Outcomes Of Chronic Total Occlusion Research Articles

Full-Moon Coronary Calcification as Detected With Computed Tomography Angiography in Chronic Total Occlusion Percutaneous Coronary Intervention

"Full moon" is a central calcification that occludes the entire vessel on coronary computed tomography angiography (CCTA). We examined the association of “full moon” calcification as identified by CCTA, on clinical and procedural outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We studied patients who underwent elective CTO PCI in two European centers and had pre-procedural CCTA. The primary endpoint was the inability to cross the lesion and/or the need for extensive debulking techniques. Secondary endpoints were procedural success, in-hospital cardiac mortality, the need for extensive debulking techniques, myocardial infarction (MI), major adverse cardiac events (MACE, defined as in hospital death, MI and clinically driven target vessel revascularization) and stent thrombosis. Secondary procedural endpoints included procedural time, fluoroscopy time, number of guidewires and balloons, stent length, number and diameter and contrast volume. Multivariable logistic regression analysis was performed identifying potential covariates related to the primary outcome according to knowledge and prior studies. Subsequently, a stepwise selection approach was performed to select factors with the greatest predictive value. Among 140 patients included, 28 (20%) had a “full moon” calcified CTO-plaque. Patients in the full moon group were older and had more cardiovascular risk factors. There was not significant difference in the need for retrograde approach and antegrade dissection and re-entry (ADR) techniques in the “full moon” group vs the other groups (32.1% vs 37.5%, p=0.59 and 0% vs 1.7%, p=0.47 respectively). Compared with patients who did not have full moon morphology, full moon patients had higher incidence of the primary outcome (53.5% vs 12.5%;p<0.001). On multivariable analysis that included chronic kidney failure and prior coronary artery bypass surgery, full moon calcification was associated with higher incidence of the primary endpoint; OR 6.5;95% CI 2.1-20.5;p=0.001). Moreover, lower procedural success (71.4% vs 87.5%;p=0.03), higher incidence of coronary perforations (14.2% vs 3.5%;p<0.02) and higher procedural [172.5 (118.0-237.5) vs 144.0 (108.50-174.75); p=0.02] and fluoroscopic time [62.6 (38.1-83.0) vs 42.8 (29.5-65.7); p=0.03] were observed in the “full moon” group. Overall MACE did not differ between the two groups (1 patient in the “full moon” group vs 1 patient in the no “full moon” group; 3.5% vs 0.8%, p=0.29). In conclusion, “full moon” calcification on CCTA was independently associated with procedural complexity and adverse outcomes in CTO-PCI.

Annual operator volume and procedural outcomes of chronic total occlusions treated with percutaneous coronary interventions: analysis based on 14,899 patients.

Low operator and institutional volume is associated with poorer procedural and long-term clinical outcomes in patients treated with percutaneous coronary interventions (PCI). This study was aimed at evaluating the relationship between operator volume and procedural outcomes of patients treated with PCI for chronic total occlusion (CTO). Data were obtained from the national registry of percutaneous coronary interventions (ORPKI) collected from January 2014 to December 2020. The primary endpoint was a procedural success, defined as restoration of thrombolysis in myocardial infarction (TIMI) II/III flow without in-hospital cardiac death and myocardial infarction, whereas secondary endpoints included periprocedural complications. Data of 14,899 CTO-PCIs were analyzed. The global procedural success was 66.1%. There was a direct relationship between the annual volume of CTO-PCIs per operator and the procedural success (OR: 1.006 [95% CI: 1.003-1.009]; P<0.001). The nonlinear relationships of annualized CTO-PCI volume per operator and adjusted outcome rates revealed that operators performing 40 CTO cases per year had the best procedural outcomes in terms of technical success (TIMI flow II/III after PCI), coronary artery perforation rate and any periprocedural complications rate (P<0.0001). Among the other factors associated with procedural success, the following can be noted: multi-vessel, left main coronary artery disease (as compared to single-vessel disease), the usage of rotablation as well as PCI within bifurcation. High-volume CTO operators achieve greater procedural success with a lower frequency of periprocedural complications. Higher annual caseload might increase the overall quality of CTO-PCI.

