In-stent Chronic Total Occlusion Research Articles

5-Year Outcomes of Drug-Coated Balloons for Peripheral Artery In-Stent Restenosis, Long Lesions, and CTOs

BackgroundLong-term data on drug-coated balloon (DCB) outcomes in complex femoropopliteal atherosclerotic lesions are limited. ObjectivesThe authors sought to report 5-year safety and effectiveness outcomes of a paclitaxel DCB for the treatment of de novo in-stent restenosis (ISR), long lesions (LL), or chronic total occlusions (CTOs) in the prespecified imaging cohorts of the IN.PACT Global Study. MethodsThe IN.PACT Global study was a prospective, international single-arm study. Assessments through 5 years included freedom from clinically driven target lesion revascularization (CD-TLR), a safety composite (freedom from device- and procedure-related death to 30 days, and freedom from major target limb amputation and freedom from clinically driven target vessel revascularization within 60 months), and major adverse events. ResultsThe prespecified imaging cohorts enrolled 132 de novo ISR, 158 LL, and 127 CTO participants. Kaplan-Meier estimates of freedom from CD-TLR through 5 years were 58.0% (ISR), 67.3% (LL), and 69.8% (CTO). The cumulative incidences of the composite safety endpoint were 56.0% (ISR), 65.7% (LL), and 69.8% (CTO). The 5-year freedom from all-cause mortality with vital status update were 81.4% (ISR), 75.2% (LL), and 78.2% (CTO). Within the ISR cohort, 15.9% of participants experienced 2 or more TLRs, compared with 9.5% and 5.5% in the LL and CTO groups, respectively. ConclusionsResults demonstrate long-term safety and effectiveness of this DCB in all 3 cohorts, with low reintervention rates in the LL and CTO cohorts and no safety issues. These results support the inclusion of this DCB into the treatment algorithm for complex femoropopliteal disease.

Abstract 14285: Comparison of Percutaneous Coronary Intervention-Related Adverse Cardiac Outcomes in Patients With In-Stent versus De Novo Chronic Total Occlusion: A Systematic Review and Meta-Analysis

Introduction: Contemporary literature reveals a range of cardiac complications in patients who receive the percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Hypothesis: This study compared the adverse cardiac outcomes and procedural/technical success rates between the patients groups of in-stent (IS) CTO PCI and de novo CTO PCI. Methods: This systematic review and meta-analysis compared odds for primary (all-cause mortality, MACE, cardiac death post PCI, stroke) and secondary (bleeding requiring blood transfusion, ischemia-driven target-vessel revascularization, PCI procedural success, PCI technical success, and target-vessel MI) endpoints between 2,734 patients who received PCI for IS CTO and 17,808 for de novo CTO. Odds ratios for outcome variables were calculated within 95% confidence intervals (CIs) via the Mantel-Haenszel method. The pooled analysis was undertaken for observational (retrospective/prospective) single- and multi-centered studies published between January 2005 and December 2021. Results: We found 57% higher, 166% higher, 129% higher, and 57% lower odds for MACE (OR: 1.57, 95% CI 1.31, 1.89, p <0.001), ischemia-driven target-vessel revascularization (OR: 2.66, 95% CI 2.01, 3.53, p <0.001), target-vessel myocardial infarction (MI) (OR: 2.29, 95% CI 1.70, 3.10, p <0.001), and bleeding requiring blood transfusion (OR: 0.43, 95% CI 0.19, 1.00, p = 0.05), respectively, in patients with IS CTO PCI as compared to that of the de novo CTO PCI. No statistically significant differences between the study groups were recorded for the other primary/secondary outcome variables. Conclusions: The findings from this study indicated a high predisposition for MACE, ischemia-driven target-vessel revascularization, target vessel MI, and a lower incidence of bleeding episodes among IS CTO PCI patients as compared to those with de novo CTO PCI. The prognostic outcomes in CTO PCI cases require further investigation with randomized controlled trials.

