Chronic Total Occlusion Revascularization Research Articles

C-43 | Causes and Predictors of 30 Days Readmission After Revascularization For Chronic Total Occlusion in Patients With History of Ventricular Tachycardia: Nationwide Readmissions Database Analysis.

C-43 | Causes and Predictors of 30 Days Readmission After Revascularization For Chronic Total Occlusion in Patients With History of Ventricular Tachycardia: Nationwide Readmissions Database Analysis.

Coronary Chronic Total Occlusion Revascularization: When, Who and How?

Coronary chronic total occlusions (CTO) are an increasingly frequent entity in clinical practice and represent a challenging percutaneous coronary intervention (PCI) scenario. Despite data from randomized trials that have not yet demonstrated a clear benefit of CTO recanalization, the widespread of CTO-PCI has substantially increased. The improvement in operators' techniques, equipment, and training programs has led to an improvement in the success rate and safety of these procedures, which will represent an important field of future development of PCI. The present review will summarize clinical outcomes and technical and safety issues of CTO revascularization with the aim to guide clinical daily cath-lab practice.

Endovascular Treatment as an Alternative to Bypass Surgery for Juxtarenal Aortic Occlusion: Results from the CHAOS (CHronic Abdominal Aortic Occlusion, ASian Multicenter) Registry

Juxtarenal aortic occlusion (JRAO), in which the occlusion of the aorta extends to just below the renal artery, is often treated by bypass surgery because of concerns about the risk of procedural failure and fatal embolization to abdominal organs when treated with endovascular treatment (EVT). This study assessed the outcome of EVT for JRAO compared with aorto-biiliac /aorto-bifemoral (AOB) or axillo-bifemoral (AXB) bypass. A retrospective review of an international database created by 30 centers in Asia (CHronic Abdominal Aortic Occlusion, ASian Multicenter registry) was performed for patients who underwent revascularization for chronic total occlusion of the infrarenal aorta from 2007 to 2017. Of the 436 patients, 130 with JRAO (Forty-seven AOBs, 32 AXBs, and 51 EVTs) from 25 institutions were included in this study. Patients were significantly older in the AXB and EVT groups and more malnourished in the EVT group than the AOB group. EVT was attempted but failed in 1 patient. Seven patients (1 [2.1%] in the AOB group, 1 [3.1%] in the AXB group, and 5 [9.8%] in the EVT group) died during hospitalization, but most of the causes in the EVT group were not related to the revascularization procedure. No visceral embolism was observed, which had been concerned, even though protection was performed only in 2 cases of the EVT group. At the latest follow-up (median duration 3.0years), the ankle-brachial pressure index was significantly higher in the order of AOB, EVT, and AXB. At 4years, the estimated primary and secondary patency rates of the AOB group (87.5% and 90.3%, respectively) were significantly higher than the AXB group (66.7% and 68.6%, respectively). AOB remains the gold standard and should be the first choice for acceptable risk patients. For frail patients, EVT is a good option and likely preferable as a first-line treatment compared to AXB.

Outcomes following coronary chronic total occlusion revascularization with drug-coated balloons.

Despite the introduction of improved drug eluting stents (DES), the rate of repeat revascularization procedures following percutaneous coronary interventions (PCI) in coronary chronic total occlusions (CTO) remains high. By leaving vessels uncaged and limiting length of stented segments, drug-coated balloons (DCB) represent an appealing alternative to DES for CTO-PCI. Since data supporting the use of DCBs in CTO-PCI is scarce, we compared the outcomes of patients undergoing CTO-PCI involving DCBs vs DES only. From 2 prospective registries, outcomes of patients undergoing CTO-PCI involving DCBs and those undergoing PCI with DES only were compared. Outcomes included major adverse cardiac and cerebrovascular events (MACCE) and cardiovascular death (CV-death). Overall, 157 patients were studied; 112 (71%) underwent CTO-PCI involving DCBs and 45 (29%) were treated with DES only. Mean J-CTO score was 1.84 ± 0.7. Most CTO-lesions involved the right coronary artery, 88 (56%), and 26 (17%) cases were in-stent occlusions. In the DCB group, 46 (41%) lesions were treated with DCBs alone. Mean lengths of the stented segments in the DCB vs DES cohorts were 59 ± 28 mm vs 87 ± 37 mm (P less than .001), respectively. After 12 months, the MACCE rate was higher in the DES only vs DCB group (26% vs 11%, P=.03). Length of the stented segment was an independent predictor for MACCE (HR 1.15 [95% CI, 1.05-1.26] per 10-mm stent length). Revascularization of CTO lesions involving DCBs appears safe and potentially lowers MACCE rates compared to treatment with DES alone. Importantly, using DCBs for CTO treatment may reduce total stent length, which determines PCI outcomes.

