Chronic Total Occlusion Lesions Research Articles

Retrograde Coronary Chronic Total Occlusion Intervention (JR-CTO) Score: From the Japanese CTO-PCI Expert Registry.

Despite the effectiveness of the retrograde approach for chronic total occlusion (CTO) lesions, there are no standardized tools to predict the success of retrograde percutaneous coronary intervention (PCI). The objective of this study was to develop a prediction tool to identify CTO lesions that will achieve successful retrograde PCI. This study evaluated data from 2,374 patients who underwent primary retrograde CTO-PCI and were enrolled in the Japanese CTO-PCI Expert Registry between January 2016 and December 2022 (NCT01889459). All observations were randomly assigned to the derivation and validation cohorts at a 2:1 ratio. The prediction score for guidewire failure in retrograde CTO-PCI was determined by assigning 1 point for each factor and summing all accrued points. The JR-CTO score (moderate-severe calcification, tortuosity, Werner collateral connection grade≤1, and nonseptal collateral channel) demonstrated a C-statistic for guidewire failure of 0.72 (95%CI: 0.67-0.76) and 0.71 (95%CI: 0.64-0.77) in the derivation and validation cohorts, respectively. Patients with lower scores had higher guidewire and technical success rates and decreased guidewire crossing time and procedural time (P< 0.01). The JR-CTO (Japanese Retrograde Chronic Total Occlusion) score, a simple 4-item score that predicts successful guidewire crossing in patients undergoing retrograde CTO-PCI, has the potential to support clinical decision-making for the retrograde approach.

Impact of Early Intervention on Health Status Outcomes in Peripheral Artery Disease Patients with Chronic Total Occlusion Lesions Using the PORTRAIT Registry

To analyze the impact of non-invasive and early invasive treatments on health status in patients with lower extremity peripheral arterial disease (PAD) without and with chronic total occlusions (CTO) after 12 months of follow-up. Using the international (U.S., Netherlands, and Australia) observational longitudinal PORTRAIT registry, we included patients with recent PAD symptoms between June 2011 and December 2015. We assessed the PAD-specific health status at initial visit, 3-, 6- and 12-month follow-up using the Peripheral Arterial Questionnaire (PAQ). On a propensity matched-weighted cohort, we compared patients' characteristics by CTO status and treatment groups as early invasive (revascularization in the 3 months) vs. non-invasive (exercise, medical therapies, or smoking cessation). We then assessed the health status trajectory over 12 months, as 3-way interaction between CTO status, and treatment groups, and months, using a multilevel generalized linear regression model for repeated measures adjusted for baseline health status with random effects at sites- and patients-level. We included 581 participants, with mean age of 66.62±9.33 years, 34.3% female, and 90.8% White, of whom 353 (60.8%) without and 228 (39.2%) with a CTO lesion. Respectively, 96 (27.2%) and 70 (30.7%) patients underwent early invasive treatment (d=0.07). While patients with CTO were more likely to have lower resting ABI, multilevel disease, and to experience severe claudication vs. their counterparts (|d|≥0.20); the patients' health status at baseline with CTO was not different from those without CTO, with mean Summary scores of 45.14±20.26 vs. 45.90±21.24 (d=0.04), respectively. The trajectory did not differ by CTO status (interaction CTO status*month: p=0.517) and was higher in early invasive vs. non-invasive treatment (treatment*month: p<0.001), regardless of CTO status (CTO status*treatment: p=0.981 and CTO status*treatment*month: p=0.264). The score increased over time with the largest improvement occurring at 3 months in both non-invasive (non-CTO: +7.82 95%CI 4.03;11.60 and CTO: +9.27 95%CI 4.45;14.09) and early invasive (non-CTO: +26.17 95%CI 20.06; 32.28 and CTO: +24.52 95%CI 17.40;31.64) groups. The mean score in CTO vs. non-CTO did not differ at each timepoint, with the 12-month mean score of 70.26 (95%CI 67.87; 74.65) vs. 71.17 (95% CI 65.91; 76.44) (p=0.99) in the non-invasive treatment and 84.93 (95%CI 78.90;90.97) vs. 79.20 (95%CI 72.77;86.14) (p=0.31) in the early invasive treatment. Patients with symptomatic PAD undergoing early revascularization exhibited higher health status over time vs. those undergoing non-invasive treatment strategy, irrespective of the presence of CTOs. The degree of the improvement was greater in the 3 months following the initial visit, especially in patients undergoing early revascularization.

