Ostial Chronic Total Occlusion Research Articles

Association between J-scores and ostial lesions: quantifying the effects of ostial lesions in chronic total occlusion percutaneous interventions

Abstract Aims We aimed to evaluate the influence of ostial lesions on the predicted probability of success in patients undergoing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). Methods 245 patients underwent CTO PCIs at our center, Germany. Of these patients, 197 (80.4%) without an ostial lesion and 48 (19.6%) with an ostial lesion were evaluated. Logistic regression models were used to estimate the interaction effect between the presence of ostial lesions and J-score. Results The ostial lesion group exhibited significantly higher pro-B-type natriuretic peptide levels (1644 pg/ml vs. 963 pg/ml, p=0.034) than the non-ostial lesion group. The final success rate was lower in the ostial lesion group than in the non-ostial lesion group (64.6% vs. 81.7%, p=0.018). The ostial lesion group had higher J-scores than the non-ostial lesion group, indicating more complex lesions (median: 2.5 vs. 2.0, p=0.005). Technical details revealed less antegrade (68.8% vs. 89.8%, p=0.001) and more retrograde access (33.3% vs. 7.6%, p<0.001) in the ostial lesion group than in the non-ostial lesion group. An ordered logistic regression with J-score as an outcome showed a statistically significant association between higher J-scores and ostial lesions (OR, 2.4; p=0.003). Investigating the association between ostial lesion and J-score categories (<3 and ≥3) revealed that ostial lesions were associated with lower success rates, especially in cases with higher J-scores (≥3), although the interaction effect was not statistically significant (p=0.506). Conclusion The presence of ostial CTO is associated with higher lesion complexity and lower technical and procedural success rates. Further studies, based on our retrospective and the previous studies, require the inclusion of the presence of ostial CTO as a factor in the currently used CTO scores to predict the difficulty of CTO procedure.Interaction EffectPredicted Probability

Echocardiography vs hemodynamic assessment of diastolic dysfunction.

Ostial CTOs can be challenging to revascularize. We aim to describe the outcomes of ostial chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 8788 CTO PCIs performed at 35 US and non-US centers between 2012 and 2022. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target-vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke. Ostial CTOs constituted 12% of all CTOs. Patients with ostial CTOs had higher J-CTO score (2.9 ± 1.2 vs 2.3 ± 1.3; P less than .01). Ostial CTO PCI had lower technical (82% vs. 86%; P less than .01) and procedural (81% vs. 85%; P less than .01) success rates compared with non-ostial CTO PCI. Ostial location was not independently associated with technical success (OR 1.03, CI 95% 0.83-1.29 P =.73). Ostial CTO PCI had a trend towards higher incidence of MACE (2.6% vs. 1.8%; P =.06), driven by higher incidence of in-hospital death (0.9% vs 0.3% P less than.01) and stroke (0.5% vs 0.1% P less than .01). Ostial lesions required more often use of the retrograde approach (30% vs 9%; P less than .01). Ostial CTO PCI required longer procedure time (149 [103,204] vs 110 [72,160] min; P less than .01) and higher air kerma radiation dose (2.3 [1.3, 3.6] vs 2.0 [1.1, 3.5] Gray; P less than .01). Ostial CTOs are associated with higher lesion complexity and lower technical and procedural success rates. CTO PCI of ostial lesions is associated with frequent need for retrograde crossing, higher incidence of death and stroke, longer procedure time and higher radiation dose.

Lesion complexity and procedural outcomes associated with ostial chronic total occlusions: Insights from the PROGRESS-CTO Registry.

