Angioplasty For Occlusion Research Articles

In-Hospital Costs and Costs of Complications of Chronic Total Occlusion Angioplasty: Insights From the OPEN-CTO Registry

ObjectivesThe aim of this study was to describe the costs of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and the association of complications during CTO PCI with costs and length of stay (LOS). BackgroundCTO PCI generally requires more procedural resources and carries higher risk for complications than PCI of non-CTO vessels. The costs of CTO PCI using the hybrid approach have not been described, and no studies have examined the impact of complications on in-hospital costs and LOS in this population. MethodsCosts were calculated for 964 patients in the 12-center OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures) registry using prospectively collected resource utilization and billing data. Multivariate models were developed to estimate the incremental costs and LOS associated with complications. Attributable costs and LOS were calculated by multiplying the independent cost of each event by its frequency in the population. ResultsMean costs for the index hospitalization were $17,048 ± 9,904; 14.5% of patients experienced at least 1 complication. Patients with complications had higher mean hospital costs (by $8,603) and LOS (by 1.5 days) than patients without complications. Seven complications were independently associated with increased costs and 6 with LOS; clinically significant perforation and myocardial infarction had the greatest attributable cost per patient. Overall, complications accounted for $911 per patient in hospital costs (5.3% of the total costs) and 0.2 days of additional LOS. ConclusionsComplications have a significant impact on both LOS and in-hospital costs for patients undergoing CTO PCI. Methods to identify high-risk patients and develop strategies to prevent complications may reduce CTO PCI costs.

Prevalence, predictors, and health status implications of periprocedural complications during coronary chronic total occlusion angioplasty.

Contemporary coronary chronic total occlusion (CTO) PCI has been associated with increased success rates. However, the rate of periprocedural complications for hybrid CTO PCI remains incompletely defined. We leveraged the OPEN CTO study in order to describe the prevalence, predictors, and health status outcomes of complications during contemporary CTO PCI. Baseline demographics, procedural characteristics and rates of in-hospital complications were prospectively collected for 1,000 consecutive procedures at 12 expert US centres from 02/2014 to 07/2015. Multivariable logistic regression was used to evaluate the association of pre-specified anatomic and physiologic variables with complications. Patient-reported health status measures over the year following CTO PCI were also compared between those with and those without periprocedural complications. The overall complication rate was 9.7% (n=97/1,000). The most common adverse events were perforation (8.8%), periprocedural myocardial infarction (2.6%), arrhythmia requiring treatment (1.2%), cardiogenic shock (1.1%), and in-hospital death (0.9%). Independent predictors of complications during CTO PCI were: use of the retrograde approach (OR 1.98, 95% CI: 1.32-2.99), age (OR 1.30, 95% CI: 1.07-1.58 per 10-year increment), and J-CTO score (OR 1.20, 95% CI: 1.03-1.41 per one point increment). Mean health status scores over 12 months were worse for patients who experienced complications compared to those who did not, even after adjusting for baseline health status. Complication rates for CTO PCI are more frequent than those reported for non-CTO PCI and were independently associated with retrograde approach, increasing age, and increasing lesion complexity. In addition, these periprocedural complications were also associated with worse long-term health status outcomes.

Algorithmic solutions to common problems encountered during chronic total occlusion angioplasty: The algorithms within the algorithm.

Improved technical equipment, dissemination of best practices, and the importance of complete coronary revascularization have led to a renewed interest in coronary chronic total occlusion (CTO) PCI. In particular, the hybrid algorithm has been associated with increasing procedural success rates in the US. However, the hybrid algorithm only covers overarching strategies in the overall approach to these lesions. Several technical challenges can occur during execution of these approaches, each of which has several potential solutions. A systematic or algorithmic approach to dealing with these challenges could contribute to improved procedural efficiency and higher procedural success. While there have been isolated attempts in the past to codify approaches to each of these situations, there has not been a contemporary, comprehensive review of the potential solutions to these problems. We present 10 common problems encountered during CTO PCI and a consensus hierarchical approach to them.

