Case Of Chronic Total Occlusion Research Articles

Annual operator volume and procedural outcomes of chronic total occlusions treated with percutaneous coronary interventions: analysis based on 14,899 patients.

Low operator and institutional volume is associated with poorer procedural and long-term clinical outcomes in patients treated with percutaneous coronary interventions (PCI). This study was aimed at evaluating the relationship between operator volume and procedural outcomes of patients treated with PCI for chronic total occlusion (CTO). Data were obtained from the national registry of percutaneous coronary interventions (ORPKI) collected from January 2014 to December 2020. The primary endpoint was a procedural success, defined as restoration of thrombolysis in myocardial infarction (TIMI) II/III flow without in-hospital cardiac death and myocardial infarction, whereas secondary endpoints included periprocedural complications. Data of 14,899 CTO-PCIs were analyzed. The global procedural success was 66.1%. There was a direct relationship between the annual volume of CTO-PCIs per operator and the procedural success (OR: 1.006 [95% CI: 1.003-1.009]; P<0.001). The nonlinear relationships of annualized CTO-PCI volume per operator and adjusted outcome rates revealed that operators performing 40 CTO cases per year had the best procedural outcomes in terms of technical success (TIMI flow II/III after PCI), coronary artery perforation rate and any periprocedural complications rate (P<0.0001). Among the other factors associated with procedural success, the following can be noted: multi-vessel, left main coronary artery disease (as compared to single-vessel disease), the usage of rotablation as well as PCI within bifurcation. High-volume CTO operators achieve greater procedural success with a lower frequency of periprocedural complications. Higher annual caseload might increase the overall quality of CTO-PCI.

Tip Detection–Antegrade Dissection and Re-Entry With New Puncture Wire in CTO Intervention: Revolution Through 3D-Wiring

BackgroundThe authors devised the tip detection (TD) method and developed AnteOwl WR intravascular ultrasound to standardize intravascular ultrasound–based 3-dimensional wiring for intraplaque tracking in chronic total occlusion (CTO)–percutaneous coronary intervention (PCI). The TD method also allowed antegrade dissection and re-entry (ADR). Combining TD-ADR with Conquest Pro 12 Sharpened Tip (CP12ST) wire, a new ADR wire with the strongest penetration force developed to date, enabled re-entry anywhere except calcification sites. ObjectivesThis study investigated the efficacy and feasibility of TD-ADR by comparison of procedural outcomes with Stingray-ADR in CTO-PCI. MethodsTwenty-seven consecutive CTO cases treated by TD-ADR with CP12ST wire between August 2021 and April 2023 and 27 consecutive CTO cases treated by Stingray-ADR with Conquest 8-20 (CP20) wire between March 2018 and July 2021 were retrospectively enrolled as the TD-ADR by CP12ST wire group and Stingray-ADR by CP20 wire group, respectively, from 4 facilities that could share technical information on these procedures. ResultsThe success rate of the ADR procedure was significantly improved (27 of 27 cases [100%] vs 18 of 27 cases [67%], respectively; P = 0.002) and total procedural time was significantly reduced (median procedural time: 145.0 [Q1-Q3: 118.0-240.0] minutes vs 185.0 [Q1-Q3: 159.5-248.0] minutes, respectively; P = 0.028) in the TD-ADR by CP12ST wire group compared to the Stingray-ADR by CP20 wire group. There were few in-hospital major adverse cardiac and cerebrovascular events or no complications in either group. ConclusionsTD-ADR by CP12ST wire can standardize highly accurate ADR in CTO-PCI.

The active pulling technique to solve microcatheter-uncrossable lesions in retrograde chronic total occlusion percutaneous coronary intervention.

