts is high following CTO recanalization, the recanalization technique does not independently correlate with presence of uncovered struts. There is a high rate of strut malapposition following CTO recanalization, particularly if achieved by means of DART.

Chronic total occlusions-Is true lumen wire passage preferred to subintimal dissection re-entry?

True lumen crossing is superior to subintimal crossing. Subintimal versus true lumen crossing may only be apparent if IVUS is performed. Newer techniques for true lumen crossing need to be developed.

Intravascular ultrasound analysis of intraplaque versus subintimal tracking in percutaneous intervention for coronary chronic total occlusions: One year outcomes

OBJECTIVES

We sought to determine the 1-year outcomes of patients receiving successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures comparing subintimal versus intraplaque wire tracking patterns.

BACKGROUND

CTO PCI utilizes both intraluminal and subintimal wire tracking to achieve successful percutaneous revascularization. Intravascular ultrasound (IVUS) can be used to precisely determine the path of wire tracking.

METHODS

From 2014 to 2016, data from patients undergoing CTO PCI were collected in a single-center database. The primary composite endpoint was target vessel failure (TVF) defined as cardiovascular death, target vessel myocardial infarction (MI), or target vessel revascularization (TVR).

RESULTS

In total 157 patients with successful CTO PCI and concomitant IVUS imaging completed 1-year follow-up. Subintimal tracking was detected in 53.5% of cases and those patients had a higher incidence of prior PCI, prior coronary artery bypass grafting, and higher J-CTO score. At 1-year, the unadjusted rate of TVF in the subintimal tracking group was higher than the intraplaque group (17.9 vs. 6.9%, HR 2.74, 95% CI 1.00-7.54, P = 0.04), driven by numerically higher rates of TVR and peri-procedural MI. After multivariable adjustment, no significant differences in the rates of the TVF between subintimal vs. intraplaque groups were present at 1-year (TVF: HR 1.51, 95% CI 0.38-6.00, P = 0.55). Landmark analysis excluding in-hospital events showed no significant differences in TVF to 1-year.

CONCLUSIONS

IVUS-detected subintimal tracking was observed in over half of successful CTO PCI cases and correlated with baseline and angiographic factors that contributed to the overall rate of TVF at 1-year.

Successful percutaneous coronary intervention for chronic total occlusion via the radial artery

Over the past decade, percutaneous coronary interventions (PCIs) performed via radial artery (RA) access have become popular among interventional cardiologists. Since the radial approach may limit the options in complex cases, most interventional cardiologists prefer femoral access to RA access for complex procedures, such as chronic total occlusions (CTOs) and bifurcation lesions. Presently described is a case of CTO of the right coronary artery that was successfully treated with PCI via the left RA. This study demonstrates that if there is an indication for revascularization and the CTO lesions are short and without poor prognostic factors, an intervention for CTO should still be considered, even if there is no femoral access.

Clinical and angiographic outcomes of true vs. false lumen stenting of coronary chronic total occlusions: Insights from intravascular ultrasound

OBJECTIVES

The clinical implications of subintimal stenting (SS) of the recanalized chronic total occlusion (CTO) segment have not been characterized. We evaluated the in-hospital and the long-term clinical and angiographic outcomes of drug-eluting stents (DESs) deployed in true vs. false lumen of successfully recanalized CTO.

METHODS AND RESULTS

Two independent reviewers analyzed the intravascular ultrasound (IVUS) images of 173 successfully recanalized CTO lesions (157 patients), between August 2011 and October 2012. After successful guidewire (GW) crossing, lesions were classified according to IVUS evaluation into two groups: (1) true lumen (TL) stenting group and (2) SS group; and compared with regards to in-hospital and long-term clinical outcomes. In 154 lesions, DESs were deployed in the TL; and in 19 (11%) lesions, DESs were deployed in the subintimal space (95% confidence interval: 6.3-15.6%). False GW tracking in the SS group resulted in increased rates of IVUS-detected dissection flaps (84% vs. 42.6%, P ≤ 0.001), intramural hematoma (32 vs. 11%, P = 0.01), and minor perforations 6/19 (31.6% vs. 8.4%, P = 0.002). At 1-year follow-up, both groups had similar cumulative rates of binary restenosis and target lesion revascularization (P = 0.73 and P = 0.97, respectively). Six patients (4.6%, 6/129 patients) in the TL group and none in the subintimal group died at 1 year.