Clinical Outcome of Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stent Implantation for the Treatment of Coronary Drug-Eluting Stent In-Stent Chronic Total Occlusion

AimsIn-stent chronic total occlusion (IS-CTO) represents a unique challenge for percutaneous coronary intervention. Whether the optimal treatment for IS-CTO is angioplasty with paclitaxel-coated balloons (PCBs) or repeat stenting with drug-eluting stents (DESs) is unclear. We aimed to evaluate the long-term clinical outcome of PCB angioplasty and DES repeat stenting for DES IS-CTO.MethodsWe retrospectively included patients with DES IS-CTO who underwent successful PCB angioplasty or DES repeat stenting from January 2016 to December 2019. The primary endpoints were major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, and target lesion revascularization (TLR). Cox proportional hazards model was performed to compare the risk of MACEs between PCB angioplasty and DES repeat stenting, and to further explore the prognostic factors of patients with DES IS-CTO.ResultsA total of 214 patients with DES IS-CTO were enrolled: 78 patients (36.4%) treated with PCB and 136 patients (63.6%) treated with DES respectively. The median follow-up was 1160 days, and MACEs were observed in 28.2% of patients with PCB angioplasty versus 26.5% of patients with DES repeat stenting (P = 0.784), mainly driven by TLR (21.8% vs. 19.9%, P = 0.735). There was no significant difference in the risk of MACEs between the PCB group and the DES group (hazard ratio [HR] 1.25, 95% confidence interval [CI] 0.64–2.46, P = 0.512). Multivariate Cox analysis revealed that chronic kidney disease and ≥ 3 stent layers in the lesion were independent predictors of MACEs, while switching to another antiproliferative drug was an independent protective factor (all P < 0.05).ConclusionsPCB angioplasty was an effective alternative treatment strategy for DES IS-CTO, which had similar long-term outcomes to DES repeat stenting in contemporary practice, but both were accompanied by a high rate of long-term MACEs. Improving the poor prognosis of patients with DES IS-CTO remains a challenge.

Influence of the Single Coronary Vessel on Acute Outcomes of In-Stent CTO Recanalization

Objective: Recanalization of in-stent chronic total occlusion (IS-CTO) is challenging and has resulted in inconsistent results. The aim of our study was to analyze the influence of the individual coronary vessels on the acute outcomes following IS-CTO PCI. Methods: This was an observational retrospective study, including 66 patients undergoing recanalization of a CTO. The CTO interventions were performed bi-femoral using 7-French guiding catheters. A composite endpoint summarizing severe complications was evaluated, including emergency coronary artery bypass grafting surgery (CABG) and cardiac death. Results: We subdivided our cohort into three groups (LAD group, LCX group, RCA group). The retrograde technique and the utilization of an extension catheter were used more frequently in patients with a RCA IS-CTO. There was no significant difference between the composite safety endpoints amongst the three groups. Technical success was independent of the involved vessel. Conclusions: Success and complication rates are independent of the occluded vessel. This challenging and complex coronary intervention is feasible and can be carried out in complete safety.

TCTAP C-057 How to Overcome Acute Bend in Antegrade Proximal Circumflex In-Stent Chronic Total Occlusion

TCTAP C-057 How to Overcome Acute Bend in Antegrade Proximal Circumflex In-Stent Chronic Total Occlusion

Recanalization of in-stent chronic total occlusion using intravascular lithotripsy and Firehawk® rapamycin target eluting coronary stents: A case report

Recanalization of in-stent chronic total occlusion using intravascular lithotripsy and Firehawk® rapamycin target eluting coronary stents: A case report

Commentary on: Angiographic scoring system for predicting successful percutaneous coronary intervention of uneasy in-stent chronic total occlusion

As the Percutaneous Coronary Intervention (PCI) is prevalent in the recent decades, In-Stent Coronary chronic Total Occlusion (IS-CTO) has become a frequently met lesion in daily PCI procedure. It is estimated IS-CTO PCI accounts for 5-25% of all CTO

Occlusion patterns, strategies and procedural outcomes of percutaneous coronary intervention for in-stent chronic total occlusion.