It is not uncommon to encounter retrograde microcatheter-uncrossable lesions in retro-recanalization of Chronic Total Occlusion (CTO) cases, existing solutions were time-consuming or complicated to operate. Therefore, the present study aimed to propose and evaluate the feasibility, safety of a novel technique termed Active Pulling retrograde microcatheter crossing Technique (APT) during retrograde CTO percutaneous coronary intervention (PCI). We retrospectively collected retrograde CTO-PCI cases from February 2017 to April 2023, only cases with the retrograde wire successfully crossed the CTO lesion were analyzed. The baseline clinical characteristics, angiographic characteristics, procedural details, and in-hospital major adverse cardiac events (MACEs) were compared. A total of 80 CTO cases were divided into the APT group and the non-APT group according to whether the APT was applied in the procedure. The APT group had a higher rate of device success than the non-APT group (100% vs. 85%, P = 0.013), with shorter duration (5.3 ± 3.8 vs. 18.6 ± 5.9min, P < 0.001) and a smaller number of retrograde microcatheters were used (P < 0.001). In the APT group, the average air kerma radiation exposure was lower (2.7 ± 1.2 vs. 4.3 ± 1.7Gy, P < 0.001), the fluoroscopy time (69.0 ± 15.0 vs. 88.1 ± 18.9min, P < 0.001) and the procedure time (116.2 ± 22.2 vs. 131.6 ± 28.7min, P = 0.009) was shorter than the non-APT group. The technical success rate of both groups reached 100% while the procedure success rate was higher in the APT group than the non-APT group (100% vs. 85%, P = 0.13). The APT is an easy and safe technique that can greatly improve procedural efficiency without adding other instruments, and allows the retrograde microcatheter to quickly crossing the CTO body after successful retrograde wire externalization.

Chronic total occlusion percutaneous coronary intervention (CTO PCI) in an intractable heart failure patient: Is there any benefit?

One of the most difficult procedures in interventional cardiology is the percutaneous coronary intervention (PCI) on a chronic total occlusion (CTO) lesion case. To rate the difficulty of guidewire crossing, several angiographic scoring methods have been developed such as the Japan CTO (J-CTO) score. Here we demonstrate the advantages of revascularization using PCI procedure in a CTO case with intractable heart failure. A 53-year-old man presented to the emergency room of Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia with acute decompensated heart failure. The patient had a history of past PCI with two patent drug eluting stents (DES): one in the left main (LM)-left anterior descending (LAD) artery and one in the distal left circumflex (LCX) artery. The patient had three times rehospitalizations in the last three months. According to single-photon emission computed tomography (SPECT) imaging, the right coronary artery was remained functional; however, the lesion was categorized into very difficult level (J-CTO >3). The PCI was carried out on the right coronary artery and the blood vessel was successfully revascularized after applying multiple techniques. Following the procedure, the heart failure was treated and the 6-minute walking test (6MWT) that performed 12 days after the PCI increased from 220 to 260 meters. The success of this case depended on a comprehensive history taking, adequate imaging methods, and the selection of the proper tools and PCI strategy. In conclusion, despite the challenges, PCI is still an option for patients with persistent complete occlusion. The PCI requires comprehensive preparation and the use of angiographic scoring systems, such as the J-CTO score, to determine the approach and the likelihood of success.

A case of chronic total occlusion in popliteal artery recanalized by double snare piercing technique

BackgroundAlthough majority of cases with chronic total occlusion (CTO) in femoro-popliteal lesion were treated with antegrade approach only, some lesions require alternative approach due to its complexity. Bi-directional approach is useful on endovascular therapy (EVT) for CTO; however guidewire passage through the lesion is impossible in some challenging cases. The present case shows a successful re-entry technique utilizing two snare catheters from an antegrade and retrograde access site (double snare piecing technique).Case presentationA 79-year-old woman with right leg intermittent claudication (Rutherford category IV), who had undergone unsuccessful EVT for popliteal CTO, required another EVT for the worsening symptom. Following the failed conventional crossing technique (wire knuckle technique, intravascular-ultrasound-guided wiring, and controlled antegrade and retrograde subintimal tracking technique), two snare catheters were placed and the snare loops were pierced by a puncture needle percutaneously. After an 0.014 wire was inserted into the needle, the needle was withdrawn. The wire was pulled from the retrograde side and was externalized. Then, the antegrade snare catheter was pulled and externalized, to make the wire across the lesion. After that, a microcatheter was advanced along the externalized wire from the retrograde side and cross the lesion. The wire was replaced with a new wire, which completely created pull-through system. After the hemostasis by balloon inflation and lesion preparation, this procedure was completed with an endoluminal-covered stent and two inter-woven stents. The re-entry site was covered by the inter-woven stent. Her symptoms improved after the procedure, and the lesion has not developed restenosis at 2-years follow-up.ConclusionsThis re-entry technique of puncturing two snare loops (double snare piercing technique) might be effective for achieving successful passage through challenging femoropopliteal CTO cases.

