Protamine for Coronary Perforation in Chronic Total Occlusion Percutaneous Coronary Intervention.

The safety and efficacy of protamine reversal of heparin anticoagulation during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is unknown. To outline the indications for and outcomes of protamine administration during CTO PCI. We conducted a multicenter registry of consecutive patients who underwent CTO PCI between January 2019 and March 2025 at five centers and received protamine. Patients were stratified into bailout (for perforation or access-site bleeding) and non-bailout cohorts. The primary endpoint was major adverse cardiovascular events (all-cause death, myocardial infarction, target vessel revascularization, and pericardiocentesis). Outcomes were reported descriptively by indication for protamine use, without formal comparative analysis. Among 2345 CTO PCI procedures, 672 patients (28.7%) received protamine, including 179 in the bailout cohort and 493 in the non-bailout cohort. The mean J-CTO score was 3.0 ± 1.3 in the bailout cohort and 2.6 ± 1.2 in the non-bailout cohort. Retrograde strategies were used in 31.8% of the bailout cohort and 19.3% of the non-bailout cohort. Overall, there were 126 coronary perforations observed (6.1%), of which 10 cases (0.5%) required pericardiocentesis. In-hospital major adverse cardiovascular events occurred in 20 patients (11.2%) in the bailout cohort and in 10 patients (2.0%) in the non-bailout cohort (reported descriptively without comparative inference). Across both cohorts, there were no reported cases of stent thrombosis or anaphylaxis. Protamine use during CTO PCI was variably applied across centers and was associated with acceptable in-hospital outcomes; however, the lack of a non-protamine comparison group limits any inference regarding safety.

E-4 | Long-term Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention Among Medicare Beneficiaries

The clinical outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in prior coronary artery bypass graft (pCABG) patients have been investigated; however, the results are inconsistent.The present meta-analysis compared the clinical outcomes of CTO PCI in patients with and without prior CABG (nCABG). The endpoints included technical success, procedural success, all-cause mortality, myocardial infarction (MI), major bleeding, coronary perforation, pericardial tamponade, emergency CABG, and vascular access complication.A total of 7 studies comprising of 11099 patients were included in this meta-analysis. The results showed that compared to nCABG patents, pCABG patients were associated with lower technical success (82.3% versus 87.8%; OR, 0.60; 95% CI, 0.53–0.68; P < .00001; I2 = 0%) and procedural success (80.4% versus 86.2%; OR, 0.61; 95% CI, 0.53–0.70; P < .00001; I2 = 10%); a higher risk of all-cause mortality (OR, 2.95; 95% CI, 1.56–5.57; P = 0.0008; I2 = 0%), MI (OR, 2.30; 95% CI, 1.40–3.80; P = .001; I2 = 5%), and coronary perforation (OR, 2.16; 95% CI, 1.51–3.08; P < 0.0001; I2 = 52%). On the other hand, the risk of pericardial tamponade (OR, 0.42; 95% CI, 0.15–1.18; P = .10; I2 = 21%), major bleeding (OR, 1.51; 95% CI, 0.90–2.53; P = .11; I2 = 0%), vascular access complication (OR, 1.50; 95% CI, 0.93–2.41; P = .10; I2 = 0%), and emergency CABG (OR, 0.99; 95% CI, 0.25–3.91; P = .99; I2 = 0%) was similar in both groups.Compared to nCABG patients, pCABG patients had lower CTO PCI success rates, higher rates of in-hospital mortality, MI, and coronary perforation, and similar risk of pericardial tamponade and vascular complication rates.