ASSESSMENT OF SAFETY AND FEASIBILITY OF ROTATIONAL ATHERECTOMY (RA) VERSUS CONVENTIONAL STENTING IN PATIENTS WITH CHRONIC TOTAL OCCLUSION (CTO) LESIONS

Chronic total occlusion (CTO) sores in coronary arteries present a challenge in percutaneous coronary intervention (PCI) because of their complex anatomy and high rates of procedural failure. Objectives: In this comparative study, we aim to investigate the safety and feasibility of rotational atherectomy (RA) versus conventional stenting in patients with chronic total occlusion (CTO) lesions. Methods: This comparative study was conducted at Ayub teaching hospital from September 2023 to December 2023. Data was collected from 110 patients from both genders. Patients aged &gt; 18 years and diagnosed with chronic total occlusion (CTO) lesions in coronary arteries confirmed by coronary angiography were included in the study. Baseline demographic and clinical data, including age, gender, comorbidities, and angiographic characteristics, were collected for each participant. Additionally, procedural details such as the type of intervention, rotational atherectomy, conventional stenting, procedural time, fluoroscopy time, contrast volume, and any adverse events encountered during the procedure were recorded. Results: Data were collected from 110 patients from both genders. The mean age of participants in the Rotational Atherectomy (RA) group was 62.4 ± 7.3 years, while in the Conventional Stenting group, it was 61.8 ± 6.9 years. There were 40 males and 15 females in the RA group, compared to 38 males and 17 females in the Conventional Stenting group. The prevalence of diabetes mellitus was 42.0% in the RA group and 45.5% in the Conventional Stenting group. Left ventricular ejection fraction (LVEF) was 53.7 ± 4.2% in the RA group and 54.1 ± 4.5% in the Conventional Stenting group. The RA group showed a success rate of 81.8%, and the conventional stenting group achieved a success rate of 90.9%. However, the RA group experienced slightly higher rates of major procedural complications (9.1% vs. 5.5%) and minor procedural complications (12.7% vs. 10.9%) than the conventional stenting group. Conventional stenting group, the mean change was -1.2 ± 0.7. Additionally, the incidence of target lesion revascularisation (TLR) was observed in 8 patients (14.5%) in the RA group and 12 patients (21.8%) in the conventional stenting group. Furthermore, major adverse cardiovascular events (MACE) occurred in 9 patients (16.4%) in the RA group and 11 patients (20.0%) in the conventional stenting group. Conclusion: It is concluded that both rotational atherectomy (RA) and conventional stenting are effective and safe treatment options for patients with chronic total occlusion (CTO) lesions. Our findings suggest that both strategies yield comparable procedural success rates, complication rates, and efficacy outcomes, including myocardial infarction frequency, troponin levels, and left ventricular ejection fraction changes.

Clinical prediction factors of nonchronic total occlusion lesion progression in patients with unstable angina receiving percutaneous coronary intervention for chronic total occlusion lesions

BackgroundIn this study, we investigated clinical prediction factors of nonchronic total occlusion lesion (NCTOL) progression in patients who underwent percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. MethodsIn total, 450 patients with unstable angina (mean age = 57.1 ± 9.2 years) who underwent PCI for CTO lesions between January 2016 and December 2018 at Beijing Anzhen Hospital were enrolled in this study. A clinical and angiographic follow-up examination was performed 12 months postoperatively. The patients were divided into NCTOL progression (145 cases) and control (305 cases) groups based on the outcome of the 12-month angiographic follow-up. The clinical and angiographic features of the participants were analyzed. ResultsThe adenosine diphosphate-induced platelet aggregation (ADP-IPA) rate and levels of lipoprotein (a) (Lp(a)) in the NCTOL progression group were significantly higher than those in the control group (51.89 ± 14.81 vs. 39.63 ± 17.12, P < 0.01; 0.22 ± 0.26 vs. 0.14 ± 0.18, P < 0.05, respectively). Logistic regression showed that the ADP-IPA rate (odds ratio = 1.047, 95 % confidence interval: 1.014–1.082, P = 0.005) and Lp(a) (odds ratio = 11.972, 95 % confidence interval: 1.230–116.570, P = 0.033) were independent predictors of NCTOL progression. Partial correlation analysis demonstrated that the ADP-IPA rate was positively correlated with NCTOL progression (r = 0. 351, P < 0.001). Receiver operating characteristic curve showed that the boundary point of the ADP-IPA rate to predict NCTOL progression was 30 % (sensitivity, 86.2 %; specificity, 68.9 %). ConclusionsNCTOL progression is an important cause of recurrent PCI in patients with coronary artery disease after PCI for CTO lesions. The ADP-IPA rate is a useful predictor for NCTOL progression in patients with unstable angina who undergo PCI for CTO lesions.

Current evidence for prognostic benefit of intravascular imaging-guided percutaneous coronary intervention in chronic total occlusion intervention.