Outcomes following coronary chronic total occlusion revascularization with drug-coated balloons.

Despite the introduction of improved drug eluting stents (DES), the rate of repeat revascularization procedures following percutaneous coronary interventions (PCI) in coronary chronic total occlusions (CTO) remains high. By leaving vessels uncaged and limiting length of stented segments, drug-coated balloons (DCB) represent an appealing alternative to DES for CTO-PCI. Since data supporting the use of DCBs in CTO-PCI is scarce, we compared the outcomes of patients undergoing CTO-PCI involving DCBs vs DES only. From 2 prospective registries, outcomes of patients undergoing CTO-PCI involving DCBs and those undergoing PCI with DES only were compared. Outcomes included major adverse cardiac and cerebrovascular events (MACCE) and cardiovascular death (CV-death). Overall, 157 patients were studied; 112 (71%) underwent CTO-PCI involving DCBs and 45 (29%) were treated with DES only. Mean J-CTO score was 1.84 ± 0.7. Most CTO-lesions involved the right coronary artery, 88 (56%), and 26 (17%) cases were in-stent occlusions. In the DCB group, 46 (41%) lesions were treated with DCBs alone. Mean lengths of the stented segments in the DCB vs DES cohorts were 59 ± 28 mm vs 87 ± 37 mm (P less than .001), respectively. After 12 months, the MACCE rate was higher in the DES only vs DCB group (26% vs 11%, P=.03). Length of the stented segment was an independent predictor for MACCE (HR 1.15 [95% CI, 1.05-1.26] per 10-mm stent length). Revascularization of CTO lesions involving DCBs appears safe and potentially lowers MACCE rates compared to treatment with DES alone. Importantly, using DCBs for CTO treatment may reduce total stent length, which determines PCI outcomes.

Updated Strategies in Non-Culprit Stenosis Management of Multivessel Coronary Disease-A Contemporary Review.

The prevalence of multivessel coronary artery disease (CAD) in acute coronary syndrome (ACS) patients underscores the need for optimal revascularization strategies. The ongoing debate surrounding percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), hybrid interventions, or medical-only management adds complexity to decision-making, particularly in specific angiographic scenarios. The article critically reviews existing literature, providing evidence-based perspectives on non-culprit lesion revascularization in ACS. Emphasis is placed on nuances such as the selection of revascularization methods, optimal timing for interventions, and the importance of achieving completeness in revascularization. The debate between culprit-only revascularization and complete revascularization is explored in detail, focusing on ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), including patients with cardiogenic shock. Myocardial revascularization guidelines and recent clinical trials support complete revascularization strategies, either during the index primary PCI or within a short timeframe following the culprit lesion PCI (in both STEMI and NSTEMI). The article also addresses the complexities of decision-making in NSTEMI patients with multivessel CAD, advocating for immediate multivessel PCI unless complex coronary lesions require a staged revascularization approach. Finally, the article provided contemporary data on chronic total occlusion revascularization in ACS patients, highlighting the prognostic impact. In conclusion, the article addresses the evolving challenges of managing multivessel CAD in ACS patients, enhancing thoughtful integration into the clinical practice of recent data. We provided evidence-based, individualized approaches to optimize short- and long-term outcomes. The ongoing refinement of clinical and interventional strategies for non-culprit lesion management remains dynamic, necessitating careful consideration of patient characteristics, coronary stenosis complexity, and clinical context.

Circ-MBOAT2 Regulates Angiogenesis via the miR-495/NOTCH1 Axis and Associates with Myocardial Perfusion in Patients with Coronary Chronic Total Occlusion.