Background: The impact of prior myocardial infarction (MI) on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains understudied. Methods: We compared the characteristics and outcomes of 15,461 patients with versus without history of prior MI who underwent 15,478 CTO PCIs between 2012-2025 at 58 US and non-US centers (PROGRESS-CTO registry). Results: 43.2% (n=6,677) of the patients had history of prior MI. Prior MI patients were younger and more likely to be men, to have hypertension, lower left ventricular ejection fraction, cerebrovascular and peripheral arterial disease. Patients with prior MI that did not have prior PCI (22.8%), were more likely to have a myocardial viability test performed (32.6% vs 27.3%, p&lt;0.001). The lesions of patients with prior MI had higher J-CTO (2.41 vs 2.34, p&lt;0.001) and PROGRESS-CTO (1.25 vs 1.16, p&lt;0.001) scores, higher lesion diameter, longer lesion length, were more likely to have proximal cap ambiguity (35.5% vs 33.8%, p=0.035), side branch at the proximal cap (58.3% vs 56.2%, p=0.014) and moderate/severe tortuosity (28.8% vs 24.6%, p&lt;0.001). They had higher use of the retrograde wiring technique (33.3% vs 29.4%, p&lt;0.001), longer procedural and fluoroscopy times and higher contrast and radiation use. Prior MI cases had lower technical (85.6% vs 88.8%, p&lt;0.001) and procedural (84.3% vs 87.7%, p&lt;0.001) success, but similar major adverse cardiac events (MACE) (2.1% vs 1.7%, p=0.113). They were more likely to experience in-hospital acute MI (0.6% vs 0.4%, p=0.046), coronary perforation (5.0% vs 4.3%, p=0.039) and have elective peripheral ventricular assist device use (2.3% vs 1.7%, p=0.006). In multivariable analysis, prior MI was independently associated with lower technical success (odds ratio (OR) 0.79, 95%CI 0.70-0.89). For 3,546 prior MI cases (53.1%) data regarding the location of the prior MI was available. Most (53.6%) had prior MI in the area that was perfused by the totally occluded vessel. These cases were more likely to have a prior myocardial viability test (29.6% vs 19.7%, p&lt;0.001), had lower technical (83.9% vs 86.3%, p=0.052), with the association persisting in the multivariable analysis (OR 0.62, 95%CI 0.47-0.83), but similar procedural success (82.9% vs 85.2%, p=0.063) and MACE (1.7% vs 1.5%, p=0.712). Conclusions: Patients with prior MI undergoing CTO PCI have more comorbidities and higher lesion complexity, achieve lower technical success but have similar MACE.

Protamine Utilization and Clinical Outcomes for Coronary Artery Perforation in Chronic Total Occlusion Percutaneous Coronary Intervention Procedures

BackgroundSeveral studies have shown that N-terminal pro-B-type natriuretic peptide (NT-proBNP) is strongly correlated with the complexity of coronary artery disease and the prognosis of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS), However, it remains unclear about the prognostic value of NT-proBNP in patients with NSTE-ACS and multivessel coronary artery disease (MCAD) undergoing percutaneous coronary intervention (PCI). Therefore, this study aimed to reveal the relationship between NT-proBNP levels and the prognosis for NSTE-ACS patients with MCAD undergoing successful PCI.MethodsThis study enrolled 1022 consecutive NSTE-ACS patients with MCAD from January 2010 to December 2014. The information of NT-proBNP levels was available from these patients. The primary outcome was in-hospital all-cause death. In addition, the 3-year follow-up all-cause death was also ascertained.ResultsA total of 12 (1.2%) deaths were reported during hospitalization. The 4th quartile group of NT-proBNP (> 1287 pg/ml) showed the highest in-hospital all-cause death rate (4.3%) (P < 0.001). Besides, logistic analyses revealed that the increasing NT-proBNP level was robustly associated with an increased risk of in-hospital all-cause death (adjusted odds ratio (OR): 2.86, 95% confidence interval (CI) = 1.16–7.03, P = 0.022). NT-proBNP was able to predict the in-hospital all-cause death (area under the curve (AUC) = 0.888, 95% CI = 0.834–0.941, P < 0.001; cutoff: 1568 pg/ml). Moreover, as revealed by cumulative event analyses, a higher NT-proBNP level was significantly related to a higher long-term all-cause death rate compared with a lower NT-proBNP level (P < 0.0001).ConclusionsThe increasing NT-proBNP level is significantly associated with the increased risks of in-hospital and long-term all-cause deaths among NSTE-ACS patients with MCAD undergoing PCI. Typically, NT-proBN P > 1568 pg/ml is related to the all-cause and in-hospital deaths.

Administration of protamine after coronary stent deployment

Incidence, Mechanisms, Treatment, and Outcomes of Coronary Artery Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention

We sought to assess in-hospital and long-term outcomes of retrograde compared with antegrade-only percutaneous coronary intervention for chronic total occlusion (CTO PCI). Procedural and clinical outcomes following retrograde compared with antegrade-only CTO PCI remain unknown. Using the core-lab adjudicated OPEN-CTO registry, we compared the outcomes of retrograde to antegrade-only CTO PCI. Primary endpoints included were in-hospital major adverse cardiac and cerebrovascular events (MACCE) (all-cause death, stroke, myocardial infarction [MI], emergency cardiac surgery, or clinically significant perforation) and MACCE at 1-year (all-cause death, MI, stroke, target lesion revascularization, or target vessel reocclusion). Among 885 single CTO procedures from the OPEN-CTO registry, 454 were retrograde and 431 were antegrade-only. Lesion complexity was higher (J-CTO score: 2.7 vs. 1.9; p < .001) and technical success lower (82.4 vs. 94.2%; p < .001) in retrograde compared with antegrade-only procedures. All-cause death was higher in the retrograde group in-hospital (2 vs. 0%; p=.003), but not at 1-year (4.9 vs. 3.3%; p=.29). Compared with antegrade-only procedures, in-hospital MACCE rates (composite of all-cause death, stroke, MI, emergency cardiac surgery, and clinically significant perforation) were higher in the retrograde group (10.8 vs. 3.3%; p < .001) and at 1-year (19.5 vs. 13.9%; p=.03). In sensitivity analyses landmarked at discharge, there was no difference in MACCE rates at 1year following retrograde versus antegrade-only CTO PCI. Improvements in Seattle Angina Questionnaire Quality of Life scores at 1-year were similar between the retrograde and antegrade-only groups (29.9 vs 30.4; p=.58). In the OPEN-CTO registry, retrograde CTO procedures were associated with higher rates of in-hospital MACCE compared with antegrade-only; however, post-discharge outcomes, including quality of life improvements, were similar between technical modalities.