Although percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has been increasing in recent years, CTO PCI is still one of the most challenging procedures with relatively higher rates of procedural complications and adverse clinical events after PCI. Due to the innate limitations of invasive coronary angiography, intravascular imaging (IVI) has been used as an adjunctive tool to complement PCI, especially in complex coronary artery disease. Considering the complexity of CTO lesions, the role of IVI is particularly important in CTO intervention. IVI has been a useful adjunctive tool in every step of CTO PCI including assisted wire crossing, confirmation of wire location within CTO segment, and stent optimization. The meticulous use of IVI has been one of the greatest contributors to recent progress of CTO PCI. Nevertheless, studies evaluating the role of IVI during CTO PCI are limited. The current review provides a comprehensive overview of the mechanistic advantages of IVI in CTO PCI, summarizes previous studies and trials, and presents future perspective of IVI 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.

The impact of concomitant chronic total occlusion on clinical outcomes in patients undergoing transcatheter aortic valve replacement: a large single-center analysis.

Coronary artery disease (CAD) is a common finding in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). However, the impact on prognosis of chronic total occlusions (CTOs), a drastic expression of CAD, remains unclear. We retrospectively reviewed 1,487 consecutive TAVR cases performed at a single tertiary care medical center. Pre-TAVR angiograms were analyzed for the presence of a CTO. At the time of TAVR, 11.2% (n = 167) patients had a CTO. There was no significant association between the presence of a CTO and in-hospital or 30-day mortality. There was also no difference in long-term survival. LV ejection fraction and mean aortic gradients were lower in the CTO group. Our analysis suggests that concomitant CTO lesions in patients undergoing TAVR differ in their risk profile and clinical findings to patients without CTO. CTO lesion per se were not associated with increased mortality, nevertheless CTOs which supply non-viable myocardium in TAVR population were associated with increased risk of death. Additional research is needed to evaluate the prognostic significance of CTO lesions in TAVR patients.

The Impact of Balloon Pre-dilatation Techniques on Drug-Coated Balloon Therapy for Femoropopliteal Artery Disease: Six-Month Results From the CIVILIAN Registry.

The purpose of this study is to compare the initial outcomes of using the Chocolate balloon pre-dilatation (CLP) and sequential enlarging angioplasty pre-dilatation (sequential balloon pre-dilation [SP]) techniques versus the conventional balloon pre-dilatation (CP) method prior to drug-coated balloon (DCB) treatment for femoropopliteal (FP) lesions. This was a retrospective analysis of prospectively collected data from the CIVILIAN (Clinical InVestigation of different lesIon preparation modaLIty followed by DCB in femoropopliteal Artery occlusioN disease) registry. Between March 2021 and November 2022, 3 pre-dilation techniques used prior to the DCB angioplasty were included. The study endpoint included intraoperative finial severe dissection after provisional stent placement, bailout stenting rate, the diameter of the largest pre-dilation balloon and DCB, as well as major adverse events (MAEs), including death, major limb amputation, or target vessel revascularization at 6 months. During the study period, 435 limbs (429 patients) were pre-dilated before DCB treatment in FP lesions, 166 limbs were pre-dilated with Chocolate balloons, 93 limbs with sequential enlarging balloon pre-dilation technique, and 176 limbs with CP. The largest pre-dilation balloon was significantly larger in CLP and SP groups than that in the CP group (CLP 4.74±0.52 mm vs CP 4.36±0.64 mm, p<0.001; SP 4.82±0.69 mm vs CP 4.36±0.63 mm, p<0.001). A consistent result was shown in DCB diameter (CLP 4.86±0.44 mm vs CP 4.71±0.51 mm, p=0.003; SP 4.90±0.58 mm vs CP 4.71±0.51 mm, p=0.006). The bailout stenting rate was significantly lower in the CLP group than that in the CP group (18.1% vs 30.1%, p=0.011). The rates of MAEs at 6 months in the CLP and SP groups were comparable to those in the CP group (7.2% and 8.6% vs 6.3%, p>0.05). The risk for intraoperative bailout stenting rate was related to TASC D classification (3.59, 95% CI: 1.83-7.05, p<0.001), chronic total occlusion (CTO) lesion (1.82, 95% CI: 1.07-3.10, p=0.028), as well as pre-dilated with the conventional balloon (1.64, 95% CI: 1.00-2.69, p=0.048). By utilizing chocolate balloon and sequential enlarging angioplasty, it becomes possible to use larger pre-dilation balloons and DCBs. In addition, the use of the chocolate balloon can significantly reduce the need for bailout stenting when compared with conventional balloons. The utilization of a chocolate balloon and sequential enlarging angioplasty has emerged as a promising technique for angioplasty procedures. This approach allows for the use of larger pre-dilation balloons and drug-coated balloons. The use of the chocolate balloon can significantly reduce the need for bail-out stenting when compared to conventional balloons. Further research is required to determine the impact of vessel preparation techniques on the primary patency.