In-stent chronic total occlusion (CTO) presents various occlusion patterns, which complicate percutaneous coronary intervention (PCI). The aim of the study was to investigate the initial outcome and strategy of PCI for in-stent CTO according to the angiographic occlusion patterns. This study assessed 791 in-stent CTOs from the Japanese CTO-PCI Expert Registry from 2015 to 2018. They were divided into four patterns: pattern A (n=419), CTO within the stent segment; pattern B (n=196), CTO beyond the distal edge; pattern C (n=85), CTO beyond the proximal edge; and pattern D (n=69) CTO beyond both the proximal and distal edges. There were significant differences in the technical success rates (96.2%, 86.2%, 92.9%, and 75.4% for patterns A-D, respectively; p<0.001), guidewire crossing times (22 [interquartile range: 10-46], 52 [24-102], 40 [20-78], and 86 [45-127] min, respectively; p<0.001), and the rates of antegrade approach alone (90.9%, 61.2%, 67.1%, and 31.9%, respectively; p<0.001). PCI for CTO within the stent segment was associated with excellent initial outcomes with the antegrade approach. However, PCI for CTO beyond both the proximal and distal edges was associated with the poorest outcomes, even with the bidirectional approach.

The impact of J-CTO score on in-stent chronic total occlusion percutaneous coronary intervention.

The purpose of this study was to investigate the impact of J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) score on in-stent chronic total occlusion (IS-CTO) percutaneous coronary intervention (PCI). A retrospective data collection was conducted on 474 patients undergoing a difficult IS-CTO PCI from January 2015 to December 2018. The primary endpoint (major adverse cardiovascular events [MACE]) consisted of target-vessel myocardial infarction (MI), cardiac death or ischemia-driven target-vessel revascularisation (TVR) at follow-up. The cut-off points were estimated by the Youden index. The overall procedural success rate was 77.6%. On multivariable analysis, factors including proximal bending (beta coefficient [β] = 3.465), tortuosity (β=3.064), stent under expansion (β=3.109) and poor distal landing zone (β=1.959) were associated with technical failure via antegrade approach but not the J-CTO score (OR = 0.632; 95% CI [0.352-1.134]; P=.124). After a median follow-up of 30months (interquartile range: 17-42months), multivariable analysis revealed that receiving >18months of dual antiplatelet therapy (DAPT) was an independent predictor of decreased risk of MACE (HR: 2.690; 95% CI: 1.346-5.347; P=.005). But the J-CTO score was not an independent predictor of MACE (HR: 1.018; 95% CI: 0.728-1.424; P=.917). J-CTO score system is not a helpful tool to predict the technical success of difficult IS-CTO PCI via antegrade approach, nor does it correlate with long-term outcomes in patients undergoing IS-CTO PCI. Nevertheless, factors associated with technical failure include proximal bending of ≥30 degrees, under expansion of ≥10mm, moderate or severe tortuosity (bending) ≥20 and poor distal target. Long-term DAPT therapy contributes significantly to decreased MACE.

Five-year clinical outcomes of patients with in-stent chronic total occlusion undergoing percutaneous coronary intervention