TCT-28 Repeat Chronic Total Occlusion Angioplasty Following an Unsuccessful CTO PCI Attempt: Predictors of Success and Association of Success with Angina Symptoms

Although success rates of CTO PCI using the hybrid algorithm are high, ∼ 10% of procedures are unsuccessful. The predictors of successful repeat CTO PCI attempts and the association of success of a repeat CTO PCI attempt with long-term angina symptoms are unknown. We studied patients undergoing

TCT-79 Quality of Life in Patients With Refractory Angina After Chronic Total Occlusion Angioplasty

Refractory angina (RA) is a debilitating disease that is often more frequent in patients with chronic total occlusions (CTOs). The degree of quality of life (QoL) improvement after CTO PCI in patients with RA has not been reported. Among 1000 consecutive patients from 12 centers who underwent CTO

Stress Test Risk Classification And Health Status Outcomes After Chronic Total Occlusion Angioplasty

Stress Test Risk Classification And Health Status Outcomes After Chronic Total Occlusion Angioplasty

Comparison of Angiographic Dissection Patterns Caused by Long vs Short Balloons During Balloon Angioplasty of Chronic Femoropopliteal Occlusions

Purpose: To describe the feasibility of balloon angioplasty using a long balloon for chronic femoropopliteal occlusions by evaluating angiographic dissection patterns for optimization of outcomes in balloon angioplasty. Methods: A retrospective, single-center analysis examined 101 symptomatic patients (mean age 75.6±9.9 years; 65 men) with single de novo femoropopliteal occlusive lesions treated with balloon angioplasty between August 2012 and October 2016. The patients were classified into 2 groups for comparison of angiographic dissection patterns: 51 patients were treated with balloon angioplasty using long balloons (L-BA; defined as ≥220 mm in length) and 50 patients were treated with short balloon angioplasty (S-BA; defined as <150-mm-long balloons). Results: Severe vessel dissection patterns, defined as type C or higher, were fewer in the L-BA group (47.1% vs 70.0% in the S-BA group, p=0.019) and the total dissection length was shorter (92.7±72.6 vs 160.4±84.6 mm in the S-BA group, p<0.001). Although the results showed no significant differences between the two groups regarding the length of chronic total occlusions (L-BA: 228.6±73.2 vs S-BA: 226.0±53.8 mm, p=0.83), inflation pressure (L-BA; 8.2±2.6 vs S-BA: 8.1±2.9 atm, p=0.86), and the other lesion characteristics, inflation time was significantly longer in the L-BA group (161.2±68.7 seconds vs 51.1±54.0 seconds in the S-BA group, p<0.001). Multivariate analysis identified a balloon length ≥220 mm as an independent negative predictor of severe vessel dissection (odds ratio 0.29, 95% confidence interval 0.11 to 0.83, p=0.02). Conclusion: Using long balloons for balloon angioplasty may help prevent severe vessel dissection in chronic femoropopliteal occlusions.

SFA Intervention: Intraluminal or Subintimal?

Subintimal angioplasty (SA) is an endovascular technique to recanalize an occluded arterial segment through an extraluminal channel between the intima and media. Since its introduction in 1989, the technical success rate has improved with the accumulation of procedural experience and the development of retrograde approaches and re-entry devices. To date, no randomized trial has compared SA with intraluminal angioplasty (IA) for chronic total occlusion (CTO) of the superficial femoral artery (SFA). Based on limited data from several registry studies, SA appears to achieve a higher technical success rate than IA, whereas mid-term primary patency rates are comparable for both endovascular wiring strategies for SFA CTO. Additional clinical data are needed to confirm that SA is as effective as IA. The optimal stenting strategy and role of drug-eluting technologies also need to be defined to improve SA outcomes.