Revascularization of coronary chronic total occlusion (CTO) still remains controversial. The factors that impact collateral circulation and myocardial perfusion are of interest. Circular RNA (circRNA) has been shown to regulate the process of angiogenesis. However, the effects of circ-membrane-bound O-acyltransferase domain containing 2 (circ-MBOAT2) on angiogenesis in patients with CTO were unclear. In this study, we evaluated circulating circRNAs and miRNAs in patients with CTO and stable coronary artery disease using high-throughput sequencing. Another cohort of patients were selected to verify the expressions of circ-MBOAT2 and miR-495. The role and mechanism of circ-MBOAT2 in the process of angiogenesis were explored through in vitro and vivo studies. Finally, we came back to a clinical perspective and investigated whether circ-MBOAT2 and miR-495 were associated with the improvement of myocardial perfusion evaluated by single-photon emission computed tomography (SPECT). We found that the expression of circ-MBOAT2 was significantly up-regulated while miR-495 was significantly down-regulated in patients with CTO. The expression of circ-MBOAT2 was negatively correlated with miR-495 in patients with CTO. In an in vitro study, we found that circ-MBOAT2 promoted tube formation and cell migration via the miR-495/NOTCH1 axis in endothelial cells. In an in vivo study, we showed that the inhibition of miR-495 caused the increase in collateral formation in mice after hindlimb ischemia. In a human study, we showed the expressions of circ-MBOAT2 and miR-495 were associated with myocardial perfusion improvement after revascularization of CTO. In conclusion, circ-MBOAT2 regulates angiogenesis via the miR-495/NOTCH1 axis and associates with myocardial perfusion in patients with CTO. Our findings suggest that circ-MBOAT2 and miR-495 may be potential therapeutic targets and prognostic factors for patients with CTO.

Long-Term Outcomes in Patients With Chronic Total Occlusion

BackgroundAlthough a chronic total occlusion (CTO) in the setting of an acute coronary syndrome is associated with higher risk, the prognosis of patients with stable CAD and CTOs remains unknown. ObjectivesTo investigate adverse event rates in patients with stable CAD with and without a CTO. MethodsIn 3597 patients with stable CAD (>50% coronary luminal stenosis) undergoing cardiac catheterization, all-cause mortality, cardiovascular mortality and the composite major adverse cardiac event (MACE) rates for cardiovascular death, myocardial infarction and heart failure hospitalization were evaluated. Cox proportional hazards and Fine and Gray sub-distribution hazard models were employed to compare event-free survival in patient subsets after adjustment for covariates. ResultsEvent rates were higher in patients with CTOs compared to those without CTOs after adjusting for demographic and clinical characteristics (cardiovascular death hazard ratio (HR) 1.29, 95% confidence interval (CI) 1.05 – 1.57, p = 0.012). Patients with CTO revascularization had lower event rates compared to those without CTO revascularization (cardiovascular death HR 0.43, CI 0.26 – 0.70, p = 0.001). Those with non-revascularized CTOs were at particularly high risk, when compared to those without CTO (cardiovascular death HR 1.52, CI 1.25 – 1.84 p < 0.001). Moreover, those with revascularized CTOs had similar event rates as patients with CAD without CTOs. ConclusionPatients with CTO have higher rates of adverse cardiovascular events compared to patients with significant CAD without CTO. This risk is greatest in individuals with non-revascularized CTO.

Revascularization of chronic total occlusion – Does the side matter?

Revascularization of chronic total occlusion – Does the side matter?

Heart Failure-Related Outcomes in Patients with Left Ventricular Dysfunction Undergoing Percutaneous Chronic Total Occlusion Revascularization

Heart Failure-Related Outcomes in Patients with Left Ventricular Dysfunction Undergoing Percutaneous Chronic Total Occlusion Revascularization

Technical aspects of entrapped coronary guidewire retrieval using rotational atherectomy device: A case series.

This article highlights four unique cases where rotational atherectomy (RA Rotapro, Boston Scientific) was used to cut and retrieve an entrapped coronary guidewire with parts extending into the aorta We discuss the technique and step by step approach to the retrieval procedure. Three of four cases described a guide wire entrapment in the right coronary artery (RCA), and one in the left anterior descending artery via retrograde route. In all cases the guide wire was intact within the intracoronary segment. In Case 1, the guide wire (Runthrough; Terumo) was entrapped in an acute marginal branch during chronic total occlusion (CTO) percutaneous coronary intervention. In Case 2, a whisper wire (Abbott) was entrapped during re-wiring of the right posterolateral branch through stent struts, the traction on the wire caused severe malformation of distal and proximal stents requiring second staged procedure to complete revascularization of the RCA CTO. In Case 3, a Runthrough wire was entrapped between two layers of stents and fractured at the proximal point with filaments extending into descending aorta. And in Case 4, a Pilot 200 (Abbott) wire was entrapped retrograde in the subintimal space via saphenous vein graft connection by tying a knot at the distal tip of the wire. In all four cases RA was used to successfully cut and remove the entrapped guide wires. Rotablation technique appears to be a safe and effective strategy for the management of entrapped coronary guidewire when conventional strategies fail.