Performance of the minimalistic hybrid approach algorithm versus other conventional algorithms in the percutaneous treatment of chronic total occlusions.

The "Minimalistic Hybrid Approach" (MHA) has been proposed to reduce the invasiveness of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). This study aims to assess whether MHA may also reduce the utilization of PCI resources (devices, radiations, and contrast) by comparing it with other conventional algorithms. We aimed to assess the impact of MHA on device, radiation, and contrast usage during CTO-PCI analyzing data from the Belgian Working Group on CTO (BWG-CTO) registry. Patients were divided, depending on the algorithm used, into two groups: Conventional versus Minimalistic. Primary objectives were procedure performance measures such as device usage (microcatheters and guidewires), radiological parameters, and contrast use. At 1-year follow-up, patients were evaluated for target vessel failure (TVF), defined as a composite of cardiac death, new myocardial infarction, and target vessel revascularization. Overall, we analyzed 821 CTO-PCIs (Conventional n = 650, Minimalistic n = 171). The Minimalistic group demonstrated higher complexity of CTO lesions. After adjusting for propensity score, the Minimalistic group had a significantly lower number of microcatheters used (1.49 ± 0.85 vs. 1.24 ± 0.64, p = 0.026), while the number of guidewires was comparable (4.80 ± 3.29 vs. 4.35 ± 2.94, p = 0.30). Both groups had similar rates of success and procedural complications, as well as comparable procedural and fluoroscopic times and contrast volume used. At the 1-year follow-up, both groups showed comparable rates of TVF (hazard ratio: 0.57; 95% confidence interval: 0.24-1.34, p = 0.195). The MHA may slightly reduce the number of dedicated devices used during CTO-PCI, without adversely affecting the procedural success or long-term outcome.

Castle Score Versus J-CTO Score for The Prediction of Technical Success in Chronic Total Occlusion Percutaneous Revascularization

Background: Chronic total occlusions (CTOs) present a significant challenge in percutaneous coronary intervention (PCI). Accurate preprocedural assessment and planning are crucial for the success of these interventions. The J-CTO score has been widely used to predict the success of PCI in CTO cases, but recent developments have introduced the EuroCTO (CASTLE) score, which may offer advantages in complex cases. Objective: This study aimed to compare the predictive accuracy of the EuroCTO (CASTLE) score with the J-CTO score in determining the success of PCI in CTO cases, with a focus on their utility in preprocedural planning and risk assessment. Methods: Conducted at a tertiary cardiac care center in Rawalpindi, Pakistan, this analytical cross-sectional study involved 120 patients undergoing PCI for CTO from January 2023 to November 2023. Inclusion criteria were patients aged 18-80 years requiring PCI for CTO, while patients with acute coronary syndromes, pregnant women, or those refusing consent were excluded. Data on clinical, angiographic, and procedural characteristics were systematically recorded. The EuroCTO (CASTLE) and J-CTO scores were calculated based on established algorithms. Technical success was defined as effective revascularization of the CTO lesion with less than 30% residual stenosis and TIMI grade 3 antegrade flow restoration. Statistical analysis was conducted using SPSS 25. Results: The mean age of the participants was 58.85 ± 11.1 years, with a male predominance (62.5%). Hypertension (67.5%) and hyperlipidemia (78.3%) were common comorbidities. The mean procedural time was 132.42 ± 5.11 minutes, and the mean fluoroscopy time was 41.19 ± 2.41 minutes. The J-CTO and EuroCTO (CASTLE) scores were 2.09 ± 0.70 and 1.91 ± 0.69, respectively. Multivariate logistic regression analysis showed comparable predictive performance between the two scores, with slightly better discriminative ability in complex cases for the EuroCTO (CASTLE) score. Conclusion: Both the EuroCTO (CASTLE) and J-CTO scores effectively predict the success of PCI in CTO cases, with the EuroCTO (CASTLE) score showing potential advantages in more complex scenarios. These scoring systems are valuable tools for clinicians in preprocedural planning and risk assessment, enhancing the decision-making process in CTO interventions.

