Heavy Calcification Research Articles

Qualitative and quantitative diagnostic performance of 320-slice computed tomography for detecting coronary artery disease with respect to atherosclerotic plaque characteristics

To investigate qualitatively and quantitatively the diagnostic performance of 320-slice CT for detection of coronary artery disease with respect to different atherosclerotic plaque characteristics. A retrospective search was performed for inpatients underwent both coronary CT and further coronary angiography (CAG) from December 1, 2008 to December 31, 2012. The diagnostic performance of 320-slice CTA for detecting significant stenosis ( ≥ 50% diameter) with respect to atherosclerotic plaque characteristics were analyzed by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, kappa index (κ), and area under the receiver operating characteristic curve (AUC). Chi-square test was used to evaluate whether there were significant differences of the true-case frequency (true positive + true negative) and false-case frequency (false positive + false negative) among groups. Bland-Altman analysis was used to determine limits of agreement between CTA and CAG. A total of 454 patients and 6 779 segments were analyzed. Diagnostic accuracy was higher in non-calcified segments; whereas they decreased in the presence of both mild-moderately and heavily calcified plaques. Excellent agreement (κ = 0.810) between CT and CAG was observed for non-calcified segments, while good agreement was observed for both mild-moderately (κ = 0.701) and heavily calcified segments (κ = 0.750). Both mild-moderate (P = 0.000) and heavy (P = 0.000) calcification decreased the true-case frequency and increased the false-case frequency when compared to non-calcification. There were no significant underestimation or overestimation for non-calcified (P = 0.087) and mild-moderately calcified (P = 0.704) segments, while there was significant overestimation for heavily calcified segments (P = 0.001). Great qualitative and quantitative diagnostic performances of 320-slice CT were observed in non-calcified coronary segments. However, qualitative diagnostic performance decreased in both mild-moderately and heavily calcified segments, and quantitative overestimation were observed in heavily calcified segments.

Long-term results (≤18 years) of the edge-to-edge mitral valve repair without annuloplasty in degenerative mitral regurgitation: implications for the percutaneous approach.

To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty in degenerative mitral regurgitation (MR). From 1993 to 2002, 61 patients with degenerative MR were treated with an isolated edge-to-edge suture without any annuloplasty. Annuloplasty was omitted in 36 patients because of heavy annular calcification and in 25 for limited annular dilatation. A double-orifice repair was performed in 53 patients and a commissural edge-to-edge in 8. Hospital mortality was 1.6%. Follow-up was 100% complete (mean length, 9.2±4.21 years; median, 9.7; longest, 18.1). Survival at 12 years was 51.3±7.75%. At the last echocardiographic examination, MR ≥3+ was demonstrated in 33 patients (55%). At 12 years, freedom from reoperation was 57.8±7.21% and freedom from recurrence of MR ≥3+ was 43±7.6%. Residual MR >1+ at hospital discharge was identified as a risk factor for recurrence of MR ≥3+ (hazard ratio, 3.8; 95% confidence interval, 1.7-8.2; P=0.001). In patients with residual MR ≤1+ immediately after surgery, freedom from MR ≥3+ at 5 and 10 years was 80±6% and 64±7.58%, respectively. In degenerative MR, the overall long-term results of the surgical edge-to-edge technique without annuloplasty are not satisfactory. Early optimal competence (residual MR ≤1+) was associated with higher freedom from recurrent severe regurgitation.

Calcifications Attenuation in Left Coronary Artery CT Images Using FDA Domain

The calcification plaque is a one kind of artifacts or noises, which is occurred in the Computed Tomography (CT) images as a very high attenuation coefficient. Computed Tomography (CT) images are more helpful than other modalities (e.g. Ultrasonic Imaging, Magnetic Resonance Imaging (MRI) etc.) for disease diagnosis but unfortunately, CT image is an affected sometime by calcification plaque. Medical image segmentation cannot be optimum because of having calcification in the CT images, which is absolutely unexpected. The calcification plaque is the major problem for optimal organ segmentation and detection. This proposed task is a subjective as well as an effective for calcification alleviation from CT images. In this paper, Firstly, we applied the Fisher's Discriminant Analysis (FDA) for optimal threshold value estimation. Secondly, the proposed optimal threshold value is used for the optimal threshold image extraction. After this, the morphological operation is used for heavy calcification erosion and the XOR operation is used for adjusting the optimal threshold image with the input image. Finally, we implemented the Extra-Energy Reduction (EER) Function to smooth the desired image. Therefore, our investigated method is the most significant and articulate in order to attenuate calcification plaque from CT images.