Ostial CTOs can be challenging to revascularize. We aim to describe the outcomes of ostial chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 8788 CTO PCIs performed at 35 US and non-US centers between 2012 and 2022. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target-vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke. Ostial CTOs constituted 12% of all CTOs. Patients with ostial CTOs had higher J-CTO score (2.9 ± 1.2 vs 2.3 ± 1.3; P less than .01). Ostial CTO PCI had lower technical (82% vs. 86%; P less than .01) and procedural (81% vs. 85%; P less than .01) success rates compared with non-ostial CTO PCI. Ostial location was not independently associated with technical success (OR 1.03, CI 95% 0.83-1.29 P =.73). Ostial CTO PCI had a trend towards higher incidence of MACE (2.6% vs. 1.8%; P =.06), driven by higher incidence of in-hospital death (0.9% vs 0.3% P less than.01) and stroke (0.5% vs 0.1% P less than .01). Ostial lesions required more often use of the retrograde approach (30% vs 9%; P less than .01). Ostial CTO PCI required longer procedure time (149 [103,204] vs 110 [72,160] min; P less than .01) and higher air kerma radiation dose (2.3 [1.3, 3.6] vs 2.0 [1.1, 3.5] Gray; P less than .01). Ostial CTOs are associated with higher lesion complexity and lower technical and procedural success rates. CTO PCI of ostial lesions is associated with frequent need for retrograde crossing, higher incidence of death and stroke, longer procedure time and higher radiation dose.

Prevalence and Predictors of Successful Percutaneous Coronary Intervention in Ostial Chronic Total Occlusion

Prevalence and Predictors of Successful Percutaneous Coronary Intervention in Ostial Chronic Total Occlusion

In-Hospital Outcomes After Recanalization of Ostial Chronic Total Occlusions

BackgroundPercutaneous coronary intervention (PCI) of chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. Recanalization of ostial lesions is challenging and complex. This present study aims to evaluate the outcome of patients with ostial and non-ostial CTO-PCI with regard to acute, in-hospital outcome. MethodsBetween 2012 and 2018 we included 600 patients. Ostial lesions (OL) were defined as a coronary arterial stenosis within 3 mm of the vessel origin. Antegrade and retrograde CTO-PCI techniques were used and a composite safety endpoint comprising in-hospital death, vascular complications, cardiac tamponade, stroke and acute myocardial infarction. ResultsThe majority of the patients were male (82.3%) and the mean age was 62.1 years (±10.3 years). The right coronary artery (RCA) was the most frequent target vessel in 58.5%, followed by the left circumflex artery (LCX) (15.4%) and the left anterior descending artery (LAD) (26.2%). The success (p = .439) and complication rates (p = .169) were independent of the target vessel. We determined that examination and fluoroscopy time were longer in patients with OL (120.7 min vs. 99.0 min, p < .001 and 44.9 min vs. 34.5 min, p < .001) and that in this group of patients the retrograde approach was used more frequent (38.8% vs. 18.2%, p < .001). Overall success rates were lower in OL than compared to NOL (74.6% vs. 86.5%, p = .016). ConclusionsOur retrospective study suggests that recanalization of ostial CTO lesions is associated with reduced PCI success rates as well as long examination and high fluoroscopy times.

Prevalence and Outcomes of Percutaneous Coronary Interventions for Ostial Chronic Total Occlusions: Insights From a Multicenter Chronic Total Occlusion Registry

BackgroundOstial chronic total occlusions (CTOs) can be challenging to recanalize. MethodsWe sought to examine the prevalence, angiographic presentation, and procedural outcomes of ostial (side-branch ostial and aorto-ostial) CTOs among 1000 CTO percutaneous coronary interventions (PCIs) performed in 971 patients between 2015 and 2017 at 14 centres in the US, Europe, and Russia. ResultsOstial CTOs represented 16.9% of all CTO PCIs: 9.6% were aorto-ostial, and 7.3% were side-branch ostial occlusions. Compared with nonostial CTOs, ostial CTOs were longer (44 ± 33 vs 29 ± 19 mm, P < 0.001) and more likely to have proximal-cap ambiguity (55% vs 33%, P < 0.001), moderate/severe calcification (67% vs 45%, P < 0.001), a diffusely diseased distal vessel (41% vs 26%, P < 0.001), interventional collaterals (64% vs 53%, P = 0.012), and previous coronary artery bypass graft surgery (CABG) (51% vs 27%, P < 0.001). The retrograde approach was used more often in ostial CTOs (54% vs 29%, P < 0.001) and was more often the final successful crossing strategy (30% vs 18%, P = 0.003). Technical (81% vs 84%, P = 0.280), and procedural (77% vs 83%, P = 0.112) success rates and the incidence of in-hospital major complication were similar (4.8% vs 2.2%, P = 0.108), yet in-hospital mortality (3.0% vs 0.5%, P = 0.010) and stroke (1.2% vs 0.0%, P = 0.030) were higher in the ostial CTO PCI group. In multivariable analysis, ostial CTO location was not independently associated with higher risk for in-hospital major complications (adjusted odds ratio 1.27, 95% confidence intervals 0.37 to 4.51, P = 0.694). ConclusionsOstial CTOs can be recanalized with similar rates of success as nonostial CTOs but are more complex, more likely to require retrograde crossing and may be associated with numerically higher risk for major in-hospital complications.