Clinical results of percutaneous coronary intervention in chronic total occlusions of the right coronary artery

Introduction and ObjectivesCoronary chronic total occlusions (CTOs) of the right coronary artery (RCA) are a relatively common finding in the context of coronary angiography. However, the benefit of revascularization remains controversial. MethodsA single-center retrospective cohort analysis prospectively collected outcomes of CTO patients undergoing percutaneous coronary intervention (PCI) in 2019 and 2020. Patients were divided into two groups according to the CTO vessel treated (left coronary artery [LCA]-CTO or RCA-CTO). The primary outcome was defined as the recurrence of angina and/or heart failure (HF) symptoms and secondary outcomes were myocardial infarction (MI) and all-cause mortality. ResultsA total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome occurred in 28 (16.6%) patients and was significantly more frequent in RCA-CTO patients (19, 24.7%, p=0.010) in a mean follow-up of 18 months. This was mainly driven by recurrence of HF symptoms (12, 15.6%, p=0.013). Treated RCA-CTO was an independent predictor of the primary outcome (p=0.019, HR 2.66, 95% CI 1.17–6.05). MI and mortality rates were no different between groups (RCA-CTO with 1.3%, p=0.361 and 2.6%, p=0.673, respectively, on survival analysis). Left ventricular ejection fraction was an independent predictor of mortality (p=0.041, HR 0.93, 95% CI 0.87–0.99). ConclusionsRevascularization of CTO lesions by PCI was associated with low rates of symptom recurrence, and clinical outcomes showed no differences regardless of which artery was treated. Recanalization of RCA-CTO was less beneficial in reducing the recurrence of HF symptoms.

Correlation between triglyceride glucose index and collateral circulation formation in patients with chronic total occlusion of coronary arteries in different glucose metabolic states

BackgroundTo investigate the correlation between triglyceride glucose index (TyG) and collateral circulation in patients with chronic total occlusion (CTO) of coronary arteries in different glucose metabolic states.MethodsA total of 681 patients who underwent coronary angiography between January 2020 and December 2021 to determine the presence of CTO lesions in at least one major coronary artery were retrospectively included in this study. Patients were categorized into a group with poor collateral circulation formation (Rentrop grade 0–1, n = 205) and a group with good collateral circulation formation (Rentrop grade 2–3, n = 476) according to the Rentrop scale. They were also categorized according to their glucose metabolism status: normal glucose regulation (NGR) (n = 139), prediabetes mellitus (Pre-DM) (n = 218), and diabetes mellitus (DM) (n = 324). Correlation between TyG index and collateral circulation formation was analyzed by logistic regression analysis and receiver operating characteristic (ROC) curves.ResultsAmong patients with CTO, TyG index was significantly higher in the group with poor collateral circulation formation than in the group with good collateral circulation formation. Logistic regression analysis showed that TyG index was an independent risk factor for poor collateral circulation formation (OR 5.104, 95% CI 3.323–7.839, P < 0.001). The accuracy of TyG index in predicting collateral circulation formation was evaluated by the ROC curve, which had an area under the curve of 0.779 (95% CI 0.738–0.820, P < 0.001). The restrictive cubic spline curves showed that the risk of poor collateral circulation formation in the Pre-DM and DM groups was initially flat and finally increased rapidly, except for the NGR group. TyG index was significantly associated with an increased risk of poor collateral circulation formation in the Pre-DM and DM groups.ConclusionsTyG index was significantly associated with the risk of poor collateral circulation formation in patients with CTO, especially those with Pre-DM and DM.

Differences between Lower Extremity Arterial Occlusion vs. Stenosis and Predictors of Successful Endovascular Interventions.

Background and Objectives: In patients with peripheral artery disease, there is insufficient understanding of characteristics that predict successful revascularization of the lower extremity (LE) chronic total occlusions (CTOs) and baseline differences in demographic, clinical, and angiographic characteristics in patients with LE CTO vs. non-CTO. We aim to explore these differences and predictors of successful revascularization among CTO patients. Materials and Methods: Two vascular centers enrolled LE-CTO patients who underwent endovascular revascularization. Data on demographics, clinical, angiographic, and interventional characteristics were collected. LE non-CTO arterial stenosis patients were compared. A total of 256 patients with LE revascularization procedures were studied; among them, 120 had CTOs and 136 had LE stenosis but no CTOs. Results: Aspirin use (Odds ratio, OR: 3.43; CI 1.32-8.88; p = 0.011) was a positive predictor whereas a history of malignancy (OR: 0.27; CI 0.09-0.80; p = 0.018) was a negative predictor of successful crossing in the CTO group. The CTO group had a higher history of myocardial infarction (29.2 vs. 18.3%, p = 0.05), end-stage renal disease (19.2 vs. 9.6%, p = 0.03), and chronic limb-threatening ischemia as the reason for revascularization (64.2 vs. 22.8%, p < 0.001). They were more likely to have advanced TransAtlantic Inter-Society Consensus (TASC) stages, multi-vessel revascularization procedures, longer lesions, and urgent treatment. Conclusions: The use of aspirin is a positive predictor whereas a history of malignancy is a negative predictor for successful crossing in CTO lesions. Additionally, LE-CTO patients have a higher incidence of comorbidities, which is expected given their higher disease burden. Successful endovascular re-vascularization can be associated with baseline clinical variables.