Evaluation of the Diamondback 360 Coronary Orbital Atherectomy System for treating de novo, severely calcified lesions

Coronary lesions with severe (or heavy) calcification are classified as complex lesions and are known to carry lower success rates and higher complication rates following percutaneous coronary intervention. The Diamondback 360® Coronary Orbital Atherectomy System is the first and only device approved for use in the USA as a treatment for severely calcified coronary lesions to facilitate stent delivery and optimal deployment. Availability of this device provides a safe and effective option for physicians to improve treatment outcomes in this patient population with severely calcified coronary lesions.

80 Importance of 3D Tee in Procedure Success of Percutaneous Paravalvular Leak Closure

PurposeParavalvular leaks (PVL) are a recognised complication post surgery, but rarely result in heart failure and haemolysis. Redo surgery may present technical challenges and is associated with significant morbidity and...

Strategies to overcome hostile subclavian anatomy during transradial coronary angiography and interventions: impact on fluoroscopy, procedural time, complications, and radial patency.

Hostile anatomy of the subclavian artery (severe tortuosity and/or heavy calcification) remains a significant obstacle for the transradial approach during coronary angiography and interventions. To assess impacts on fluoroscopy and procedural times, complications, and radial artery patency in patients with hostile subclavian anatomy by using multiple catheter-guide techniques. We retrospectively reviewed the medical and equipment data of 4,580 consecutive patients (mean age 74.4 ± 26.7 years, 49.5% females) who have been referred for transradial coronary angiography and/or interventions within the last 3 years (September 2010-September 2013). In order to overcome the strangling hold of a hostile subclavian artery, 2 techniques have been used: (1) for a coronary angiography-only procedure, a double mother and child technique; (2) for percutaneous coronary intervention, a triple mother and child technique. Ninety-five patients (2.1%) from the entire study population exhibited a hostile subclavian artery. Fifty-two patients (1.1%) underwent coronary angiography only and 43 patients (1%) underwent interventions requiring the use of the above double or triple mother and child techniques, respectively. The 2 techniques were successful in 94.7% of patients (90/95 patients). The procedural time was significantly longer in the patients with hostile subclavian artery while there were no differences in the fluoroscopy time. The radial artery was patent at 30 days in 92.6% of patients (88/95 patients). Our data showed that in the presence of hostile subclavian anatomy, the mother and child techniques appeared safe and effective, allowing for the completion of the intended procedure.

Feasibility and Efficacy of Bioresorbable Vascular Scaffolds Use for the Treatment of In-Stent Restenosis and a Bifurcation Lesion in a Heavily Calcified Diffusely Diseased Vessel

A 70-year-old man underwent coronary angio-graphy that demonstrated in-stent restenosis (ISR) and long calcified disease extending from the left main stem (LMS) to the left anterior descending coronary artery (LAD), with involvement of the LAD/diagonal bifurcation ([Fig. 1][1]A). After rotational

Is Calcification of Intracranial Arteries Important and How?