There is a paucity of data on the use of protamine after PCI. The purpose of this study was to assess the incidence of thrombotic complications of protamine after high-risk PCI. The authors conducted a retrospective analysis of 168 patients. All patients received protamine intra- or immediately post-index PCI. Baseline characteristics and procedural characteristics including heparin dosing, protamine dosing, and bleeding and thrombotic complications were evaluated. The primary outcome was the incidence of acute stent thrombosis (ST), subacute ST, and 'other' thrombotic complications. Secondary outcomes included mortality within 24 hours and within 30 days of the index procedure. A total of 168 patients were included. The majority of patients received dual anti-platelet therapy prior to the index procedure (85%). The average procedure time was 202 ± 103 minutes, and an average of 2.59 (± 1.38) stents were deployed. An average protamine dose of 32mg was administered, and the median dose was 20mg (IQR 20). Seventy-three (43%) had a coronary perforation and five (3%) had access site related bleeding requiring transfusion. Four (2%) patients had acute ST, no patients experienced subacute ST, and 2 (1%) patients developed non-coronary arterial thrombosis. Eight (5%) died within 24 hours of their PCI and 14 (8%) patients died within 30 days after PCI. In our cohort, administration of protamine was well tolerated in the majority of patients, however, 3.6% of patients did experience coronary or peripheral arterial thrombosis warranting caution when using protamine in these challenging scenarios.

Introduction: Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 10,454 CTO PCIs performed in 10,219 patients between 2012 and 2022. Results: The incidence of coronary perforation was 4.9% (n=503). Patients who experienced coronary perforation were older and were more likely to have had prior coronary artery bypass graft surgery. Procedures that resulted in perforation were more complex, with higher J-CTO and PROGRESS-CTO scores. Technical (66% vs. 87%; p&lt;0.01) and procedural (55% vs. 87%; p&lt;0.01) success rates were lower among perforation cases. The most common site of perforation was the CTO target vessel (66%), the retrograde approach was responsible for the perforation in 47% of the cases and guidewire exit was the most common mechanism of perforation. The proportion of Ellis Class 1, 2, 3 and 3 -“cavity spilling” coronary perforations was 20%, 41%, 28% and 11%, respectively. In 52% of perforations, one or more interventions were required: prolonged balloon inflation (23%), covered stent deployment (21%), coil embolization (6%) and/or autologous fat embolization (4%). Tamponade requiring pericardiocentesis occurred in 69 patients (14%). The incidence of major adverse cardiovascular events (MACE) was higher in perforation cases (18.1% vs. 1.3%; p&lt;0.01). Conclusions: Coronary artery perforation occurred in 4.9% of CTO PCIs performed by experienced operators and was associated with lower technical success and higher in-hospital MACE.

The aim of this study was to describe the epidemiology, mechanisms, management, and outcomes of coronary artery perforation during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We included 1,811 consecutive patients undergoing CTO PCI at five centres between 2011 and 2018. Coronary perforation was observed in n=99 (5.5%). Patients with perforation were older, had a higher J-CTO score, more often required antegrade dissection/re-entry and the retrograde approach, and had lower success rates. The frequency of Ellis type I, II, III and III "cavity spilling" perforations was 11%, 46%, 28%, and 14%, respectively. In 48% of cases, perforation involved the CTO vessel, while the retrograde approach was responsible for 46% of cases. In 53% of cases perforations required intervention. The most frequently applied management strategies included clinical observation (47%), covered stent implantation (25%), balloon occlusion (9%), and coil/fat embolisation (9%). Tamponade was observed in 20/99 (20%) perforation cases. Ellis type III perforations were most frequently observed at the CTO site. These were accountable for 16/20 tamponades and 3/5 deaths. In-hospital mortality was 5.1% vs 0.3% in patients with versus those without perforation (p<0.001). Older age, occlusion length >20 mm, rotational atherectomy, antegrade dissection/re-entry, and the retrograde approach were independently associated with coronary perforation. Patients with perforation suffered an increased incidence of target vessel failure on short-term follow-up. Coronary perforation is observed in a non-negligible proportion of CTO PCIs, often requires intervention, and is associated with tamponade and mortality in a minority of patients. CTO vessel-related perforations are associated with the highest burden of morbidity and mortality.