Retrograde percutaneous coronary intervention of chronic total occlusion via discontinuous septal channels.

The study aims to investigate the safety and feasibility of retrograde CTO intervention via collateral connection grade 0 (CC-0) septal channel and to identify predictors of collateral tracking failure. Guidewire crossing a collateral channel is a critical step for successful retrograde percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Retrograde PCI was attempted in 122 cases of CTO with CC-0 septal collaterals from December 2018 to May 2021. A hydrophilic polymer coating guidewire was used for crossing all intended CC-0 collaterals. A multivariable logistic regression analysis was performed to identify the predictors of guidewire tracking failure via the CC-0 collaterals. Successful guidewire tracking via CC-0 septal channel was achieved in 98 (80.3%) of 122 cases. The independent predictors of CC-0 septal channel guidewire tracking failure included well-developed non-septal collateral (OR: 5.297, 95% CI: 1.107-25.353, p = 0.037) and the ratio length of posterior descending artery (PDA) versus the distance of PDA ostium to cardiac apex ≤2/3 (OR: 3.970, 95% CI: 1.454-10.835, p = 0.007). Collateral perforation, target vessel perforation, and cardiac tamponade occurred in 5 (4.1%), 3 (2.5%), and 6 (4.9%) cases, respectively. There were no complications requiring emergency cardiac surgery or revascularization of nontarget vessel. Retrograde PCI via CC-0 septal channels with a hydrophilic polymer-coated guidewire is feasible and safe in patients with CTO. Well-developed nonseptal collaterals and short PDA length influence the procedure success and the risk of guidewire tracking failure via CC-0 septal channels.

Novel dual guiding catheter technique for kissing balloon inflation in percutaneous coronary intervention for bifurcated chronic total occlusive lesion

Traditionally, two bigger-sized guiding catheters (GCs) via the femoral artery have been used in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). However, those GCs are associated with an increased incidence of bleeding. Therefore, the use of smaller GCs (e.g., 5-Fr) may lessen the invasiveness of this procedure. However, the use of 5-Fr GCs in PCI is complicated by device limitations. A novel technique was developed to overcome the challenges with regard to kissing balloon inflation. This approach involves simultaneous balloon inflation through a dual 5-Fr GC technique for CTO-PCI. In our hospital, this technique was successfully performed in 9 cases of CTO with 10 bifurcated lesions (including four left main-related bifurcations). During the study period, there was no requirement for an additional invasive procedure or occurrence of complications related to the PCI procedure. This technique may be a good option for performing KBI during CTO-PCI through the use of two 5-Fr GCs.

Calcium Modification Therapies in Contemporary Percutaneous Coronary Intervention.

Coronary Artery Calcification (CAC) has been known to be associated with worse Percutaneous Coronary Intervention (PCI) short- and long-term outcomes. Nowadays, with the increased prevalence of the risk factors leading to CAC in the population and also more PCI procedures done in older patients and with the growing number of higher-risk cases of Chronic Total Occlusion (CTO) PCI and PCI after Coronary Artery Bypass Grafting (CABG), severe cases of CAC are now encountered on a daily basis in the catheterization lab and remain a big challenge to the interventional community, making it crucial to identify cases of severe CAC and plan a CAC PCI modification strategy upfront. Improved CAC detection with intravascular imaging helped identify more of these severe CAC cases and predict response to therapy and stent expansion based on CAC distribution in the vessel. Multiple available therapies for CAC modification have evolved over the years. Familiarity with the specifics and special considerations and limitations of each of these tools are essential in the choice and application of these therapies when used in severe CAC treatment. In this review, we discuss CAC pathophysiology, modes of detection, and different available therapies for CAC modification.