Intracranial atherosclerosis is a well-recognized and common cause of stroke in Asian, black, and Hispanic individuals.1,2 Recent studies showed that intracranial occlusive disease is also a more common cause of stroke in white individuals than previously thought.3 In this issue of JAMA Neurology, Bos and colleagues4 provide evidence that intracranial carotid artery calcification is an important risk factor for stroke in an elderly white Dutch population. As part of the prospective, population-based Rotterdam study, the authors followed up 2323 individuals to determine the incidence of stroke (parenchymal brain hemorrhage or ischemic) after they had nonenhanced computed tomography (CT) scanning that imaged the coronary arteries, aortic arch, extracranial carotid arteries, and intracranial carotid arteries. The authors used calcification volume in these arteries as an indicator of atherosclerosis and correlated this with the risk for all stroke and ischemic stroke. They found that larger intracranial carotid calcification volume was independently associated with all stroke and that intracranial carotid calcification was a more important risk factor for stroke than aortic arch calcification or extracranial carotid calcification. The apparent discrepancy between the importance of intracranial carotid calcification as a major risk factor for stroke in this study and the low frequency of stroke caused by intracranial atherosclerosis in most studies of white patients is largely explained by the different design of these studies. Prior studies identified consecutive patients with stroke and determined the frequency of proximal intracranial atherosclerotic arterial stenosis. In the current study, intracranial carotid calcification (not stenosis) was measured and correlated with subsequent stroke regardless of the territory of the stroke. Data on the size, location (cortical or subcortical), and vascular territory of brain infarcts were not collected. While the current study suggests that intracranial carotid artery calcification is an important, previously seldom considered, risk factor for subsequent stroke in any vascular territory in white patients, the study did not show that the intracranial vascular lesions were the cause of the strokes. Many of the ischemic strokes in this study were almost surely not caused by intracranial carotid atherosclerosis because the strokes were either in a different vascular territory or were caused by other vascular diseases (eg, coexisting penetrating artery disease,5 a cardiac source of embolism). Moreover, at least 11% of the strokes in the study were hemorrhagic and no causal relationship has been established between intracranial arterial calcification and parenchymal brain hemorrhage. Recent interest in calcification of arteries has been spurred on by the strong association between coronary calcification detected by cardiac CT and the risk for future cardiac events.6 The situation appears to be different in relation to carotid artery disease in the neck where the presence of heavy calcification on spiral CT has been correlated with stable, noninflammatory, asymptomatic plaques.7 Whether intracranial arterial calcification is also associated with stable plaque that is unlikely to cause a distal stroke is unknown. What is known is that severe stenosis of an intracranial artery is strongly associated with a high risk for stroke distal to the stenosis in patients presenting with a transient ischemic attack or stroke.8 If the presence of severe intracranial carotid calcification implied coexistent severe arterial stenosis of the artery, that would provide some evidence of a potential causal link between calcification and risk for stroke attributable to the affected artery. However, the relationship between calcification of the intracranial carotid artery and coexistent stenosis is unsettled. Older pathological studies found that heavy calcification of the carotid siphon did not necessarily indicate stenosis of the lumen9; however, a more recent neuroimaging study showed that the positive predictive value of severe carotid siphon calcification on CT for a stenosis of greater than 50% on angiography was 86% using bone window measurements.10 It is also possible that intracranial carotid calcification may cause stroke without the presence of coexistent stenosis if calcification is associated with unstable plaque features that predispose to distal embolism. This study by Bos and colleagues4 raises important questions about the role of calcification in the pathophysiology of intracranial atherosclerosis and should reawaken interest in intracranial atherosclerosis as a cause of stroke inwhite individuals. The study indicates that intracranial carotidcalcification isamajor risk factor for stroke inwhite individuals but does not establish a pathophysiologic causal relationshipbetweenthe two.Establishing thatwill require further prospective studies that correlate the association between intracranial arterial calcification and stenosis more clearly, identifyatheroscleroticplaque featuresassociatedwith calcification thatmay be associatedwith a high risk for distal embolism, and classify ischemic strokes that occur in patientswith intracranial carotid calcification according to size, location (cortical or subcortical), vascular territory, and thecoexistenceofotherpotential causesof stroke.Muchworkneeds to be done. Related article page 405 Opinion

TCTAP C-068 A Case of Successful PCI to Left Main Bifurcation Lesion with Heavy Calcification

TCTAP C-068 A Case of Successful PCI to Left Main Bifurcation Lesion with Heavy Calcification

TCTAP A-083 Impact of Diabetes on Heavily Calcified Plaque in Extremely Late In-stent Restenosis Lesions After Bare-metal Stent Implantation

TCTAP A-083 Impact of Diabetes on Heavily Calcified Plaque in Extremely Late In-stent Restenosis Lesions After Bare-metal Stent Implantation

Intravascular Ultrasound Assessment of Acute Expansion of the Balloon-expandable Stent in Heavy Calcified Iliac Artery Lesions or in Lesions Resistant to Dilation by a Self-expanding Stent