A New Technique of “Tip-In” for Retrograde Chronic Total Occlusion Revascularization: The Modified Tip-In Technique

A New Technique of “Tip-In” for Retrograde Chronic Total Occlusion Revascularization: The Modified Tip-In Technique

Evaluation of Left Ventricular Function After Revascularization of Chronic Total Occlusion of Left Anterior Descending Coronary Artery Using Speckle Tracking Echocardiography

Evaluation of Left Ventricular Function After Revascularization of Chronic Total Occlusion of Left Anterior Descending Coronary Artery Using Speckle Tracking Echocardiography

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 13874: N Terminal Pro-Brain Natriuretic Peptide Levels and Benefits of Chronic Total Occlusion Revascularization

Background: The management of chronic total occlusion (CTO) remains a subject of debate, as the mortality benefit from revascularization remains controversial. Whether specific populations gain a survival benefit from CTO revascularization remains unknown. Purpose: In this prospective study of patients with stable coronary artery disease (CAD), we investigated whether patients with CTO have higher adverse event rates and higher N terminal pro-brain natriuretic peptide (NT pro-BNP) levels than patients without CTO. We also investigated whether a higher NT pro-BNP level predicts adverse events in patients with CTO and whether those with elevated NT pro-BNP levels have a survival benefit from revascularization. Methods: In 2,253 patients with significant CAD ( &gt; 50% coronary luminal stenosis) undergoing cardiac catheterization, all-cause mortality, cardiovascular mortality and the composite of cardiovascular death, myocardial infarction and heart failure hospitalization rates were evaluated. Unadjusted and adjusted Cox proportional and Fine and Gray sub-distribution hazard models were performed to determine the association between NT pro-BNP level and event rates. Results: Patients with CTO had higher incident event rates by &gt; 20% and had higher NT pro-BNP levels than those without CTO (median 230.0 vs. 177.7 pg/mL, p=&lt;0.001). In patients with CTO, every doubling of NT pro-BNP level was associated with &gt; 25% greater risk of adverse events. In patients with elevated NT pro-BNP level (&gt; 125 pg/mL), CTO revascularization was associated with &gt;50% lower adverse event rates than those without CTO revascularization (adjusted cardiovascular death hazard ratio 0.24, 95% confidence interval 0.07 - 0.81). Among patients with low NT pro-BNP level (&lt; 125 pg/mL), event rates were similar in those with and without CTO revascularization. Conclusion: Patients with CTO have higher adverse event rates than those with significant CAD without CTO. NT pro-BNP levels are higher in patients with CTO and higher levels portend a worse prognosis. Moreover, NT pro-BNP levels can help identify individuals who may benefit from CTO revascularization.

High Sensitivity Troponin Level and Benefits of Chronic Total Occlusion Revascularization.

Background The survival benefit of revascularization of chronic total occlusion (CTO) of the coronary arteries remains a subject of controversy. We measured high sensitivity troponin-I (hsTn-I) levels as an estimate of myocardial ischemia in patients with stable coronary artery disease, with the hypothesis that (1) patients with CTO have higher levels of hsTn-I than patients without CTO, (2) hsTn-I levels will predict adverse cardiovascular events in patients with CTO, and (3) patients with elevated hsTn-I levels will have a survival benefit from CTO revascularization. Methods and Results In 428 patients with stable coronary artery disease and CTO undergoing coronary angiography, adverse event rates were investigated. Cox proportional hazards models and Fine and Gray subdistribution hazard models were performed to determine the association between hsTn-I level and incident event rates in patients with CTO. HsTn-I levels were higher in patients with compared with those without CTO (median 6.7 versus 5.6 ng/L, P=0.002). An elevated hsTn-I level was associated with higher adverse event rates (adjusted all-cause mortality hazard ratio, 1.19 [95% CI, 1.08-1.32]; P=0.030) for every doubling of hsTn-I level. CTO revascularization was performed in 28.3% of patients. In patients with a high (>median) hsTn-I level, CTO revascularization was associated with substantially lower all-cause mortality (adjusted hazard ratio, 0.26 [95% CI, 0.08-0.88]; P=0.030) compared with those who did not undergo revascularization. In patients with a low (<median) hsTn-I level, event rates were similar in those with and without CTO revascularization. Conclusions HsTn-I levels may help identify individuals who benefit from CTO revascularization.