Objective: To evaluate the safety and long-term clinical efficacy of percutaneous coronary intervention (PCI) in patients with in-stent chronic total occlusion (IS-CTO) lesions. Metheds: This is a retrospective analysis. Patients with IS-CTO who underwent PCI in Fuwai hospital from January 2010 to December 2013 were enrolled. A total of 212 patients who met the inclusion criteria were included in the IS-CTO group, 212 matched patients with primary CTO lesions were included in the de novo CTO group. The incidence of complications and the success rate of PCI were compared between the two groups. Successful PCI was defined as successfully implantation of stent(s) at target CTO lesions. The primary endpoint was defined as a composite event of cardiac death and myocardial infarction (MI). Secondary endpoints including PCI success, all-cause death, cardiac death, MI, target vessel related MI, revascularization, target vessel revascularization, heart failure for rehospitalization. The patients were followed up for 5 years after PCI. Results: A total of 424 cases were included. The mean age was (57.8±10.5) years, there were 364 males in this cohort. The left ventricular ejection fraction was significantly lower ((58.7±9.2)% vs. (61.0±7.7)%, P=0.01) and the SYNTAX scores was significantly higher (19.4±8.3 vs. 15.3±10.0, P<0.01) in IS-CTO group than that in de novo CTO group. The proportion of patients with target CTO lesions in left anterior descending artery was significantly higher (42.9% (50/212) vs. 23.6% (91/212), P<0.01) in IS-CTO group than that in de novo CTO group. The rate of successful PCI (71.7% (152/212) vs. 69.8% (148/212), P=0.70) and complication (40.6% (86/212) vs. 36.3% (77/212), P=0.37) was similar between the two groups. The incidence of primary endpoint at 5 years was significantly higher in IS-CTO group (10.8% (23/212) vs. 4.7% (10/212), P=0.02), which was driven by higher incidence of MI (9.0% (19/212) vs. 4.2% (9/212), P=0.05). There were a trend of higher secondary endpoints in IS-CTO group (all P>0.05). Conclusion: The safety and effectiveness of PCI are acceptable in patients with IS-CTO, but the risk of long-term cardiac death and MI is higher among patients with IS-CTO as compared to patients with primary CTO lesions.

A novel technique for management of long in-stent chronic total occlusions: Anchor-Knuckle technique: two case reports

A novel technique for management of long in-stent chronic total occlusions: Anchor-Knuckle technique: two case reports

The therapeutic effects of excimer laser coronary atherectomy therapy for in-stent restenosis chronic total occlusions

ObjectivesTo evaluate the safety and efficacy of excimer laser coronary atherectomy (ELCA) in patients with in-stent restenosis chronic total occlusions (ISR CTOs).BackgroundISR CTOs are a challenge in percutaneous coronary intervention (PCI). Although they can be treated by ELCA, limited data are available on the effects of ELCA treatment in these patients.MethodsFifty-nine consecutive patients underwent PCI for ISR CTOs at Beijing Hospital between December 2017 and September 2020. According to whether or not ELCA was performed, they were divided into two groups. Quantitative coronary angiography (QCA) analyses were performed routinely, including measurement of the minimal lumen diameter and calculation of the percentage diameter stenosis. The procedural success rate, the frequency of peri-procedural complications, and the incidence rates of major adverse cardiac events (MACEs) over nine months were assessed. The primary endpoint in the study was the percentage diameter stenosis.ResultsProcedure success was achieved in most patients in both groups (75.9%). Patients in the ELCA group exhibited a lower percentage diameter stenosis (24.5 ± 9.09 vs. 35.1 ± 18.6, p = 0.048) and a larger minimal lumen diameter (2.36 ± 0.29 mm vs. 1.78 ± 0.64 mm, p < 0.001) than those in the control group and the 9-month incidence rates of MACEs did not differ (9.5% vs 15.8%, p = 0.699).ConclusionsThis study demonstrated that ELCA may be a safe and effective technique in the treatment of ISR CTOs, and the use of ELCA can achieve good immediate angiographic results, as measured by QCA, without increasing peri-procedural complications or the incidence rates of 9-month MACEs.

In-Stent CTO Percutaneous CoronaryIntervention: Individual PatientData Pooled Analysis of 4MulticenterRegistries.

The authors sought to examine the outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusions (CTOs). The outcomes of PCI for ISR CTOs have received limited study. The authors examined the clinical and angiographic characteristics and procedural outcomes of 11,961 CTO PCIs performed in 11,728 patients at 107 centers in Europe, North America, Latin America, and Asia between 2012 and 2020, pooling patient-level data from 4 multicenter registries. In-hospital major adverse cardiovascular events (MACE) included death, myocardial infarction, stroke, and tamponade. Long-term MACE were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. ISR represented 15% of the CTOs (n=1,755). Patients with ISR CTOs had higher prevalence of diabetes (44%vs. 38%; p<0.0001) and prior coronary artery bypass graft surgery (27% vs. 24%; p=0.03). Mean J-CTO (Multicenter CTO Registry in Japan) score was 2.32 ± 1.27 in the ISR group and 2.22 ± 1.27 in the de novo group (p=0.01). Technical (85% vs. 85%; p=0.75) and procedural (84% vs. 84%; p=0.82) success was similar for ISR and de novo CTOs, as was the incidence of in-hospital MACE (1.7% vs. 2.2%; p=0.25). Antegrade wiring was the most common successful strategy, in 70% of ISR and 60% of de novo CTOs, followed by retrograde crossing (16% vs. 23%) and antegrade dissection and re-entry (15% vs. 16%; p<0.0001). At 12months, patients with ISR CTOs had a higher incidence of MACE (hazard ratio: 1.31; 95% confidence interval: 1.01 to 1.70; p=0.04). ISR CTOs represent 15% of all CTO PCIs and can be recanalized with similar success and in-hospitalMACE as de novo CTOs.