A predictors for 10-year mortality and clinical events in patients with chronic coronary total occlusion lesion

Abstract Background Despite advances in cardiovascular intervention techniques and devices, the treatment of patients with chronic coronary total occlusion CTO lesions is challenging yet. We evaluated predictors of 10-year mortality and clinical events in patients with CTO lesions in this study. Methods This study is a single-center, prospective, all-comer registry designed to reflect "real world" practice since 2001. Of a total of 1,672 consecutive patients were diagnosed with CTO lesions by coronary angiogram. The primary endpoints were all-cause death or major adverse cerebral, and cardiac events (MACCE) defined as the composite of all-cause death, myocardial infarction (MI), any coronary revascularization, and stroke up to 10 years. We derived for final results, from survival analysis by Kaplan-Meier and Cox-proportional regression analysis. Results In this study, males were 1,255 (75.1%), and the mean age was 65.2±10.9. Also, a total of 660 patients had received a successful PCI for CTO lesions at enrollment. A total of 267 patients was heart failure. Ten years of clinical follow, MACCE occurs in 407 cases (56.6%), all-cause death in 152 cases (18.5%), cardiac death in 87 cases (9.9%), myocardial infarction (MI) in 54 cases (7.7%), any revascularization of 251 cases (30.7%), and stroke of 41 cases (6.3%) by Kaplan-Meier analysis. In a multiple Cox-proportional regression analysis, a prior myocardial infarction, reduced LV ejection fraction less than 50%, chronic kidney disease, multi-vessel disease had increased a risk of MACCE and the use of statin, and aspirin had reduced a risk of MACCE. Also, an aging, prior MI, reduced LV ejection fraction less than 40%, and multi-vessel disease had increased a risk of all-cause death and the use of statin, and renin-angiotensin system inhibitors, nitrates, statin, and aspirin had reduced a risk of risk of all-cause death. However, PCI for CTO lesions could not reduce both of MACCE and all-cause death. Conclusions The study found that a prior myocardial infarction, reduced LV ejection fraction, chronic kidney disease, and multi-vessel disease were associated with an increased risk of MACCE, while the use of statins and aspirin reduced the risk of MACCE. Furthermore, PCI for CTO lesions did not reduce the incidence of MACCE or all-cause death. These findings highlight the need for further research and development of more effective treatment strategies for patients with CTO lesions.

Revascularization of coronary chronic total occlusions in the elderly: what results? - The insights of a multicentre national registry

Abstract Lately, the remarkable progress in knowledge and treatment of cardiovascular diseases has been significantly impacting society's morbidity and mortality. However, the burden of coronary artery disease (CAD) remains non-negligible. In addition, as a consequence of demographic changes, age, as a non-modifiable cardiovascular risk factor, makes it increasingly important to focus on the elderly. Up to one-fifth of patients with CAD have a chronic total occlusion (CTO) of a coronary artery, defined as a lesion with 100% stenosis and Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 that exists for more than 3 months. There is current evidence that successful CTO-percutaneous coronary intervention (PCI) is associated with clinical benefits. However, elderly patients are currently underrepresented in CTO-PCI randomized controlled trials and registries, and its clinical impact and safety in this group of patients are still debated. This study aims to characterise patients submitted to CTO-PCI and compare the baseline characteristics, coronary intervention features, intraprocedural complications and in-hospital mortality between patients younger and older than 75. The authors performed a retrospective analysis of adult patients submitted to a CTO-PCI, included in the Portuguese Registry on Interventional Cardiology between January 2019 and December 2022. Comparison tests between groups for parametric and non-parametric variables were performed. A p-value less than 0.05 was considered statistically significant. A total of 353 patients who underwent CTO-PCI were analysed, 271 (76.8%) with 18 to 74 years old (group 1) and 82 (23.2%) with 75 or more years old (group 2). Table 1 shows the most important baseline characteristics, with similar features for both groups except body mass index and smoking habits. Table 2 demonstrates the differences between the groups regarding PCI, with the left main and left anterior descending arteries being more treated among older patients and the right coronary artery in younger patients. Complete coronary revascularization and procedure success rate did not differ significantly between groups (p-value=0.19 and p-value=0.59, respectively). Finally, table 3 presents the main intra-procedural and in-hospital complications, with a significant difference only for occlusion of the side branch, occurring in 2 patients aged over 75 years (p-value=0.01). In conclusion, in our registry, the elderly presents a high success rate in the complete recanalization of CTO lesions, comparable to the group under 75 years of age. However, the presence of side branch occlusion was higher in older patients, without other significant differences in intraprocedural and in-hospital complications, including mortality. Further studies including a large sample and follow-up analysis would be essential to better understand the rate of risks related to PCI-CTO potentially associated with the complexity and comorbidities of the elderly.Table 1Table 2 and 3