To evaluate the acute stent expansion of a balloon-expandable stent (BES) by intravascular ultrasound (IVUS) in lesions with heavy calcification or in lesions resistant to dilation by a self-expanding stent (SES). Primary stent placement using the Express LD was performed for 72 limbs in 56 patients. The BES was deployed both for ostial lesions of the common iliac artery (CIA) in 63 limbs and for additional dilation of an SES using a stent-in-stent maneuver in 9 limbs. Of the CIA ostial lesions, 71% (45 of 63) had heavy calcification. The primary endpoint was an acute stent expansion as assessed by IVUS. The ratio of the IVUS-measured minimal stent diameter (MSD) to the diameter predicted by the manufacturer's compliance chart was used as a measure of the acute stent expansion. The ratio was compared between noncalcified and calcified CIA lesions and between before and after additional placement of the BES in the case of insufficient expansion of an SES. The BES achieved 81 ± 10% of the predicted MSD in noncalcified CIA lesions and 78 ± 12% of the predicted MSD in heavy calcified CIA lesions (P = 0.346). In the 9 limbs with insufficient expansion of an SES, deployment of the BES resulted in an improvement in MSD from 39 ± 16% to 77 ± 8% of the predicted MSD (P < 0.001). Sufficient acute expansion of the BES was demonstrated in heavy calcified lesions or in lesions with insufficient expansion of an SES.

Feasibility and safety of a virtual 3‐Fr sheathless‐guiding system for percutaneous coronary intervention

To evaluate the feasibility and safety of a virtual 3-Fr system [5-Fr sheathless-guiding catheter (GC)] for percutaneous coronary intervention (PCI). The use of miniaturized devices for PCI is gaining popularity because of increased patient comfort and decreased risk of access site complications. From July 2010 to December 2012, consecutive patients who underwent elective PCI (planned or ad hoc PCI) at our hospital were enrolled. PCI using the virtual 3-Fr system was attempted as our initial strategy, unless a 6-Fr or larger GC was considered to be suitable [lesions with heavy calcification, large (>2 mm) side branches, or chronic total occlusion]. Five hundred sixty-six patients underwent elective PCI during the study period, and 132 patients who met the criteria underwent PCI using the virtual 3-Fr system. Procedures using the virtual 3-Fr system were successful in 126 patients (95%); 111 (84%) were performed using the transradial approach, 110 (83%) were ad hoc procedures, and 45 (31%) were complex coronary lesions (type B2 or C). Six patients required conversion to a conventional 5- or 6-Fr sheath and catheter system. No intraoperative complications occurred, and radial artery patency was achieved in all patients who underwent transradial procedures. PCI using the virtual 3-Fr system is a feasible and viable alternative to conventional procedures that use a sheath and GC in appropriately selected patients. This small-caliber system may minimize endovascular trauma, particularly during transradial coronary procedures.

Positive Association of Coronary Calcium Detected by Computed Tomography Coronary Angiography with Periprocedural Myocardial Infarction

BackgroundPeriprocedural myocardial infarction (PMI) may occur in approximately 5% to 30% of patients undergoing percutaneous coronary intervention. Whether the morphology of coronary plaque calcium affects the occurrence of PMI is unknown.Materials and MethodsA total of 616 subjects with stable angina and normal baseline cardiac troponin I levels who had undergone computed tomography angiography (CTA) were referred to elective percutaneous coronary intervention. The morphology of coronary calcium was determined by CTA analysis. PMI was defined as an elevation in 24-h post-procedural cardiac troponin I levels of > 5 times the upper limit of normal with either symptoms of myocardial ischemia, new ischemic electrocardiographic changes, or documented complications during the procedure. Logistic regression was performed to identify the effect of the morphology of coronary calcium on the occurrence of PMI.ResultsAccording to the presence or morphology of coronary calcium as shown by CTA, 210 subjects were grouped in the heavy calcification group, 258 in the mild calcification group, 40 in the spotty calcification group and 108 in the control group. The dissection rate was significantly higher in the heavy calcification group than in the control group (7.1 % vs. 1.9%, p = 0.03). The occurrence of PMI in the heavy calcification group was significantly higher than that in the control group (OR 4.38, 95% CI 1.80–10.65, p = 0.001). After multivariate adjustment, the risk of PMI still remained significantly higher in the heavy calcification group than in the control group (OR 4.04, 95% CI 1.50–10.89, p = 0.003).ConclusionsThe morphology of coronary calcium determined by CTA may help to predict the subsequent occurrence of PMI. A large amount of coronary calcium may be predictive of PMI.

Metastatic Pulmonary Calcification An Uncommon Clinical Condition in End-Stage Renal Disease

Patients with end-stage renal diseases have frequent pulmonary complicationsrelated to fluid overload, infection, and associated cardiovascular diseases. We reporta 73-year-old man with renal failure on peritoneal dialysis who had elevated serum calcium,phosphorous, and parathyroid hormone levels. He had progressive dyspnea andan abnormal chest x-ray. A high resolution computed tomography scan revealed calcifiednodules, large cavities with heavy calcification in the upper zones, calcifications inthe tracheobronchial tree, and calcified vessels. This patient had metastatic pulmonarycalcification and possibly dystrophic calcification due to renal failure which probablycontributed to his pulmonary symptoms.