Background and Objectives: Acquired coronary fistulas (ACFs) are rare coronary artery abnormalities in CTO patients. It has been found after revascularization, and may cause fluster during the CTO PCI. How to distinguish between ACFs and Coronary perforation (CP) is very important for the CTO operators. CTO reopening may reveal microchannel of the advential vascular layers. Some of ACFs have been seen after revascularization. This study aimed to investigate the characteristics of ACFs after successful chronic total occlusion percutaneous coronary intervention (CTO PCI). Methods: The clinical and procedural characteristics, medical history, and findings in electrocardiography, echocardiography and coronary angiography were collected from 2169 consecutive patients undergoing CTO PCI between January 2018 and December 2019 and analyzed retrospectively. Results: 1844 (85.02%) underwent successful CTO PCI with complete revascularization. ACFs were found in 49 patients (2.66%): The majority of patients with ACFs were male (81.63% vs. 60.78%; p=0.016) and younger (62.8 vs. 66.69 years; p=0.003), had a history of myocardial infarction (MI) or Q-wave (69.39% vs. 54.21%; p=0.035); 38 (77.55%) patients had multiple fistulas (>3), and ACFs affected multiple branches of the CTO vessel (>3) in 29 (59.18%) patients. None had pericardial effusion, tamponade and hemodynamic abnormality before or after PCI. Conclusion: ACFs after successful CTO PCI are mainly present in young and male patients with a history of MI, and often involve multiple fistulas and distal CTO vessel.

Background and Objectives: Acquired coronary fistulas (ACFs) are rare coronary artery abnormalities in CTO patients. It has been found after revascularization, and may cause fluster during the CTO PCI. How to distinguish between ACFs and Coronary perforation (CP) is very important for the CTO operators. CTO reopening may reveal microchannel of the advential vascular layers. Some of ACFs have been seen after revascularization. This study aimed to investigate the characteristics of ACFs after successful chronic total occlusion percutaneous coronary intervention (CTO PCI). Methods: The clinical and procedural characteristics, medical history, and findings in electrocardiography, echocardiography and coronary angiography were collected from 2169 consecutive patients undergoing CTO PCI between January 2018 and December 2019 and analyzed retrospectively. Results: 1844 (85.02%) underwent successful CTO PCI with complete revascularization. ACFs were found in 49 patients (2.66%): The majority of patients with ACFs were male (81.63% vs. 60.78%; p=0.016) and younger (62.8 vs. 66.69 years; p=0.003), had a history of myocardial infarction (MI) or Q-wave (69.39% vs. 54.21%; p=0.035); 38 (77.55%) patients had multiple fistulas (>3), and ACFs affected multiple branches of the CTO vessel (>3) in 29 (59.18%) patients. None had pericardial effusion, tamponade and hemodynamic abnormality before or after PCI. Conclusion: ACFs after successful CTO PCI are mainly present in young and male patients with a history of MI, and often involve multiple fistulas and distal CTO vessel.

&lt;p&gt;Background and Objectives: Acquired coronary fistulas (ACFs) are rare coronary artery abnormalities in patients with chronic total occlusion (CTO). It has been found after revascularization, and it may cause fluster during the CTO percutaneous coronary intervention (CTO PCI). How to distinguish between ACFs and coronary perforation (CP) is very important for CTO operators. Chronic total occlusion reopening may reveal the microchannel of the adventitial vascular layers. Some of ACFs have been seen after revascularization. This study aimed to investigate the characteristics of ACFs after successful CTO PCI.&lt;/p&gt;&lt;p&gt;Methods: The clinical and procedural characteristics, medical history, and findings in electrocardiography (ECG), echocardiography, and coronary angiography were collected from 2,169 consecutive patients undergoing CTO PCI between January 2018 and December 2019 and analyzed retrospectively.&lt;/p&gt;&lt;p&gt;Results: About 1,844 (85.02%) underwent successful CTO PCI with complete revascularization. Acquired coronary fistulas were found in 49 patients (2.66%): the majority of patients with ACFs were men (81.63 vs. 60.78%; p = 0.016) and younger (62.8 vs. 66.69 years; p = 0.003), and had a history of myocardial infarction (MI) or Q-wave (69.39 vs. 54.21%; p = 0.035); 38 (77.55%) patients had multiple fistulas (≥3), and ACFs affected multiple branches of the CTO vessel (≥3) in 29 (59.18%) patients. None had pericardial effusion, tamponade, and hemodynamic abnormality before or after PCI.&lt;/p&gt;&lt;p&gt;Conclusion: Acquired coronary fistulas after successful CTO PCI are mainly present in young and male patients with a history of MI, and they often involve multiple fistulas and distal CTO vessels.&lt;/p&gt;