Abstract 16108: Impact of Early Intervention on Quality of Life Outcomes in Peripheral Artery Disease Patients With Chronic Total Occlusion Lesions: Results From the PORTRAIT Registry

Background: Peripheral artery disease (PAD) is associated with functional impairment, decreased quality of life, and increased risk of cardiovascular events and mortality. Chronic total occlusion (CTO) lesions occur in up to 40% of PAD patients and pose a challenge for successful endovascular revascularization. We aim to evaluate the baseline characteristics, presentations, procedural outcomes, and quality of life (QOL) outcomes of CTO lesions in PAD compared to non-CTO lesions and the interaction with invasive therapy. Methods: The PORTRAIT registry is a prospective, multicenter, international study that enrolled patients with new or worsening claudication symptoms and an abnormal resting or post-exercise ankle brachial index. Patients with CTO lesions were compared to those without CTO lesions and divided into those who received early invasive treatment (revascularization within three months of enrollment) or noninvasive treatment with medical management. Quality of life outcomes were evaluated using the Peripheral Artery Questionnaire (PAQ) at baseline and during follow-up at 3, 6, and 12 months. Results: A total of 581 matched patients were identified, of which 39% had CTOs and 61% did not. Of the patients with CTOs, 31% underwent early invasive treatment and 69% were noninvasively managed. Patients with CTOs were more likely to present with higher Rutherford classification. The PAQ Summary Score was similar at baseline in patients with CTOs compared to those without CTOs. At 12-month follow-up, early invasive treatment resulted in higher PAQ summary scores in the non CTO arm (82.48 ± 22.79 vs. 67.83 ± 27.00, P&lt;0.001). In the CTO arm, while PAQ summary score was higher at 3 and 6 months in the early invasive arm, the difference was not significant at 12 months (76.18 ± 25.16 vs. 70.60 ± 24.24, P=0.14) Conclusions: Patients with CTO lesions present with higher Rutherford classification than their non-CTO counterparts and both have similar PAQ summary scores at presentation. Early invasive treatment for CTO and non-CTO lesions in PAD patients is associated with significant improvements in quality-of-life outcomes.

Abstract 15313: Prognostic Impact of Intravascular Imaging-Guided Percutaneous Coronary Intervention in Chronic Total Occlusion

Background: Limited data exist regarding use of intravascular image during chronic total occlusion (CTO) intervention. Objectives: Current study investigated the prognostic impact of intravascular imaging-guided PCI in CTO lesions. Methods: Study population was derived from the RENOVATE-COMPLEX-PCI (n=1639) which demonstrated superiority of intravascular imaging-guided PCI than angiography-guided PCI in patients with complex coronary artery lesions. Current prespecified study selected patients who underwent CTO intervention and clinical outcomes were compared between intravascular imaging-guided PCI and angiography-guided PCI groups. Results: Among 1639 patients, 319 patients with CTO underwent intravascular imaging-guided PCI (n=220) or angiography-guided PCI (n=99). At a median follow-up of 2.1 years (interquartile range 1.1-3.0 years), the risk of TVF was significantly lower in intravascular imaging-guided PCI group than in the angiography-guided PCI group (5.0% vs. 13.5%; HR 0.303; 95% CI 0.130-0.710, P=0.006). When patients in imaging-guided PCI group were divided according to stent optimization, both patients with (1.3% vs. 13.5%; HR 0.14; 95% CI 0.02-0.56; P=0.003) and without (6.8% vs. 13.5%; HR 0.41; 95% CI 0.17-0.99; P=0.049) stent optimization had significantly lower risk of TVF than the angiography-guided PCI group. Conclusions: In patients with CTO, intravascular imaging-guided PCI was associated with reduced risk of TVF. Graded risk of TVF according to stent optimization by intravascular imaging supports the importance of intravascular imaging-guided PCI and achievement of stent optimization in CTO intervention.