ЭКОНОМИЧЕСКАЯ ЭФФЕКТИВНОСТЬ ИСПОЛЬЗОВАНИЯ РАЗЛИЧНЫХ ТИПОВ СТЕНТОВ ПРИ КОРРЕКЦИИ ХРОНИЧЕСКИХ ОККЛЮЗИЙ КОРОНАРНЫХ АРТЕРИЙ

Aim. To study cost-effectiveness of different types of stents in the correction of chronic total occlusion (CTO). Methods. The study included 119 patients after successful coronary artery CTO recanalization in 2009–2012. After 6.1±0.9 months and 12.7±1.6 months a control examination was performed (coronary angiography, intravascular ultrasound, optical coherence tomography). Negative events (in-stent restenosis and thrombosis) were analyzed. Taking into account the obtained data, direct costs were calculated including the cost of implants, and the cost of restenosis and thrombosis treatment. Results. The highest frequency of in-stent restenosis (p &lt; 0.05) was registered after IntrepideTM (in 57.1% cases) and Prolim® (in 47.4% cases) stent implantation while the similar events in cases of Taxus® Express 2, Xience V®/Xience Prime® LL, Endeavor® Resolute, Nobori® stent implantation were registered in 0-11.1% of cases. There weren’t differences in the thrombosis incidence between studied types of implants (p &gt; 0.05). Based on the data obtained, the stents were classified as devices with low rate of adverse events (Taxus® Express 2, Xience V®/Xience Prime® LL, Endeavor® Resolute, Nobori® – LRAE group), and those with a high rate of restenosis and thrombosis (IntrepideTM and Prolim® – HRAE group). The average cost of stents in the LRAE group was 2155.1 US dollars. Endovascular correction of in-stent restenosis were performed in 6.3% of cases, thrombosis – in 1.3%, the average direct treatment cost per patient over 12.7±1.6 months totaled 3906.4 US dollars. In the HRAE group the cheaper devices were implanted (median cost was $1650.8). Repeated PCIs due to restenosis were performed in 52.5% of cases, one patient (2.5%) with verified thrombosis underwent CABG. The average direct treatment cost per patient over 12.7±1.6 months period was 4993.5 US dollars, which was $1,087.1 more than in the LRAE group. Conclusion. The obtained data indicate higher financial cost during 12.7±1.6 months follow-up period after IntrepideTM and Prolim® stent implantation in the recanalized CTO areas. This emphasizes the impotance of using coronary stents with proven minimal risks of in-trastent restenosis and thrombosis in CTO cases.

The effect of recanalization of a chronic total coronary occlusion on P-wave dispersion.

Introduction: P-wave dispersion (PWD) obtained from the standard 12-lead electrocardiography (ECG) is considered to reflect the homogeneity of the atrial electrical activity. The aim of this investigation was to evaluate the effect of percutaneous chronic total occlusion (CTO) revascularization on the parameters of P wave duration and PWD on ECG in cases before and after procedure at 12th months. Methods: We analyzed 90 consecutive CTO cases who were on sinus rhythm and underwent percutaneous coronary intervention (PCI). P-wave maximum (P-max) and P-wave minimum (P-min), P-wave time, and PWD were determined before and twelve months after the CTO intervention. The study population was categorized into two groups as successful and unsuccessful CTO PCI groups. Results: The CTO PCI was successful in 71% of cases (n=64) and it was unsuccessful in 29% of cases (n=26). Both groups, except for age and hypertension, were similar in terms of demographic and clinical aspects. CRP levels were significantly elevated in the unsuccessful CTO PCI group. Pre-PCI ECG parameters showed no significant difference. Irrespective of the target vessel revascularization, we observed that PWD and P-max values were significantly lower in the 12th months follow-up. In all Rentrop classes, PWD values were significantly decreased at 12th months follow-up in comparison to the pre-CTO PCI values. Conclusion: This study has determined that PWD and P-max, which are both risk factors for atrial arrhythmias, are significantly reduced within 12th months after successful CTO PCI regardless of the target vessel.