Late-acquired Peri-stent Contrast Staining after Coronary Angioplasty for In-stent Occlusion: A Case with Optical Frequency Domain Imaging and Angioscopic Assessment

Late-acquired Peri-stent Contrast Staining after Coronary Angioplasty for In-stent Occlusion: A Case with Optical Frequency Domain Imaging and Angioscopic Assessment

Association of Stress Test Risk Classification With Health Status After Chronic Total Occlusion Angioplasty (from the Outcomes, Patient Health Status and Efficiency in Chronic Total Occlusion Hybrid Procedures [OPEN-CTO] Study)

Stress testing is endorsed by the American College of Cardiology/American Heart Association Appropriate Use Criteria to identify appropriate candidates for Chronic Total Occlusion (CTO) Percutaneous Coronary Intervention (PCI). However, the relation between stress test risk classification and health status after CTO PCI is not known. We studied 449 patients in the 12-center OPEN CTO registry who underwent stress testing before successful CTO PCI, comparing outcomes of patients with low-risk (LR) versus intermediate to high-risk (IHR) findings. Health status was assessed using the Seattle Angina Questionnaire Angina Frequency (SAQ AF), Quality of Life (SAQ QoL), and Summary Scores (SAQ SS). Stress tests were LR in 40 (8.9%) and IHR in 409 (91.1%) patients. There were greater improvements on the SAQ AF (LR vs IHR 14.2 ± 2.7 vs 23.3 ± 1.3 points, p <0.001) and SAQ SS (LR vs IHR 20.8 ± 2.3 vs 25.4 ± 1.1 points, p = 0.03) in patients with IHR findings, but there was no difference between groups on the SAQ QoL domain (LR vs IHR 24.8 ± 3.4 vs 27.3 ± 1.6 points, p = 0.42). We observed large health status improvements after CTO PCI in both the LR and IHR groups, with the greatest reduction in angina among those with IHR stress tests. Although patients with higher risk studies may experience greater reduction in angina symptoms, on average, patients with LR stress tests also experienced large improvements in symptoms after CTO PCI, suggesting patients with refractory symptoms should be considered appropriate candidates for CTO PCI regardless of stress test findings.

Central vein rupture during percutaneous transluminal angioplasty for central vein stenosis or occlusion in haemodialysis patients

Background: Endovascular treatments such as percutaneous transluminal angioplasty (PTA) and stent placements are becoming the standard method in managing haemodialysis access failure. Venous rupture is the most common complication during endovascular procedures. Complications during endovascular treatments of central venous stenosis or occlusion have been rarely reported.Objectives: To investigate the incidence and management of central vein rupture while performing PTA for central vein stenosis or occlusion in haemodialysis patients.Method: Between 1998 and 2013, PTA was performed using various techniques in haemodialysis patients for central vein stenoses (n = 2437) and occlusions (n = 666). When the guide wire passed through the stenosis or the occlusion, PTA was performed regardless of the presence of a venous rupture. The incidence of central vein rupture was analysed using the chi-square test according to the gender, location, right versus left, presence of thrombosis and stenosis versus occlusion. Percutaneous management of central vein rupture was also evaluated.Results: Central vein rupture occurred in 12 cases (0.39%). All ruptures occurred in the cases with occlusion. Only stenosis versus occlusion reflected a significant correlation (p &lt; 0.001) with central vein rupture. Central vein ruptures were managed by low-pressure balloon tamponade (n = 2), stent/stent-graft (n = 5) and balloon-mediated haemostasis blocking venous inflow followed by the observation (n = 5).Conclusion: Central vein rupture is a rarely occurring complication while performing PTA for central vein stenosis and occlusion, and the majority can be successfully managed by percutaneous techniques.