Complex Coronary Instent Chronic Total Occlusion Lesions: Oxidative Stress, Inflammation, and Coronary Stent Lengths.

The oxidative stress and inflammation played the key roles in the development of atherosclerotic coronary plaques. However, the relationships between pro/antioxidant, pro/anti-inflammatory status, and complex coronary instent chronic total occlusion lesions were not clear in the elderly patients with very long stent implantations. We tried to evaluate the roles of pro/antioxidant and pro/anti-inflammatory biomarkers in the diagnosis of complex reocclusion lesions in elderly patients after coronary stenting. We evaluated the expression levels of acrolein (ACR), malondialdehyde (MDA), high sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), superoxide dismutase 3 (SOD3), paraoxonase-1 (PON-1), endothelial nitric oxide synthase (eNOS), and stromal cell-derived factor-1α (SDF-1α) in the elderly patients with very long stent implantations and complex reocclusion lesions. Levels of ACR, MDA, hs-CRP, and TNF-α were remarkably increased (P < 0.001), and levels of SOD3, PON-1, eNOS, and SDF-1α were decreased significantly (P < 0.001) in the elderly patients with very long stents and complex reocclusion lesions. The prooxidant and proinflammatory biomarkers were remarkably increased, as well as antioxidant and anti-inflammatory biomarkers were decreased significantly in the elderly patients with very long stent implantations and complex reocclusion lesions after coronary stenting. In conclusion, these findings indicated that the imbalance between prooxidant/proinflammatory and antioxidant/anti-inflammatory status was associated with complex reocclusion lesions, suggesting that oxidative stress and inflammation played the key roles in progression of complex reocclusion lesions in the elderly patients with very long stent implantations.

TCTAP C-047 Retrograde Recanalization of In-stent Chronic Total Occlusion of Left Type Circumflex with the Subsequent Trifurcation Stenting of Left Main

TCTAP C-047 Retrograde Recanalization of In-stent Chronic Total Occlusion of Left Type Circumflex with the Subsequent Trifurcation Stenting of Left Main

Angiographic Scoring System for Predicting Successful Percutaneous Coronary Intervention of In-Stent Chronic Total Occlusion.

The purpose of this study was to develop a scoring model to predict the technical success of recanalizing via antegrade approach in-stent chronic total occlusion (IS-CTO) by percutaneous coronary intervention (PCI). We retrospectively collected data from 474 patients who underwent an uneasy IS-CTO PCI via antegrade approach from January 2015 to December 2018, consecutively. We selected clinical and angiographic factors and utilized a derivation and validation cohort (4:1 sampling ratio) analysis. Factors with strong correlations with technical failure, according to multivariable analysis, were assigned 1 point, and a scoring system with a 4-point maximum was established. The model was then validated with a validation cohort. The overall procedural success rate was 77.4%. On multivariable analysis, the factors that correlated with technical failure were proximal bending (beta coefficient [β] = 2.142), tortuosity (β= 2.622), stent under expansion (β = 3.052), and poor distal landing zone (β = 2.004). The IS-CTO score demonstrated good calibration and excellent predicting capacity in the derivation (receiver-operator characteristic [ROC] area = 0.973 and Hosmer-Lemeshow chi-squared = 5.252; p = 0.072) and validation (ROC area = 0.976 and Hosmer-Lemeshow chi-squared = 0.916; p = 0.632) cohorts. In the validation subset, the IS-CTO score demonstrated superior performance to the Japanese chronic total occlusion score (J-CTO) and PROGRESS CTO scores for predicting technical success (area under the a curve [AUC] 0.976 vs. 0.642 vs. 0.579, respectively; difference in AUC between the IS-CTO score and J-CTO score = 0.334, p < 0.01; difference in AUC between the IS-CTO score and PROGRESS score = 0.397, p < 0.01). Our results suggest that the IS-CTO score system is a helpful tool to predict the technical success of IS-CTO PCI via antegrade approach in china. Graphical Abstract.