Racial disparities in chronic total occlusion percutaneous coronary interventions: insights from the PROGRESS-CTO registry.

There is limited data on race and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The authors sought to evaluate CTO PCI techniques and outcomes in different racial groups. We examined the baseline characteristics and procedural outcomes of 11 806 CTO PCIs performed at 44 US and non-US centers between 2012 and March 2023. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, repeat target-vessel revascularization, pericardiocentesis, cardiac surgery, and stroke prior to discharge. The most common racial group was White (84.5%), followed by Black (5.7%), "Other" (3.9%), Hispanic (2.9%), Asian (2.4%), and Native American (0.7%). There were significant differences in the baseline characteristics between different racial groups. When compared with non-White patients, the retrograde approach and antegrade dissection re-entry were more likely to be the successful crossing strategies in White patients without any significant differences in technical success (86.4% vs 86.4%; P = .93), procedural success (84.8% vs 85.0%; P = .79), and in-hospital MACE (2.0% vs 1.5%; P = .15) between the 2 groups. The technical success rate was significantly higher in the "Other" racial group (91.0% vs 86.4% in White, 86.9% in Asian, 84.5% in Black, 84.5% in Hispanic, and 83.3% in Native American; P = .03) without any significant differences in procedural success or in-hospital MACE rates between the groups. Despite differences in baseline characteristics and procedural techniques, the procedural success and in-hospital MACE of CTO PCI were not significantly different between most racial groups.

Abstract 15589: Impact of Preprocedural Anemia on In-Hospital and Follow-Up Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention

Background: The impact of preprocedural anemia on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods: We examined the clinical and angiographic characteristics and procedural outcomes of 8,633 CTO PCIs performed at 39 US and non-US centers between 2012 and 2023. Anemia was defined as a hemoglobin level of &lt;13 g/dL for men and &lt;12 g/dL for women. Results: Anemia was present in 1,652 (19%) patients undergoing CTO PCI. These patients had a higher incidence of comorbidities, such as diabetes mellitus, hypertension, dyslipidemia, heart failure, cerebrovascular disease, and peripheral arterial disease. CTOs in anemic patients were more likely to have complex angiographic characteristics, including smaller diameter, longer length, moderate to severe calcification, and moderate to severe proximal tortuosity. Anemic patients required longer procedure (119 vs. 107 min; p&lt;0.001) and fluoroscopy (45 vs. 40 min; p&lt;0.001) times but received similar contrast volumes. Technical success was similar between the two groups. In-hospital major adverse cardiac events (MACE) rates were higher in patients with anemia; however, this association was no longer significant after adjusting for confounding factors. Baseline anemia was independently associated with follow-up MACE (adjusted HR: 1.63; 95% CI: 1.07-2.49; p=0.023) and all-cause mortality (adjusted HR: 3.03; 95% CI: 1.41-6.49; p=0.004). Conclusions: Preprocedural anemia is associated with more comorbidities, higher lesion complexity, longer procedure times, and higher follow-up MACE and mortality after CTO PCI.

Abstract 15646: Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Patients With Prior Coronary Artery Bypass Graft Surgery

Background: The long-term outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI) in patients with prior coronary artery bypass graft surgery (CABG) have received limited study. Methods: We examined the baseline characteristics and outcomes of CTO PCIs performed at 47 US and non-US centers between 2012 and 2023. Results: Of the 12,164 patients who underwent CTO PCI during the study period, 3,475 (29%) had prior CABG. Prior CABG patients were older, more likely to be men, with higher incidence of comorbidities and lower left ventricular ejection fraction and eGFR. Their CTOs were more likely to have moderate/severe calcification and proximal tortuosity, proximal cap ambiguity, longer lesion length and higher J-CTO scores. The first and final successful crossing strategy was more likely to be the retrograde approach. They had lower technical (82.1% vs 88.2%, p&lt;0.001) and procedural (80.8% vs 86.8%, p&lt;0.001) success, but similar incidence of in-hospital major complications. The incidence of in-hospital death (0.8% vs 0.3%, p&lt;0.001), acute myocardial infarction (0.9% vs 0.5%, p=0.007) and perforation (7.0% vs 4.2%, p&lt;0.001) was higher in prior CABG patients, while pericardial tamponade was less common (0.1% vs 1.3%, p&lt;0.001). At 2-year follow-up, the incidence of major adverse cardiac events, repeat PCI and acute coronary syndromes was significantly higher in prior CABG patients, while all-cause mortality was similar. Conclusions: Prior CABG patients undergoing CTO PCI have more complex clinical and angiographic characteristics and lower success rate, but similar incidence of in-hospital major complications, and had higher incidence of MACE but similar all-cause mortality during long-term follow-up. Abbreviations: eGFR= estimated glomerular filtration rate