Efficacy of navigating through the intraplaque route using AnteOwl WR intravascular ultrasound in femoropopliteal chronic total occlusion

BackgroundThere is no consensus on the optimal guidewire passage route for femoropopliteal (FP) chronic total occlusion (CTO). If intraplaque wiring can be performed, a stent-less strategy using a drug-coated balloon can be realized even with FP CTO, and there is a high possibility that good expansion can be obtained even when stent deployment is performed. AnteOwl WR (AnteOwl) is a novel intravascular ultrasound (IVUS) device useful for navigating the second guidewire into the intraplaque route under IVUS observation from the subintimal space. Here, we describe representative cases of FP CTO in which CTO-specific IVUS was extremely useful.Case presentationCase 1 involved a 79-year-old man with total occlusion of the left superficial femoral artery (SFA). We used a contralateral antegrade approach, but the guidewire was advanced into the subintimal space. We advanced AnteOwl into the CTO. By utilizing the asymmetric structure of the transducer and the IVUS wire, we were able to reflect the positional relationship among the IVUS transducer, IVUS wire, and target plaque onto the angiographic image. By aiming the wiring in that direction, we succeeded in traversing the center of the plaque and finally succeeded in obtaining good expansion using the drug-coated balloon. Case 2 involved a 76-year-old woman with total occlusion from the SFA to the popliteal artery. We used an ipsilateral antegrade approach. When AnteOwl was placed on the wire and advanced to the popliteal artery, the subintimal space in the middle of the SFA could be visualized. We employed an IVUS-guided parallel wiring technique and succeeded in passing through all intraplaque routes. Although the CTO was long, we could easily advance through the intraplaque route by reflecting the information obtained from AnteOwl in angiography.ConclusionsAnteOwl is an effective IVUS for FP CTO and facilitates a complex IVUS-guided procedure.

Safety and efficacy of a low frame rate protocol for percutaneous coronary intervention for chronic total occlusions.

Safety and efficacy of a low frame rate protocol for percutaneous coronary intervention for chronic total occlusions.

Fate of lumen size in distal coronary segment following successful chronic total occlusion recanalization

BackgroundRestoration of anterograde blood flow leads to alterations in vascular wall stress that may influence lumen size distal to chronic total occlusion (CTO) lesions. We sought to assess changes in lumen diameter of segments distal to the stent segment of successfully recanalized CTO. MethodsWe analyzed 507 consecutive CTO cases with stent implantation that underwent follow-up angiography at a single high-volume center (mean follow-up of 13.5 months). Segments ≤40 mm distal to the stent edge were analyzed using quantitative coronary angiography. ResultsAt follow-up, lumen diameters significantly increased; diameter changes of 0.26 ± 0.47 (percent diameter change of 18.2%) at 5 mm distal, mean lumen diameter changes of 0.23 ± 0.35 (14.3%) and minimal lumen diameter changes of 0.22 ± 0.80 (24.7%) (all p < 0.001). Lumen enlargement was similar between visually shrunken and stenosed vessels (degree of stenosis ≥20% with luminal irregularities) distal to stents; 5 mm distal (0.32 ± 0.48 vs. 0.30 ± 0.48, p = 0.76), mean lumen diameter changes (0.26 ± 0.37mm vs. 0.26±0.33 mm, p = 0.94), minimal lumen diameter changes (0.28 ± 0.43 mm vs. 0.22 ± 1.30 mm, p = 0.48). There was no association between degree of in-stent narrowing and changes in distal lumen diameter (Spearman r = −0.02, p = 0.59). Multivariate logistic regression for the predictors of greater lumen enlargement indicated that patients with left ventricle dysfunction (ejection fraction ≤45%) had greater enlargement [odds ratio (OR): 2.53, 95% confidence interval (CI): 1.23–5.23, p = 0.01]. Conversely, a low hematocrit (male <40%, and female <35%) was associated with attenuated lumen enlargement (OR: 0.68 95% CI: 0.47–0.98; p = 0.04). ConclusionsLumen diameter distal to CTO lesions significantly increased following successful revascularization, regardless of diseased status of the distal bed or degree of in-stent narrowing. These findings implicate appropriate determination of stent size, stent coverage length, as well as management strategies of distal vessels.