TCT-17 Procedural characteristics, Outcomes and Complications in patients undergoing percutaneous coronary chronic total occlusion angioplasty: Pooled analysis from RECHARGE, Expert JCTO, EURO CTO, PROGRESS and OPEN CTO Registries

Recent improvement in clinical skills, technology and hardware has resulted in improved success rates with chronic total occlusion angioplasty. We sought to perform pooled analysis of procedural characteristics, procedural outcomes and complications following contemporary chronic toatal occlusion

TCT-258 Impact of Complications During Chronic Total Occlusion Angioplasty on Hospitalization Costs and Length of Stay: Insights from the OPEN-CTO Registry

TCT-258 Impact of Complications During Chronic Total Occlusion Angioplasty on Hospitalization Costs and Length of Stay: Insights from the OPEN-CTO Registry

Morphological characteristics of chronic total occlusion: predictors of different strategies for long-segment femoral arterial occlusions.

To investigate morphological characteristics used to predict recanalisation strategies in long-segment (>10 cm) femoral chronic total occlusion (LSF-CTO) angioplasty. We retrospectively evaluated a range of morphological CTA and DSA features in patients who underwent recanalisation of LSF-CTO. The stage of CTO was classified into early (3-12 months) and late (>12 months) according to estimated duration. Characteristics including stump morphology, lesion length and calcification, proximal side branches, collaterals circulation, runoff vessels and concomitant arterial occlusion were used as predictors, and multivariate logistic regression analysis was performed to identify variables associated with late-stage CTO and retrograde technique. A total of 119 patients with 137 CTOs in 137 limbs were enrolled. Overall, successful recanalisation was achieved in 122 CTOs (89.1%). Flush occlusion [odds ratio (OR) 2.958; 95% confidence interval (CI) 1.172-7.465; p = 0.022], large collateral (OR 2.778; 95% CI 1.201-6.427; p = 0.017) and TransAtlantic Inter-Society Consensus II class D (TASC D) lesion (OR 1.743; 95% CI 1.019-2.981; p = 0.042) were predictors for late-stage CTO. Flush occlusion (OR 75.278; 95% CI 10.664-531.384; p < 0.001) and large collateral (OR 23.213; 95% CI 3.236-166.523; p = 0.002) were associated with high likelihood for retrograde approach. Flush occlusion and large collateral were associated with a CTO at late-stage which may require retrograde recanalisation. • CTO morphological characteristics help estimate lesion duration and optimise recanalisation strategies. • Flush occlusion and large collateral is associated with late-stage CTO and retrograde recanalisation. • Application of anterograde and retrograde recanalisation for long-segment femoral CTO is effective.

P516Impact of the J-CTO score on long-term target lesion revascularization rate after native chronic total coronary occlusion angioplasty

P516Impact of the J-CTO score on long-term target lesion revascularization rate after native chronic total coronary occlusion angioplasty

Early Procedural and Health Status Outcomes After Chronic Total Occlusion Angioplasty: A Report From the OPEN-CTO Registry (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures)

ObjectivesThis study sought to accurately describe the success rate, risks, and patient-reported benefits of contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BackgroundIn light of the evolving techniques to successfully revascularize CTO lesions, there remains a compelling need to more accurately quantify the success rates, risks, and benefits of these complex procedures. MethodsUsing a uniquely comprehensive, core-lab adjudicated, single-arm, multicenter registry of 1,000 consecutive patients undergoing CTO PCI by the hybrid approach, we evaluated the technical success rates, complication rates, and raw and adjusted health status benefits at 1 month among successfully as compared to unsuccessfully treated patients. ResultsTechnical success was high (86%). In-hospital and 1-month mortality was 0.9% and 1.3%, respectively, and perforations requiring treatment occurred in 48 patients (4.8%). Among those who survived and completed the 1-month interview (n = 947), mean ± SEM Seattle Angina Questionnaire quality of life scores improved from 49.4 ± 0.9 to 75.0 ± 0.7 (p < 0.01), mean Rose Dyspnea Scale scores improved (decreased) from 2.0 ± 0.1 to 1.1 ± 0.1 (p < 0.01), and physician health questionnaire (for depression) scores improved (decreased) from 6.2 ± 0.2 to 3.5 ± 0.1 (p < 0.01) at 1 month. After adjusting for baseline differences the mean group difference in Seattle Angina Questionnaire quality of life between successful and unsuccessful CTO PCI was 10.8 (95% confidence interval: 6.3 to 15.3; p < 0.001). ConclusionsClarifying the success rates, risks, and benefits of CTO PCI will help to more accurately contextualize the informed consent process for these procedures so that patients with appropriate indications for CTO PCI can more effectively share in the decision to pursue this or other therapeutic options.