Long-term outcomes of percutaneous coronary intervention for in-stent chronic total occlusion.

BackgroundThe development of the technique has improved the success rate of percutaneous coronary intervention (PCI) for in-stent chronic total occlusion (IS-CTO). However, long-term outcomes remain unclear. The present study sought to investigate long-term outcomes of PCI for IS-CTO.MethodsA total of 474 IS-CTO patients were enrolled at two cardiac centers from 2015 to 2018 retrospectively. These patients were allocated into either successful or failed IS-CTO PCI groups. The primary endpoint (major adverse cardiac events [MACE]) consisted of recurrent angina pectoris (RAP), target-vessel myocardial infarction (MI), heart failure, cardiac death, or ischemia-driven target-vessel revascularization (TVR) at follow-up. Multivariable Cox regression analysis was used to investigate the association between treatment appropriateness and clinical outcomes.ResultsA total of 367 patients were successfully treated with IS-CTO PCI while 107 patients had failed recanalization. After a median follow-up of 30 months (interquartile range: 17–42 months), no significant difference was observed between the two groups for the following parameters: cardiac death (successful PCI vs. failed PCI: 0.9% vs. 2.7%; adjusted hazard ratio [HR]: 1.442; 95% confidence interval [CI]: 0.21–9.887; P = 0.709), RAP (successful PCI vs. failed PCI: 40.8% vs. 40.0%; adjusted HR: 1.025; 95% CI: 0.683–1.538; P = 0.905), heart failure (successful PCI vs. failed PCI: 6.1% vs. 2.7%; adjusted HR: 0.281; 95% CI: 0.065–1.206; P = 0.088), target-vessel related MI (successful PCI vs. failed PCI: 1.5% vs. 2.7%; adjusted HR: 1.150; 95% CI: 0.221–5.995; P = 0.868), MACE (successful PCI vs. failed PCI: 44.2% vs. 45.3%; adjusted HR: 1.052; 95% CI: 0.717–1.543; P = 0.797). More patients were free of angina in the successful IS-CTO PCI group compared with failed PCI in the first (80.4% vs. 60%, P < 0.01) and second years (73.3% vs. 60.0%, P = 0.02) following up. Successful IS-CTO PCI had a lower incidence of MACE in the first and second years (20.2% vs. 40.0%, P < 0.01; 27.9% vs. 41.3%, P = 0.023) compared with failed PCI. After a median follow-up of 30 months, the reocclusion rate was 28.5% and TVR was 26.1% in the successful IS-CTO PCI group. Receiving >18 months of dual antiplatelet therapy (DAPT) was an independent predictor of decreased risk of TVR (HR: 2.682; 95% CI: 1.295–5.578; P = 0.008) or MACE (without TVR) (HR: 1.898; 95% CI: 1.036–3.479; P = 0.038) in successful IS-CTO PCI.ConclusionsAfter a median follow-up of 30 months, the successful IS-CTO PCI group had MACE similar to that of the failed PCI group. However, the successful IS-CTO PCI group had improved angina symptoms and were free from requiring coronary artery bypass grafting in the first or second years. To decrease MACE, DAPT was found to be essential and recommended for at least 18 months for IS-CTO PCI.