Ocelot catheter for the treatment of long SFA occlusion

Long saphenous femoral artery (SFA) chronic total occlusions (CTOs) are considered the "Achilles heel" of the lower extremity percutaneous interventions. Antegrade, retrograde, or transcollateral approaches, intraluminal or subintimal techniques with re-entry and specialized CTO devices using microdissection, vibrational energy, and laser have all been tried for the management of such challenging lesions with various success rates. Ocelot is the first CTO crossing device using real-time OCT technology. Its crossing catheter utilizes spiral wedges to corkscrew the CTO cap, while real-time OCT offers direct visualization to facilitate intravascular true-lumen orientation. The recently presented results of the CONNECT-II study demonstrated crossing success of 97% and freedom from major adverse events of 98%. We present one of the most challenging SFA CTOs with ambiguous proximal cap in the ostium of the SFA, heavy calcification and involving almost the entire length of the SFA. The Ocelot catheter assisted to the successful true-lumen recanalization of that complex lesion.

Transpulmonary Correction of an Isolated Aortopulmonary Window in an Adult

We describe the operative management of a 65-year-old patient with a congenital type I aortopulmonary window. At surgery, heavy calcifications on the aortic side of the defect, and close proximity with the left coronary ostium, prevented patch repair from the transaortic access. Patch closure through a combined transpulmonary approach was therefore required. This case illustrates unique features of a late-presenting aortopulmonary window.

Endovascular treatment of inoperable acute type A dissection via the transapical approach

An 83-year-old female patient was admitted to our department for thoracic pain. Her medical history composed of hypertension, atrial fibrillation, two thoracic aortic endoprostheses for penetrating aortic ulcer, an aorto-bi-iliac endoprosthesis for subrenal aortic aneurysm, as well as a right ilio-femoral bypass. ( Panel A ). At admission, the computer tomography (CT) scan showed a dissecting haematoma of the ascending aorta, with heavy calcifications …

Carotid artery stenting

From the earliest experiences with carotid artery stenting (CAS) presumptive high risk features have included thrombus-containing lesions, heavily calcified lesions, very tortuous vessels, and near occlusions. In addition patients have been routinely excluded from CAS trials if they have contra-indications to dual antiplatelet therapy (aspirin and thienopyridines), a history of bleeding complications and severe peripheral arterial disease (PAD) making femoral artery vascular access difficult. Variables that increase the risk of CAS complications can be attributed to patient characteristics, anatomic or lesion features, and procedural factors. Clinical features such as older age (≥80 years), decreased cerebral reserve (dementia, multiple prior strokes, or intracranial microangiopathy) and angiographic characteristics such as excessive tortuosity (more than two 90° bends within 5 cm of the target lesion) and heavy calcification (concentric calcification ≥ 3 mm in width) have been associated with increased CAS complications. Other high risk CAS features include those that prolong catheter or guide wire manipulation in the aortic arch, make crossing a carotid stenosis more difficult, decrease the likelihood of successful deployment or retrieval of an embolic protection device (EPD), or make stent delivery or placement more difficult. Procedure volume for the operator and the catheterization laboratory team are critical elements in reducing the risk of the procedure. In this article, we help CAS operators better understand procedure risk to allow more intelligent case selection, further improving the outcomes of this emerging procedure.

Impact of coronary calcium score as gatekeeper for coronary CT angiography

Purpose: The aim of this study is to determine the thresholds of coronary calcium score (CCS) above which coronary CT angiography (CCTA) should be aborted because of the limitation of diagnostic ability. Methods: Consecutive 500 symptomatic patients (64±12 years old) who were referred for diagnostic CCTA were investigated. Subjects underwent CCS measurements and CCTA using 64-slice high definition CT. Inconclusive CCTA was defined as the case with at least one non-evaluable segment in major coronary vessels due to heavy calcification. Results: Mean CCS of all 500 patients was 152±368 (0-2595). Of these, 17 (3%) resulted in inconclusive CCTA due to heavy calcification. The sensitivity and specificity curves identified 540 as optimal thresholds of CCS to predict inconclusive CCTA (sensitivity 0.94, specificity 0.94). Area under the curve of ROC analysis was 0.98. Among the 17 cases with inconclusive CCTA (CCS 1380±675), 14 (82%) underwent catheter coronary angiography (CAG), of these, 13 (93%) needed subsequent coronary revascularization (PCI 10, CABG 3). Conclusions: In cases with inconclusive CCTA due to heavy calcification, high prevalence of severe coronary artery disease was revealed with CAG. CCS>540 should alert us to potential diagnostic limitation with CCTA, thus further evaluation with CCTA is not warranted as those patients should be referred to CAG to avoid repeat radiation exposure.