Device-based antegrade dissection re-entry versus parallel wire techniques for the percutaneous revascularization of coronary chronic total occlusions.

Device-based antegrade dissection re-entry (ADR) and parallel wire technique (PWT) are two important techniques in the antegrade approach in percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). The study is aimed to compare the procedural and mid-term outcomes between device-based ADR using the CrossBoss/Stingray system and PWT in CTO PCI. Data was retrospectively collected from consecutive patients who underwent CTO PCI using device-based ADR or PWT. CTO due to in-stent restenosis were excluded. A total of 273 patients were included in the study (n = 55 in device-based ADR group, n = 218 in PWT group). Baseline characteristics were similar across groups except for higher prevalence of prior PCI and lower level of lipid profile in the ADR group. Moreover, although patients in the ADR group showed higher contrast volume (441.6 ± 162.4 mL vs. 361.5 ± 142.1 mL, p < 0.001), more intravascular ultrasound guidance (50.9% vs. 22.9%, p < 0.001), more guidewires used (4.6 ± 1.4 vs. 3.4 ± 1.2, p < 0.001) and higher troponin T level after PCI (0.167 vs. 0.087, p = 0.004), the technical success, procedural success and in-hospital complications were similar between the two groups. During a median follow-up of 1 year, the ADR group showed no difference in major adverse cardiac events (MACE, including all cause death, nonfatal myocardial infarction, and ischemia driven target vessel revascularization) (7.3% vs. 14.7%, p = 0.150) as compared with the PWT group. In the documented center, the use of device-based ADR for CTO PCI showed no difference in in-hospital complications and mid-term MACE as compared with PWT, despite higher procedure complexity in ADR group.

Safety and efficacy of the expressman extension system for complex coronary lesions during percutaneous coronary intervention.