Vascular Access Site and Outcomes Among 26,807 Chronic Total Coronary Occlusion Angioplasty Cases From the British Cardiovascular Interventions Society National Database

ObjectivesThe aim of this study was to assess, using a national percutaneous coronary intervention (PCI) database, access-site choice and outcomes after chronic total occlusion (CTO) PCI. BackgroundGiven the influence of access site on outcomes, the use of radial access in CTO PCI warrants further investigation. MethodsData were analyzed from the British Cardiovascular Intervention Society dataset of 26,807 elective CTO PCI procedures performed in England and Wales between 2006 and 2013. Multivariate logistic regression was used to identify predictors of access-site choice and its association with outcomes. ResultsThere was a significant decrease in femoral artery (FA) access from 84.6% in 2006 to 57.9% in 2013. Procedural factors associated with FA access included dual access (odds ratio [OR]: 3.89; 95% confidence interval [CI]: 3.45 to 4.32), CrossBoss/Stingray (OR: 1.87; 95% CI: 1.43 to 2.12), intravascular ultrasound (OR: 1.32; 95% CI: 1.21 to 1.53), and microcatheter use (OR: 1.18; 95% CI: 1.03 to 1.39). There was an association between FA access and the number of CTO devices used (p = 0.001 for trend). Access-site complications (1.5% vs. 0.5%; p < 0.001), periprocedural myocardial infarction (0.5% vs. 0.2%; p = 0.037), major bleeding (0.8% vs. 0.2%, p < 0.001), transfusion (0.4% vs. 0%; p < 0.001), and 30-day death (0.6% vs. 0.1%; p = 0.002) were more frequent in patients undergoing CTO PCI using FA access. An access-site complication during CTO PCI was associated with significant increases in transfusion (8.0% vs. 0.1%; p < 0.001), procedural coronary complication (17.3% vs. 5.8%; p < 0.0001), major bleeding (8.4% vs. 0.3%; p < 0.001), and mortality at all time points. ConclusionsFA access remains predominant during CTO PCI, with case complexity and device size associated with its use. Access-site complications were more frequent with FA use and strongly correlated with adverse outcomes.

The use of a Colapinto TIPS Needle under cone-beam computed tomography guidance for true lumen re-entry in subintimal recanalization of chronic iliac artery occlusion

BackgroundTo report the technique and clinical outcome of subintimal re-entry in chronic iliac artery occlusion by using a Colapinto transjugular intrahepatic portosystemic shunt (TIPS) needle under rotational angiography (cone-beam computed tomography; CT) imaging guidance. MethodsPatients with chronic iliac artery occlusion with earlier failed attempts at conventional percutaneous recanalization during the past 5 years were enrolled in our study. In these patients, an ipsilateral femoral access route was routinely utilized in a retrograde fashion. A Colapinto TIPS Needle was used to aid the true lumen re-entry after failed conventional intraluminal or subintimal guidewire and catheter-based techniques. The puncture was directed under rotational angiography cone-beam CT guidance to re-enter the abdominal aorta. Bare metallic stents 8–10 mm in diameter were deployed in the common iliac artery, and followed by balloon dilation. ResultsTen patients (9 male; median age, 75 years) were included in our investigation. The average occlusion length was 10.2 cm (range, 4–15 cm). According to the Trans-Atlantic Inter-Society Consensus (TASC) II classification, there were five patients each with Class B and D lesions. Successful re-entry was achieved in all patients without procedure-related complications. The ankle–brachial index (ABI) values increased from 0.38–0.79 to 0.75–1.28 after the procedure. Imaging follow-up (> 6 months) was available in six patients with patency of all stented iliac artery. Thereafter, no complaints of recurrent clinical symptoms occurred during the follow-up period. ConclusionThe use of Colapinto TIPS needle, especially under cone-beam CT image guidance, appears to be safe and effective to re-enter the true lumen in a subintimal angioplasty for a difficult chronic total iliac occlusion.