CONCLUSIONS

Acknowledging some limitations, our observations may suggest that, subintimal stent deployment in a recanalized CTO segments, using second generation DES and IVUS guidance, might have a comparable success rate and long-term angiographic and clinical outcomes as TL stenting.

Mid-term outcomes of chronic total occlusion percutaneous coronary intervention with subadventitial vs. intraplaque crossing: A systematic review and meta-analysis

BACKGROUND

Some reports have demonstrated increased risk with subadventitial chronic total occlusion (CTO) crossing, whereas others suggest equipoise between subadventitial and intraplaque crossing techniques. We sought to clarify the effect of subadventitial lesion crossing on mid-term outcomes of CTO percutaneous coronary intervention (PCI).

METHODS

We conducted a systematic review and meta-analysis of studies reporting post-discharge outcomes after CTO PCI performed via subadventitial vs. intraplaque approaches.

RESULTS

Five studies comprising a total of 2,539 patients were included. Compared with intraplaque crossing (n=1,654, 65.1%), subadventitial cases (n=885, 34.9%) had a higher J-CTO score (2.9±1.2 vs. 1.6±1.2, p<0.001), and required significantly longer stent lengths (difference in means: 19.66 mm [95% confidence interval (CI), 11.23 to 28.08]; p<0.001). At a median follow-up of 12.0months, subadventitial CTO crossing was associated with a higher overall rate of target vessel revascularization (TVR, crude rate, 11.5% vs. 7.6%, odds ratio [OR]: 2.19 [95% CI, 1.62 to 2.95]; p<0.001); the risk was higher in studies of extensive compared with limited dissection and re-entry techniques (OR: 3.46 [95% CI: 2.24 to 5.36] vs. 1.52 [95% CI, 0.94 to 2.46], p_interaction=0.013). The rates of stent thrombosis, myocardial infarction, and cardiovascular mortality did not vary significantly between subadventitial and intraplaque crossing.

CONCLUSIONS

CTOs treated with subadventitial crossing were significantly more complex as compared with CTOs treated with intraplaque crossing. Extensive subadventitial crossing techniques were associated with higher TVR rates as compared with limited techniques, supporting the important role of limited techniques in the treatment of complex CTOs.

Incidence and impact on midterm outcome of intimal versus subintimal tracking with both antegrade and retrograde approaches in patients with successful recanalisation of chronic total occlusions: J-PROCTOR 2 study

AIMS

The aim of this study was to assess the incidence and impact on midterm outcomes of intimal versus subintimal tracking with both antegrade and retrograde approaches in patients undergoing successful percutaneous coronary intervention for chronic total occlusion (CTO).

METHODS AND RESULTS

In 2012, a total of 1,573 CTO cases from 30 hospitals were enrolled in the Japanese CTO registry. Successful guidewire crossing was performed in 1,411 cases (89.7%). Among them, the guidewire penetration position was clearly identified using intravascular ultrasound (IVUS) imaging in 352 cases, and clinical follow-up at 12 months was performed in 323 cases. These 323 cases were enrolled in this retrospective study: 242 cases were treated with the antegrade approach (antegrade group) and 81 cases were treated with the retrograde approach (retrograde group). The endpoint of this study was target vessel revascularisation (TVR) and major adverse cardiac events (MACE) at 12-month follow-up. Subintimal tracking occurred more frequently in the retrograde group (11.6% vs. 30.9%, p<0.01). TVR was more frequent in the subintimal tracking group in the retrograde group (7.1% vs. 16.0%, p=0.03) but not in the antegrade group (2.8% vs. 3.6%, p=0.99). Although the occlusion length was similar, the subintimal tracking group required a longer stent length compared to the intimal tracking group in the retrograde approach (59.7±24.4 mm vs. 74.0±24.4 mm, p<0.01).