To the Editor: The main cause for failed complex coronary lesions especially chronic total occlusion (CTO) revascularization is the inability of device delivery due to the lack of adequate guide support or the failure of guidewire manipulation, such as unsuccessful externalization of the retrograde guidewire and incapable reentry into the true lumen. Some devices and techniques have been used to deal with these problems, and the guide catheter extension system (GCES) is one of the effective solutions. Currently, five GCES devices are commercially available, the Proxis, Heartrail II (Terumo, Tokyo, Japan), GuideLiner (GL; Vascular Solutions, Charlotte, NC, USA), Guidezilla (GZ; Boston Scientific, Marlborough, MA, USA), and the Expressman extension system (EES; APT Medical Inc., Hunan, China). GL and GZ have been reported to enable procedural success not only by providing extra backup support but also by accommodating multiple devices and facilitating device delivery.[1] Besides, they also ensure little trauma to the ostium of CTO vessels.[2,3] However, the rate of GZ- or GL-related events, including inaccessibility to the target lesions, device damage, or coronary artery dissection, became major obstacles in using GCES in CTO percutaneous coronary intervention (PCI).[4,5] Moreover, the size of the radial artery guiding catheter limits the application of GCES in a guiding catheter that is no larger than 7 F, and it should be applied with more caution when delivering stents with a 4 mm diameter. The EES was newly developed to provide a strong backup support and an efficient approach through deep intubation. It has a 35 cm exchange tube, which is long enough to cross the aortic arch (femoral approach)/subclavian artery (radial approach) to the coronary artery; this design could avoid the circuity and fracture of the oblique mouth of the catheter caused by the bending part of the aortic arch/subclavian artery and also reduces resistance when devices are entering the catheter [Figure 1A,B]. Additionally, the side hole in the tip allows adequate antegrade blood flow and reduces the risk of blood pressure incarceration after deep insertion into the target vessel. It has two radiopaque markers at the proximal end, which show the accurate position in the coronary arteries. The tip is soft and contains an indicator ring, which decreases the incidence of vessel damage and helps to ascertain the precise placement. The hydrophilic coating provides a smooth advancing property [Figure 1A]. Moreover, the design of variable diameter at distal 10 cm allows deeper insertion and reduces the incidence of vessel dissection [Figure 1C]. It also has various specifications (3.2 F, 5.0 F, 5.5 F, 6.0 F, 6.5 F, 7.0 F, 7.5 F) to fit for different interventional conditions. This study aimed to evaluate the efficacy and safety of the EES in a series of EES-facilitated PCI.Figure 1: Design of the EES and angiographic images. (A) Special design of the EES. (a) Exchange tube; (b) hydrophilic coating; (c) side hole; (d) radiopaque markers; (e) the tip with indicator ring. (B) The 35 cm exchange tube of EES. (left) The exchange tube is long enough to cross the subclavian artery (radial approach), (right) or the aortic arch (femoral approach). (C) The design of variable diameter at distal 10 cm. (D) The EES was advanced through the stents (the stent diameter was 2.5 mm and 3.0 mm, respectively) to the distal of RCA. (E) The EES was introduced via the antegrade approach to the site of the microcatheter advanced via the retrograde approach. (F) The retrograde guidewire was advanced to the antegrade guiding catheter through the EES. Black arrow: EES; White arrow: microcatheter. EES: Expressman extension system.This retrospective study was approved by the Ethics Committee at our hospital (No. 20200119) and was conducted according to the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all patients. Analyses were performed using SPSS 21.0 (IBM Corp., Armonk, NY, USA). Continuous data were expressed as mean ± standard deviation for normal distribution and median for non-normally distributed continuous variables, while categorical variables were expressed as n (%). Between March 2020 and July 2020, 25 patients with complex coronary artery lesions using EES to enhance support for device delivery and manipulation were included. The average age was 67.52 ± 10.74 years, and men accounted for 64.0%. The mean left ventricular ejection fraction was 59.36 ± 5.72%. A total of 21 (84.0%) patients had hypertension, 10 (40.0%) patients had hypercholesterolemia, and 12 (48.0%) patients had diabetes mellitus. A total of four (16.0%) patients had a current smoking status, eight (32.0%) patients had undergone a previous PCI, five (20.0%) patients had a previous myocardial infarction, and two (8.0%) patients had chronic renal impairment. The majority of CTO target vessel was the right coronary artery (60.0%), which was followed by the left descending artery (32.0%) and the left circumflex artery (8.0%). The target lesions all belonged to type C, and the CTO accounted for 92.0%. The median J-CTO score was 3, and the mean syntax score was 30.45 ± 10.10. About 20.0% of the procedure were performed via the femoral route, while 80.0% were performed via the bilateral route. About 8.0% (n = 2) of patients were treated with EES using the 6 F mother guiding catheters, and 92% (n = 23) of patients were using the 7F mother guiding catheters. The most commonly used EES (96.0%) was with 5F specification, and in one patient (4.0%), the 3.2 F specification was applied via the microcatheter. The median depth of intubation was 4.0 cm. Besides, the forward blood flow was nearly unaffected, and no blunted blood pressure was observed during the procedure, even if the EES was introduced to the distal site of the target vessel [Figure 1D]. No EES-related complications have been observed, and no in-hospital target vessel revascularization, deaths, or acute in-stent thrombosis occurred before patient discharge. One procedure suffered hypotension because of femoral artery hematoma caused by a femoral puncture. For EES efficacy analysis, four (16.0%) patients used the EES to facilitate the externalization of the retrograde guidewire [Figure 1E,F], and all have succeeded (100%). About 20 (80.0%) patients used the EES to aid the guidewires, balloons, or stents to cross the target lesion and had a success rate of 85%. In one (4.0%) patient, EES was applied to assist the performance of the antegrade dissection reentry technique. The total technique success was achieved in 22 procedures (88.0%). One procedure failed because of the inability to cross the collateral circulation during the retrograde approach, one procedure failed due to the severe calcification of the lesion even after rotational atherectomy, and one procedure failed due to the inability to advance the guidewire to the distal vessel via the EES. As the EES is developed to provide a strong backup support and an efficient approach through deep intubation, this study highlights the safety and efficacy of the EES used for antegrade or retrograde approach. During the PCI procedure, a strong backup support is critical for the delivery of balloons and stents.[6] The EES has a stepped-diameter design of 10 cm from the distal part, such as 6 F to 5 F and 5 F to 4 F, and this unique design allows the EES to intubate deeper, which could provide extra support and is able to increase the successful rate of PCI. In this study, the deep insertion of EES provided better support for effective delivery of devices thro ugh the target lesion. A total of 80% of the enrolled cases used this effect to deliver the devices, yielding an 85% success rate among these cases. Additionally, EES was also used to provide better backup support for manipulating the guidewire reentry to the true lumen, which suggests that guidewire manipulation became more precise with EES. Externalization of the retrograde guidewire is vital for a successful retrograde approach,[7] the application of the EES shortened the distance between the antegrade guiding catheter and the reentry site, and it could even reach up to the reentry site, making the retrograde guidewire easier to enter the antegrade catheter. In this study, 16% of the enrolled cases used EES to pick up the retrograde guidewire with a 100% success rate. An EES with 5F specification was used more often due to the technical improvement of CTO PCI, as the usage of 6 F guiding catheter has increased and 5 F EES can be used under 7 F and 6 F guiding catheter. Besides, 5F EES can be delivered with the assistance of a smaller balloon. It also had a good ability of deep incubation, good trafficability, and less damage to vessels. The EES demonstrated a safety profile with no device-related complication and no in-hospital MACE as well. Moreover, the EES could be advanced inside the stent without causing stent dislodgement. It had little effect on the antegrade blood flow during the deep intubation procedure, this was credited to the design of the side hole at the tip of the EES, which allows adequate antegrade blood flow and reduces the risk of blood pressure incarceration after deep insertion into the target vessel. However, deep insertion is not recommended in some situations, such as lesions at the ostium, stents at the ostial and proximal parts of the artery, severe calcification, and vulnerable plaques; otherwise, evacuate as soon as possible after the delivery equipment is in place. Notably, it is safer and more efficient with the assistance of a small balloon (diameter 1.5–2.5 mm) when deeply inserting the EES, because direct deep insertion of the EES along the guidewire can easily cause coronary dissection or hematoma. In summary, the EES is a device designed to provide better backup support for device delivery and manipulation, and it is especially useful to serve as a connector to a shorter distance between the antegrade guiding catheter and the site of the retrograde guidewire with deeper insertion into the target vessel. Acknowledgments None Funding This study was supported by a grant from the Key Project of Medical Science Research in Hebei Province (No. 20130001). Conflicts of interest None.