The Outcomes, Patient Health Status, and Efficiency IN Chronic Total Occlusion Hybrid Procedures registry: rationale and design.

Patients with chronic total occlusions of a coronary artery represent a complex, yet common, clinical conundrum among patients with ischemic heart disease. Chronic total occlusion angioplasty is increasingly being used as a treatment for these complex lesions. There is a compelling need to better quantify the safety, efficacy, benefits, and costs of the procedure. To address these gaps in knowledge, we designed the Outcomes, Patient Health Status, and Efficiency IN Chronic Total Occlusion Hybrid Procedures (OPEN CTO) study, an investigator-initiated multicenter, single-arm registry including 12 centers with a planned enrollment of 1000 patients. To ensure the accuracy of our observations, we used a unique auditing process through the National Cardiovascular Disease Registries' Cath/PCI Registry, angiographic core lab analysis, clinical events adjudication, and a systematic collection of patient-reported outcomes and costs. Between 21 January 2014 and 22 July 2015, 1000 patients were enrolled in OPEN CTO. A total of 28 patients either refused (N=26) or were missed by the screening process (N=2). In the National Cardiovascular Disease Registry Cath/PCI registry audit, there were 1096 chronic total occlusion-percutaneous coronary intervention procedures that were performed by participating operators during the time they enrolled in OPEN CTO. Overall, 987 of those patients could be definitively matched to an OPEN CTO enrolled patient (enrolled group). The remaining 109 were considered to be not enrolled in OPEN CTO (not enrolled group). Compared with the enrolled group, the patients in the nonenrolled group were less frequently of White race and more frequently of Hispanic origin. Procedural outcomes including National Cardiovascular Disease Registry-defined technical success, procedural success, and major adverse coronary events rates were similar. OPEN CTO is the most comprehensive and rigorously collected dataset to date that will provide unique insights into the success, safety, benefits, and the costs of chronic total occlusion-percutaneous coronary intervention using a reproducible technical approach to patients with these complex lesions.

A Case Report of Duplex-Guided Femoral Angioplasty in a Patient with Severe Renal Insufficiency Still an Option to Consider

1.1 Introduction One of the main concern of percutaneous transluminal angioplasty (PTA) is the risk of renal injury in nephropathic patients. A valid alternative is represented by CO2 angiography, which is however contraindicated in patients with chronic obstructive pulmonary disease and is not always available in hospitals. In these cases, the role of duplex guided balloon angioplasty (Du-PTA) should be reassessed. 1.2 Case presentation We describe the case of a 75 years-old nephropathic Caucasian male patient who underwent a duplex-guided percutaneous transluminal angioplasty (Du-PTA) for a 10-cm occlusion of his right femoral superficial artery causing rest pain. A review of the literature about the use of duplex ultrasound for the endovascular treatment of infrainguinal vascular disease in selected high-risk nephropathic patients was also performed. 1.3 Conclusion In well selected patients who present with critical limb ischemia and are at high risk for contrast-induced nephropathy, and when CO2 angiography cannot be performed, Du-PTA of femoral-popliteal district can still be a safe and effective alternative to conventional PTA and should be taken into account.