Abstract 12812: Temporal Trends of Calcium Modification Therapies in Chronic Total Occlusion Percutaneous Coronary Intervention

Introduction: Various techniques with different mechanisms of action are presently available for the modification of coronary calcium in chronic total occlusions (CTOs). Hypothesis: We sought to examine the temporal trends in the use of calcium modification therapies in a large multicenter CTO percutaneous coronary intervention (PCI) registry. Methods: We analyzed data from 13,079 CTO PCIs performed in 12,799 patients at 46 US and non-US centers between 2012 and 2023. Calcification was assessed by angiography as mild (spots), moderate (involving ≤50% of the reference lesion diameter), or severe (involving &gt;50% of the reference lesion diameter). Results: Moderate or severe calcification was present in 6,094 CTOs (46.6%). Among CTO lesions with moderate or severe calcium, one or more calcium modification techniques was used in 1,006 cases (16.9%); rotational atherectomy (7.2%, n=434), laser atherectomy (3.4%, n=203), intravascular lithotripsy (IVL) (3.4%, n=200), scoring balloon (3.0%, n=178), cutting balloon (1.8%, n=109), orbital atherectomy (1.5%, n=91), and Chocolate balloon (Teleflex, 0.3%, n=15). Over time, the use of calcium modification techniques for lesions with moderate to severe calcification increased from 2.5% in 2012 to 25.7% in 2023 (p for trend &lt;0.001), with a significant increase in the use of IVL (from 0.6% in 2020 to 16.6% in 2023; p for trend &lt;0.001) (Central Illustration). In the last 2 years (2021-2023), IVL was the most commonly used calcium modification technique followed by rotational atherectomy. Conclusions: The use of calcium modification techniques for calcified CTO lesions increased over time, with a significant increase in the use of IVL in the last years.

Abstract 18560: External Calcium Modification Technique to Recanalize a Balloon Uncrossable Chronic Coronary Total Occlusion

Introduction: Despite improvements in equipment and techniques, uncrossable chronic total occlusion (CTO) coronary lesions remain challenging.Case: A 66-year-old male with typical angina and a history of failed CTO PCI was referred to our CTO tertiary center as he did not wish to undergo coronary artery bypass grafting. Transthoracic echocardiography revealed an ejection fraction of 45%, and cardiac MRI demonstrated viability in the LAD region. Coronary angiography revealed a long LAD CTO over 20 mm with heavy calcification (Figure 1a). The J-CTO score was calculated to be 4. The cap of the CTO was semi-ambiguous. The wire was advanced through the highly calcified lesion with the support of a microcatheter but the microcatheter and low-profile balloons were unable to be advanced despite backup with 7 French femoral access and an EBU catheter in place (Figure 1b) Upon failure on using Leopard crawl technique and grenadoplasty and with unfavorable side branch anatomy for STAR technique, cracking the calcification with a balloon advanced over a subintimal hydrophilic wire was considered. A fielder XT-A guidewire was advanced around the CTO lesion in the subintimal area (Figure 1c). A 2x12 mm balloon was inflated at 8 atm over the wire situated in the subintimal area in order the crack the calcification from outside. After extraluminal plaque modification, the wire and the balloon were withdrawn. A microcatheter was then able to be advanced with the support of an anchor balloon over the original true lumen wire (Figure 1d). Then the procedure was successfully completed with balloon dilatation and stent implantation (Figure 1e-f). Conclusion: External Calcium Modification technique which consists of plaque modification using a balloon in subintimal space (over an intentionally directed wire in subintima and around the calcium) and cracking the calcium from the outer vessel structure can be used as a last resort to overcome balloon uncrossable CTO lesions.

Abstract 12780: Impact of Target Vessel on the Procedural Techniques and Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention

Introduction: There is limited information on the impact of the target vessel on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 11,580 CTO PCIs performed between 2012 and 2022 at 44 centers. Results: The most common CTO target vessel was the right coronary artery (RCA) (53.1%) followed by the left anterior descending artery (LAD) (26.0%) and the left circumflex artery (LCX) (19.8%). RCA CTO lesions were longer and more complex with higher J-CTO score compared with LAD or LCX CTO lesions. Technical success was higher among LAD (88.8%) lesions when compared with RCA (85.7%) or LCX (85.8%) lesions (p&lt;0.001). The incidence of major adverse cardiovascular events (MACE) was overall 1.9% (n=220) and was similar among target vessels (p=0.916). There was a tendency towards more frequent utilization of the retrograde approach for more proximal occlusions in all three target vessels. When compared with all other RCA lesions combined, distal RCA lesions had higher technical success (87.7% vs. 85.3%; p=0.048). Technical success was similar between various locations of LAD CTOs (p=0.704). First/second/third obtuse marginal branch had lower technical success when compared with all other LCX lesion locations (82.7% vs. 86.8%; p=0.014). There was no association between MACE and CTO location in all three target vessels. Conclusions: LAD CTO PCIs had higher technical and procedural success rates among target vessels. The incidence of MACE was similar among target vessels, and also among various locations within the target vessel.