CONCLUSIONS

Subintimal tracking was more frequent in the retrograde approach. Intimal tracking should be recommended in the retrograde approach to reduce stent length and to improve follow-up outcomes.

Intravascular Ultrasound Analysis of Intraplaque Versus Subintimal Tracking in Percutaneous Intervention for Coronary Chronic Total Occlusions and Association With Procedural Outcomes

OBJECTIVES

Using intravascular ultrasound (IVUS), the authors compared outcomes by observed wire position (intraplaque vs. subintimal) achieved during successful chronic total occlusion (CTO) lesion treatment.

BACKGROUND

Recent successes in CTO percutaneous coronary intervention (PCI) have used both intraluminal and subintimal wire tracking to improve procedural success. IVUS may be used to determine the course of wire tracking after crossing a CTO.

METHODS

From March 2014 to March 2016, data were collected into a single-center database from 219 patients undergoing CTO PCI with concomitant IVUS imaging. IVUS-visualized wire tracking patterns were then retrospectively examined. Clinical outcomes with a composite in-hospital cardiovascular endpoint of all-cause death, periprocedural myocardial infarction, and in-hospital target lesion revascularization were analyzed along with IVUS-detected vascular injury.

RESULTS

Of the 524 lesions assessed, 219 patients with successfully recanalized CTO lesions had adequate IVUS imaging and were included. Subintimal tracking was detected in 52.1% of overall cases (86.7% dissection re-entry, 27.9% wire escalation). Minimal stent area of the CTO segment and prevalence of significant edge dissection were similar in the 2 groups. In the subintimal tracking group, there was a higher rate of the composite endpoint, mostly driven by periprocedural myocardial infarction. Subintimal tracking was associated with significantly greater IVUS-detected vascular injury, angiographic dye staining/extravasation, and branch occlusion.

CONCLUSIONS

IVUS-detected subintimal tracking is observed in approximately one-half of all successful CTO PCI cases and is associated with an expected higher, yet acceptable, event rate with no difference in minimal stent area or edge dissection among patients undergoing contemporary hybrid CTO PCI.

One-year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re-entry techniques

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re-entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer-term outcomes are unknown, particularly in relation to dissection and re-entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid-trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One-year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2-4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re-entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re-entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re-entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire-based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one-year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.

A Case of Chronic Total Occlusion of the Left Anterior Descending Artery Successfully Treated with Side Branch Technique Using the Soutenir CV

Patient: Male, 54

Final Diagnosis: Old myocardial infarction

Symptoms: Lower extremity swelling • respiratory distress

Medication: —

Clinical Procedure: Success

Specialty: Cardiology

Development and Validation of a Novel Scoring System for Predicting Technical Success of Chronic Total Occlusion Percutaneous Coronary Interventions: The PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Score

OBJECTIVES

This study sought to develop a novel parsimonious score for predicting technical success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) performed using the hybrid approach.

BACKGROUND

Predicting technical success of CTO PCI can facilitate clinical decision making and procedural planning.

METHODS

We analyzed clinical and angiographic parameters from 781 CTO PCIs included in PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) using a derivation and validation cohort (2:1 sampling ratio). Variables with strong association with technical success in multivariable analysis were assigned 1 point, and a 4-point score was developed from summing all points. The PROGRESS CTO score was subsequently compared with the J-CTO (Multicenter Chronic Total Occlusion Registry in Japan) score in the validation cohort.

RESULTS

Technical success was 92.9%. On multivariable analysis, factors associated with technical success included proximal cap ambiguity (beta coefficient [b] = 0.88), moderate/severe tortuosity (b = 1.18), circumflex artery CTO (b = 0.99), and absence of "interventional" collaterals (b = 0.88). The resulting score demonstrated good calibration and discriminatory capacity in the derivation (Hosmer-Lemeshow chi-square = 2.633; p = 0.268, and receiver-operator characteristic [ROC] area = 0.778) and validation (Hosmer-Lemeshow chi-square = 5.333; p = 0.070, and ROC area = 0.720) subset. In the validation cohort, the PROGRESS CTO and J-CTO scores performed similarly in predicting technical success (ROC area 0.720 vs. 0.746, area under the curve difference = 0.026, 95% confidence interval = -0.093 to 0.144).