TCT-119 High-Sensitivity Troponin Level and Benefits of Chronic Total Occlusion Revascularization

TCT-119 High-Sensitivity Troponin Level and Benefits of Chronic Total Occlusion Revascularization

Gender-Based Differences in Outcomes After Percutaneous Coronary Intervention of Chronic Total Occlusions (Insights from a Large Single-Center Registry)

Patients who undergo percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) are at a high risk for both periprocedural and post-procedural adverse events. Whether gender-differences in outcomes exist after PCI of CTO remain unclear. Therefore, we sought to investigate gender-based differences in outcomes after CTO-PCI. All patients who underwent elective CTO intervention from January 2012 to December 2017 at The Mount Sinai Hospital (New York, New York) were included. The primary end point of interest was major adverse cardiac events defined as the composite of death, myocardial infarction, and target vessel revascularization at 1year of follow-up. A total 1,897 patients were included, of which 368 were women (19.4%). Mean follow-up time was 174days. Women were older (66.8 ± 11.3years vs 62.6 ± 10.9years) and had a higher prevalence of co-morbidities including diabetes and chronic kidney disease. There were no significant differences in the rate of successful CTO-PCI between groups (73.5% vs 73.2%, p=0.91). Women had higher rates of procedure-related complications including increased risk of post-procedural bleeding (4.1% vs 1.8%, p=0.009) and acute vessel closure (1.36% vs 0.2%, p=0.009). In multivariable-adjusted analysis, female gender was associated with higher risk of major adverse cardiac event and target vessel revascularization at 1year. In conclusion, in this large single-center study, women who underwent percutaneous CTO revascularization experienced higher rates of periprocedural complications and worse clinical outcomes at 1year compared with men. Further research is needed to address disparities in gender-specific outcomes of CTO-PCI.