An algorithmic approach for the management of ostial right coronary artery chronic total occlusions.

Treatment of ostial chronic total occlusions (CTOs) of the right coronary artery (RCA) can be challenging. We present an algorithmic approach to the management of such lesions that incorporates all contemporary equipment and techniques. If the RCA ostium can be engaged with a guide catheter then antegrade crossing attempts should be performed. If the antegrade guidewire enters the subintimal space, re-entry into the distal true lumen is performed provided that the antegrade guide catheter provides enough support. If re-entry cannot be achieved, the antegrade wire is left in place to facilitate retrograde recanalization attempts (usually performed using the reverse controlled antegrade and retrograde tracking and dissection-reverse CART-technique). If the RCA ostium cannot be engaged with a guide catheter (for example in flush ostial occlusions) or if the guide catheter does not provide sufficient support, a primary retrograde approach is required, aiming for retrograde guidewire puncture into the aorta, followed by snaring and externalization. Retrograde guidewire puncture can be challenging, requiring use of stiff, highly penetrating guidewires or occasionally use of the Carlino technique. The aforementioned algorithm can facilitate crossing of ostial RCA CTOs.

PERCUTANEOUS CORONARY INTERVENTIONS FOR AORTOOSTIAL CHRONIC TOTAL OCCLUSIONS: INSIGHTS FROM A MULTICENTER REGISTRY

Ostial chronic total occlusions (CTOs) can be challenging to recanalize. We analyzed the prevalence, angiographic and procedural characteristics of ostial CTOs (within ≤5 mm of aortocoronary ostium) in 1,000 CTO PCIs performed in 969 patients between 2015 and 2017 in 14 US and European centers.

Intravascular ultrasound guidance of percutaneous coronary intervention in ostial chronic total occlusions: a description of the technique and procedural results.

Inability to cross the lesion with a guidewire is the most common reason for failure in percutaneous revascularization (PCI) of chronic total occlusions (CTOs). An ostial or stumpless CTO is an acknowledged challenge for CTO recanalization due to difficulty in successful wiring. IVUS imaging provides the opportunity to visualize the occluded vessel and to aid guidewire advancement. We review the value of this technique in a single-centre experience of CTO PCI. This series involves 22 patients who underwent CTO-PCI using IVUS guidance for stumpless CTO wiring at our institution. CTO operators with extensive IVUS experience in non-CTO cases carried out all procedures. Procedural and outcome data was prospectively entered into the institutional database and a retrospective analysis of clinical, angiographic and technical data performed. 17 (77%) of the 22 procedures were successful. The mean age was 59.8 ± 11.5years, and 90.9% were male. The most commonly attempted lesions were located in the left anterior descending 36.4% (Soon et al. in J Intervent Cardiol 20(5):359-366, 2007) and Circumflex artery (LCx) 31.8% (Mollet et al. in Am J Cardiol 95(2):240-243, 2005). Mean JCTO score was 3.09 ± 0.75 (3.06 ± 0.68, 3.17 ± 0.98 in the successful and failed groups respectively p = 0.35). The mean contrast volume was 378.7ml ± 114.7 (389.9ml ± 130.5, 349.2ml ± 52.2 p = 0.3 in the successful and failed groups respectively). There was no death, coronary artery bypass grafting or myocardial infarction requiring intervention in this series. When the success rates were analyzed taking into account the date of adoption of this technique, the learning curve had no significant impact on CTO-PCI success. This series describes a good success rate in IVUS guided stumpless wiring of CTOs in consecutive patients with this complex anatomical scenario.