A thirty-four-year-old chronic total occlusion successfully treated by percutaneous coronary intervention

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) represents a major challenge for interventional cardiology. CTOs are identified in up to 30% of patients with significant coronary disease on angiography and represent only 10–15% of cases treated by PCI, with the majority of patients being treated medically or referred for surgery [ [1] Stone G.W. Kandzary D.E. Mehran R. et al. Percutaneous recanalization of chronically occluded coronary artery: a consensus document: part I. Circulation. 2005; 112: 2364-2372 Crossref PubMed Scopus (456) Google Scholar ]. This may be explained considering the lower procedural success achieved in these lesions in comparison with non-occluded lesions [ [2] Stone G.W. Rutherford B.D. Mc-Conahay D.R. et al. Procedure outcome of angioplasty for total coronary occlusion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol. 1990; 15: 849-856 Abstract Full Text PDF PubMed Scopus (212) Google Scholar ]. The major reason for procedural failure is represented by the inability to cross the occlusion, with a guidewire or a balloon [ 2 Stone G.W. Rutherford B.D. Mc-Conahay D.R. et al. Procedure outcome of angioplasty for total coronary occlusion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol. 1990; 15: 849-856 Abstract Full Text PDF PubMed Scopus (212) Google Scholar , 3 Stone G.W. Colombo A. Teirstein P.S. et al. Percutaneous recanalization of chronically occluded coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc Interv. 2005; 66: 217-236 Crossref PubMed Scopus (127) Google Scholar ]. A number of predictors of procedural success have been reported in the literature. It is accepted that a blunt occlusion stump, heavy calcification, proximity to a side branch, presence of bridging collaterals and longer occlusions, all impact unfavorably on the likelihood of procedural success [ [4] Kinoshita I. Katoh O. Nariyama J. et al. Coronary angioplasty of chronic total occlusions with bridging collateral vessels: immediate and follow-up outcome from a large single-center experience. J Am Coll Cardiol. 1995; 26: 409-415 Abstract Full Text PDF PubMed Scopus (154) Google Scholar ]. In addiction previous studies have reported that long occlusion duration may also be associated with procedural failure [ 5 Kereiakes D.J. Selmon M.R. McAuley D.B. et al. Angioplasty in total coronary artery occlusion: experience in 76 consecutive patients. J Am Coll Cardiol. 1985; 6: 526-533 Abstract Full Text PDF PubMed Scopus (140) Google Scholar , 6 Melchoir J.P. Meire B. Urban P. et al. Percutaneous transluminal coronary angioplasty for chronic total occlusion. Am J Cardiol. 1987; 59: 535-538 Abstract Full Text PDF PubMed Scopus (149) Google Scholar ]. It was supposed that this issue was related to the increase lesion organization with deposition of fibrous tissue and severe calcifications, which occur in the course of time. Furthermore aging of occlusion may determine a change in plaque composition with an increase of frequency and severity of plaque calcification [ [7] Suzuki T. Hosokawa H. Yokoya K. et al. Time-dependent morphologic characteristics in angiographic chronic total coronary occlusions. Am J Cardiol. 2001; 88: 167-169 Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar ]. A study of Barlis et al. underlined how indetermination of occlusion duration (IOD) could play a role in prediction of procedural failure and cardiac adverse events [ [8] Barlis P. Kaplan S. Dimopoulos K. et al. An indeterminate occlusion duration predicts procedural failure in the recanalization of coronary chronic total occlusions. Catheter Cardiovasc Interv. 2008; 71: 621-628 Crossref PubMed Scopus (23) Google Scholar ]. However Tomasello et al. have recently showed that IOD and long duration of CTO do not affect procedural and clinical outcome of patients who underwent CTO PCI [ [9] Tomasello S.D. Costanzo L. Campisano M.B. et al. J Interv Cardiol. 2011; 24: 223-231 Crossref PubMed Scopus (14) Google Scholar ].