Successful recanalization of previously subintimal stenting of the right coronary artery

Stent placement in the subintimal or false lumen is a rare complication of coronary interventions. Subintimal stenting can cause chronic total occlusion. Angiography images of previously treated CTO cases should be carefully monitored. To avoid placing a stent in the false lumen, it must be absolutely sure that it is inside the lumen. In this case, we presented a successful case of chronic total occlusion in the right coronary artery with a subintimal stent.

P6526Short and long-term outcomes of coronary perforation managed by coil embolization: a single-center experience

Abstract Background Coronary perforation is a serious complication in percutaneous coronary intervention (PCI), as it can lead to pericardial effusion causing tamponade, often necessitating emergency pericardiocentesis and rarely, cardiac surgery. With increasing treatment of complex coronary lesions, such as chronic total occlusion (CTO), the incidence of coronary perforation is also increasing. Distal wire perforation and collateral vessel perforation can be managed by coil embolization during PCI, which prevented the need of cardiac surgery. Purpose To report the short and long-term outcomes of patients with coronary perforation as a complication of PCI managed by coil embolization in our center Methods We retrospectively analyzed 66 patients who had coronary perforation treated by coil embolization during PCI from 32007 PCI procedures performed in our center from Oct 2012 to June 2018. Results Of sixty-six cases of coronary perforation, twenty-six cases were distal coronary perforation, while 40 cases were collateral perforation. The average coil number used in distal coronary and collateral perforation lesion is 1.8±0.9 and 1.8±1.0, respectively. The maximum number of coil implanted in each patient is 4 in both groups. Two emergency cardiac surgery to seal the perforation was performed after coil embolization in distal coronary perforation and pericardiocentesis, including one distal left circumflex artery perforation and one distal left anterior descending artery perforation. In collateral perforation, one case of CABG was performed due to myocardial ischemia caused by CTO lesion. During a follow-up of 707±476 days, one patient in collateral perforation group had CABG one month later, while no death or myocardial infarction (MI) was detected. Fifty-four (81.2%) cases of perforations occurred while treating chronic total occlusion, and 74.0% of these perforations were located in collateral vessels, mostly epicardial vessels. Thirty-nine CTO cases (72.2%) were revascularized successfully with the aid of coil embolization. Conclusion Coil embolization is feasible and effective in treating distal coronary perforation and collateral perforation during PCI procedure. In CTO lesions, coil embolization facilitates the success of revascularization by PCI.

Guide catheter extension lock enables the strongest backup force during the antegrade approach in percutaneous coronary intervention.

Sufficient guide catheter backup is crucial for successful percutaneous coronary intervention (PCI). We have developed a new technique for locking a small child catheter to the vessel wall by balloon dilatation outside the child catheter at the proximal site of the main branch. We call this the "guide catheter extension lock" ("Kiwami® lock", Kiwami® child catheter, Terumo Corp. Tokyo, Japan). The guide catheter extension lock backup force was evaluated in an experimental model, and we report a case of chronic total occlusion treated with PCI using this technique. The guide catheter backup force was measured using an artificial cardiac vessel model with a right coronary artery and side branch. We evaluated the backup forces of the guide catheter extension lock and other techniques using an 8Fr Judkins right guide catheter (child catheter: 45.0 ± 4.6g force [gf]; a 7Fr delivery catheter (Guide-Liner®, Vascular Solutions, Minneapolis MN, USA): 67.4 ± 14.4gf; an anchoring balloon technique at the side branch: 98.3 ± 11.9gf; and the guide catheter extension lock: 112.1 ± 13.0gf). The guide catheter extension lock technique provided the strongest backup force. Our clinical experience shows that this technique is effective during PCI.