CONCLUSIONS

The PROGRESS CTO score is a novel useful tool for estimating technical success in CTO PCI performed using the hybrid approach.

Comparable 2-Year Restenosis Rates Following Subintimal and Intraluminal Drug-Eluting Stent Implantation for Femoropopliteal Chronic Total Occlusion

Purpose: To report midterm outcomes after subintimal vs intraluminal drug-eluting stent (DES) implantation for femoropopliteal (FP) chronic total occlusion (CTO). Methods: This subanalysis of the prospective, multicenter ZEPHYR study (ZilvEr PTX for tHe Femoral ArterY and Proximal Popliteal ArteRy) included 176 patients (mean age 74±8 years; 130 men) with 192 de novo FP CTOs that were evaluated by intravascular ultrasound after successful guidewire crossing. The primary outcome was the 2-year restenosis rate after subintimal (n=73) or intraluminal (n=119) DES implantation. Propensity score matching extracted 61 matched pairs (mean age 75 years; 49 men) for patency analysis to minimize baseline intergroup differences. Restenosis rates are reported with the 95% confidence interval (CI). Results: The 1-year restenosis rates in the groups with subintimal and intraluminal DES implantation were 45% (95% CI 32% to 59%) and 35% (95% CI 22% to 49%), respectively (p=0.352), whereas the corresponding rates at 2 years were not significantly different (p=0.648) at 56% (95% CI 41% to 71%) and 51% (95% CI 34% to 68%). Baseline characteristics had no significant interaction effect on the association of subintimal angioplasty with restenosis risk. Conclusion: In FP CTO, 2-year restenosis rates were comparable after subintimal or intraluminal DES implantation.

Update on Coronary Chronic Total Occlusion Percutaneous Coronary Intervention

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly evolved during recent years. High success rates are being achieved by experienced centers and operators, but not at less-experienced centers. Use of CTO crossing algorithms can help improve the success and efficiency of these potentially lengthy procedures. There is a paucity of clinical trial data examining clinical outcomes of CTO PCI, which is critical for further adoption and refinement of the procedure. We provide a detailed overview of the clinical evidence and current available crossing strategies, with emphasis on recent developments and techniques.

Impact of Crossing Strategy on Intermediate-term Outcomes After Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND

There is ongoing controversy about the optimal crossing strategy selection for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially regarding the relative merits of antegrade dissection/re-entry and the retrograde approach.

METHODS

We retrospectively examined the clinical outcomes of 173 consecutive patients who underwent successful CTO PCI at our institution between January 2012 and March 2015.

RESULTS

The mean age was 65 ± 8 years, and 98% of the patients were men with a high prevalence of diabetes (60%), previous coronary artery bypass grafting (CABG) (31%), and previous PCI (54%). The successful CTO crossing strategy was antegrade wire escalation in 79 patients (45.5%), antegrade dissection/re-entry in 58 patients (33.5%), retrograde wire escalation in 11 patients (6.4%), and retrograde dissection and re-entry in 25 patients (14.5%). The retrograde approach was more commonly used in lesions with interventional collaterals (P < 0.0001), moderate/severe calcification (P = 0.02), blunt stump (P = 0.01), and a higher Japan Chronic Total Occlusion score (P = 0.0002). Use of dissection and re-entry (both antegrade and retrograde) was associated with bifurcation and the distal cap (P = 0.004), longer CTO occlusion length (P < 0.0001), and longer stent length (P < 0.0001). Median follow-up was 11 months. The 12-month incidence of death, myocardial infarction, and the composite of acute coronary syndrome/target lesion revascularization/target vessel revascularization was 2.5%, 4.9%, and 24.4%, respectively, and was similar with intimal and subintimal crossing strategies.

CONCLUSIONS

Antegrade dissection/re-entry and retrograde approaches are frequently used during CTO PCI and were associated with similarly favorable intermediate-term outcomes as antegrade wire escalation.