45 Intravascular ultrasound guidance of percutaneous coronary interventions in ostial chronic total occlusions

Background Inability to cross the lesion with a guidewire is the most common reason for failure in percutaneous revascularisation (PCI) of chronic total occlusions (CTOs). An ostial or stumpless CTO is an acknowledged challenge for CTO recanalisation due to difficulty in successful wiring. IVUS imaging provides the opportunity to visualise the occluded vessel and to aid guidewire advancement. We review the value of this technique in a single-centre experience of CTO PCI. Methods This series involves 22 patients who underwent CTO-PCI using IVUS guidance for stumpless CTO wiring at our institution. CTO operators with extensive IVUS experience in non-CTO cases carried out all procedures. Procedural and outcome data in this population was prospectively entered into the institutional database and a retrospective analysis of clinical, angiographic and technical data was performed. Results 17 (77%) of the 22 procedures were successful. The mean age was 59.8 ± 11.5 years, and 90.9% were male. The most commonly attempted lesions were located in the Left Anterior Descending (LAD) 36.4% (8) and Circumflex artery (LCx) 31.8% (7). Mean JCTO score was 3.09 ± 0.75 (3.06 ± 0.68, 3.17 ± 0.98 in the successful and failed groups respectively p = 0.35). The mean contrast volume was 378.7 ml ± 114.7 (389.9 ml ± 130.5, 349.2 ml ± 52.2 p = 0.3 in the successful and failed groups respectively). There was no death, coronary artery bypass grafting or myocardial infarction requiring intervention in this series. When the success rates were analysed taking into account the date of adoption of this technique, the learning curve had no significant impact on CTO-PCI success. Conclusions This series describes a good success rate in IVUS guided stumpless wiring of CTOs in consecutive patients with this complex anatomical scenario.

TCTAP C-229 Double Anterograde Approach Percutaneous Coronary Intervention for Left Main Ostial Chronic Total Occlusion

### Patient initials or identifier number LSW ### Relevant clinical history and physical exam A 51 year-old male was presented with dyspnea on exertion for 4 months. He was a smoker and had hypertension with medication for 10 years. His clinical presentation was unstable angina. Physical

TCTAP C-107 Successful Retrograde Coronary Angioplasty of Left Circumflex Ostial Chronic Total Occlusion by Pulling RG3 Guidewire with Gooseneck Wire Because of Stucking at Acute Branching of Circumflex from Left Main Trunk

TCTAP C-107 Successful Retrograde Coronary Angioplasty of Left Circumflex Ostial Chronic Total Occlusion by Pulling RG3 Guidewire with Gooseneck Wire Because of Stucking at Acute Branching of Circumflex from Left Main Trunk

Absorb bioresorbable scaffold implantation for the treatment of an ostial chronic total occlusion

Absorb bioresorbable scaffold implantation for the treatment of an ostial chronic total occlusion

Intravascular ultrasound guided percutaneous coronary intervention for chronic total occlusion of left anterior descending artery

Chronic total occlusions (CTO) remain a technical challenge in interventional cardiology despite remarkable advances in the strategies, expertise, and equipment. The success of percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) depends in majority of cases whether or not a lesion is crossed by guidewire. This report illustrates successful use of intravascular ultrasound (IVUS) to enter true lumen and to confirm the wire position in an ostial chronic total occlusion without visible stump. It also highlights the importance of simultaneous left and right coronary injections to visualise the distal part of the occluded vessel filling through collaterals. Introduction Chronic total occlusions (CTO) is observed in about 10% of all percutaneous coronary intervention (PCI) and remain technical challenging despite remarkable advances in the strategies, expertise, and equipment. Improvement has been observed in procedural success rate but presence of CTO has been one of the commonest indications for referral for surgical revascularisation [1]. Successful percutaneous recanalisation of CTO results in improved survival, as well as enhanced left ventricular function, reduction of angina, and amelioration in exercise tolerance [2–4]. We report successful revascularisation of an ostial CTO of left anterior descending (LAD) artery with invisible stump, where intravascular ultrasound guidance confirmed entry of the stiff wire into the true lumen.