Precision Percutaneous Coronary Intervention of a Complex Lesion

Balloon dilation and atherectomy have several limitations in the treatment of heavily calcific coronary lesions. Intravascular lithotripsy (IVL) is a state-of-the-art system that modifies severe calcific coronary plaques efficiently. In this paper, we report our experience with IVL in the context of a calcific in-stent chronic total occlusion. A 75-year-old gentleman whose status was post percutaneous coronary intervention, with the deployment of two overlapping bare-metal stents in the mid-left anterior descending artery (LAD) 20 years ago, was admitted to our cardiac center for the elective intervention of in-stent chronic total occlusion (CTO) of LAD, which was performed using an antegrade wire escalation (AWE) technique. After recanalization of the CTO body, optical coherence tomography pullback confirmed a very high calcium score. Balloon dilatation attempts failed, so we proceeded with shockwave lithotripsy with successful full expansion of the 3.5-mm IVL balloon followed by a straightforward stent delivery. The procedure was complicated by distal wire perforation, which was handled in a timely manner with coil embolization. The patient's postoperative course was uneventful. This case illustrates the feasibility and effectiveness of IVL that powerfully cracks coronary calcium while minimizing vessel wall trauma in the context of heavily calcific in-stent CTO. In our case, coronary perforation occurred in a small-caliber side branch, which was identified in a timely manner before hemodynamic compromise and treated successfully straight away with coil embolization.

Outcomes of percutaneous intervention in in-stent versus de-novo chronic total occlusion: a meta-analysis

ABSTRACT Background Chronic total occlusion (CTO) is defined as coronary artery obstruction with no luminal continuity. Comparative outcomes of PCI in patients with in-stent CTO (IS-CTO) versus de-novo CTO are unclear. Methods An extensive literature search was done for outcomes of PCI in patients undergoing IS-CTO and de-novo CTO. The primary endpoint was major adverse cardiac events (MACE) and secondary endpoints were cardiovascular mortality, MI, and procedural success. Odds ratio (OR) with a 95% confidence interval (CI) was calculated using RevMan 5.3. Results Five studies consisting of 3,681 patients (IS-CTO = 464, de-novo CTO = 3,217) were included. PCI in IS-CTO was associated with a significantly higher odds of MACE (OR 2.21, 95% CI 1.32–3.68, p = 0.002) and MI (OR 4.31, 95% CI 1.94–9.58, p = 0.0003) compared to patients with de-novo CTO. Mortality outcome (OR 1.49, 95% CI 0.93–2.39, p = 0.10) between the two groups was similar. Overall odds of procedural-success were similar among the groups (OR 1.11, 95% CI 0.84–1.46, p = 0.47). Conclusion PCI for in-stent CTO might be associated with higher odds of MACE and MI compared to PCI for de-novo CTO. However, cardiovascular mortality or failure of procedure are similar.

Clinical outcomes after percutaneous coronary intervention for in-stent chronic total occlusion.

The aim of this study was to compare percutaneous coronary intervention (PCI) outcomes in relation to stent optimisation profiles between in-stent chronic total occlusions (CTOs) and de novo CTOs. We evaluated 1,516 consecutive patients who underwent PCI for 147 in-stent CTOs (9.3%) and 1,439 de novo CTOs between 2007 and 2018. The primary endpoint was target vessel failure (TVF) consisting of a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularisation. The final post-stenting intravascular ultrasound (IVUS) images were analysed. Target lesion complexity reflected by the Japanese CTO score was similar, albeit calcification was more prevalent in de novo CTOs, whereas occlusion length >20 mm was more frequent in in-stent CTOs. The technical success (88.4% vs 87.5%, p=0.84) and in-hospital adverse event (1.4% vs 3.6%, p=0.26) rates were similar between CTO types. Among those who received drug-eluting stents, the five-year TVF (11.0% vs 10.7%, p=0.99) and target vessel revascularisation (4.2% vs 3.7%, p=0.81) rates were similar between groups. Total stent length, minimum stent area (5.4±1.8 vs 5.5±1.8 mm2, p=0.77), and maximal plaque burden of the reference segments were largely comparable between groups. In-stent CTO PCI with drug-eluting stents optimised by IVUS guidance offers as acceptable long-term clinical results as those achieved in de novo CTOs.