A journey to CTO interventions-CTO in ARMS: 2018 CTO Cases Competition.

Chronic total occlusion (CTO) is a formidable challenge for interventionists. To overcome this challenge and provide practical information on CTO intervention, the 2018 CTO Cases Competition was held. This competition offered a great platform for contestants to make extensive discussions and exchanges on CTO treatment solutions and strategies, bringing about much better impacts on CTO treatment than the initial expectation.

TCTAP C-074 A Complex Chronic Total Occlusion Case Requiring Stent Ablation with Rotablator

### Patient Initials or Identifier Number Y.I ### Relevant Clinical History and Physical Exam A 70-year-old female with coronary risk factors such as hypertension, dyslipidemia and diabetes was admitted with exertional dyspnea for 6 months. This symptom was gradually worsening. She never had

A weighted angiographic scoring model (W-CTO score) to predict success of antegrade wire crossing in chronic total occlusion: analysis from a single centre.

The aim of this study was to derive a weighted score model predicting success/failure of antegrade wire crossing in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Four hundred and four consecutive CTO cases (408 lesions) undergoing CTO-PCI between January 2009 and March 2015 were included. Data were divided into two sets, namely "derivation" and "validation", in a 70:30 ratio. The score was derived using multivariate analysis to identify independent predictors of wire crossing failure from the derivation set (n=285 lesions) and validated on the remaining 123 lesions (validation set). The overall procedural success rate was 83.6%. Independent predictors of CTO-PCI failure and their contribution to the weighted score were a blunt stump (beta coefficient 2.12), length of occlusion >20 mm (beta coefficient 1.71), presence of calcification (beta coefficient 0.72), presence of tortuosity (beta coefficient 1.06) and collateral with Rentrop grade <2 (beta coefficient 1.06). The respective scores allotted were +2.0, +1.5, +1, +1, +1 (total 6.5), rounding the coefficient to the nearest 0.5. Score values of 0-2, >2-4 and >4 were classified as low, intermediate and high levels of difficulty for CTO-PCI success and were associated with 98%, 74.2%, and 42.5% (p<0.0001), respectively, of antegrade wire crossing success in the derivation set. This was also validated on the validation set with CTO success in the three derived difficulty levels being 100%, 82.4% and 48.4%, respectively. Our weighted angiographic CTO score is a strong predictor of final antegrade wire crossing success and could be used in day-to-day clinical practice of CTO interventions.

Long-term Survival Benefit of Statin in Patients with Coronary Chronic Total Occlusion without Revascularization.

BackgroundLimited data are available on the efficacy of statin therapy in stable ischemic heart disease with chronic total occlusion (CTO) without revascularization. We investigated whether statin therapy could be beneficial in stable patients with CTO without revascularization.MethodsFrom March 2003 to February 2012, 2,024 patients with at least one CTO were enrolled in a retrospective, single-center registry; 664 of these patients were managed conservatively without an initial revascularization strategy. Among them, we excluded CTO cases involving acute coronary syndrome, in-hospital death or incomplete data and classified 551 patients into statin (n = 369) and non-statin (n = 182) groups according to use of statin at discharge. Propensity score matching analysis was also performed in 148 pairs. The primary outcome was cardiac death.ResultsThe median overall follow-up duration was 45.7 months (interquartile range: 19.9–70.5 months). Cardiac death occurred in 22 patients (6.0%) in the statin group vs. 24 patients (13.2%) in the non-statin group (P < 0.001). In propensity score matching analysis, statin therapy was associated with a low risk of cardiac death (adjusted hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.18–0.85; P = 0.022) and major adverse cardiac events (adjusted HR, 0.66; 95% CI, 0.43–0.98; P = 0.043). On multivariate analysis, independent predictors for cardiac death were age > 70 years, renal insufficiency, prior myocardial infarction, left ventricular ejection fraction < 40%, proximal-to-mid CTO location, and no use of statin in CTO patients.ConclusionStatin therapy at discharge may be associated with a reduction in long-term cardiac mortality in stable CTO patients without revascularization.