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

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

Pericoronary adipose tissue attenuation predicts outcome of percutaneous intervention for chronic total occlusion

To investigate the association between pericoronary adipose tissue (PCAT) attenuation (PCATA) and outcomes of chronic total occlusion (CTO) after percutaneous coronary intervention (PCI), and to establish a clinical model that can be easily generalised to predict the outcomes of PCI-CTO. Between September 2015 and September 2019, patients from two centres were enrolled retrospectively. The primary endpoint was a procedural success (defined as achieving residual stenosis of <30% and a grade 3 thrombolysis in myocardial infarction [TIMI] flow). The new predictive model was generated by factors that were determined by multivariate analysis. The PCATA of CTO (PCATA-CTO) score was developed by assigning 1 point for each independent predictor, and then summing all points accrued. In addition, the predictive efficacy and interobserver and intraobserver agreement of PCATA-CTO and other scoring systems based on coronary computed tomography angiography (CCTA) were compared. A total of 201 patients (mean age 58.9±10.8 years, 85% male) were enrolled. The PCI success was achieved in 76% of the lesions. PCAT was higher in the PCI success group (-72.44±10.45HU versus -76.76±10.54 HU, p<0.05). Multivariable analysis yielded severe calcification, lesion length ≥15 mm, and perivascular fat attenuation index (FAI) ≤-69.5HU as independent negative predictors for procedural success. The area under the receiver operating characteristic curves for the PCATA-CTO score was 0.72. Comparing the PCATA-CTO score with other predictive scores, the PCATA-CTO score showed the highest interobserver (kappa=0.74) and intraobserver agreement (kappa=0.90, all p<0.01). FAI ≤-69.5HU is an independent negative predictor of procedural success. The PCATA-CTO score improved the reliability of the prediction model. Its potential for clinical implementation requires evaluation.

Impact of preprocedural anemia on in-hospital and follow-up outcomes of chronic total occlusion percutaneous coronary intervention.

The impact of preprocedural anemia on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We examined the clinical and angiographic characteristics and procedural outcomes of 8633 CTO PCIs performed at 39 US and non-US centers between 2012 and 2023. Anemia was defined as a hemoglobin level of <13 g/dL in men and <12 g/dL in women. Anemia was present in 1652 (19%) patients undergoing CTO PCI. Anemic patients had a higher incidence of comorbidities, such as diabetes mellitus, hypertension, dyslipidemia, heart failure, cerebrovascular disease, and peripheral arterial disease. CTOs in anemic patients were more likely to have complex angiographic characteristics, including smaller diameter, longer length, moderate to severe calcification, and moderate to severe proximal tortuosity. Anemic patients required longer procedure (119 vs. 107 min; p < 0.001) and fluoroscopy (45 vs. 40 min; p < 0.001) times but received similar contrast volumes. Technical success was similar between the two groups. In-hospital major adverse cardiac events (MACE) rates were higher in patients with anemia; however, this association was no longer significant after adjusting for confounding factors. Baseline anemia was independently associated with follow-up MACE (adjusted hazard ratio [HR]: 1.63; 95% confidence interval [CI]: 1.07-2.49; p = 0.023) and all-cause mortality (adjusted HR: 3.03; 95% CI: 1.41-6.49; p = 0.004). Preprocedural anemia is associated with more comorbidities, higher lesion complexity, longer procedure times, and higher follow-up MACE and mortality after CTO PCI.

Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Patients With Previous Coronary Artery Bypass Graft Surgery

The outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) in patients with previous coronary artery bypass graft (CABG) surgery have received limited study. We examined the baseline characteristics and outcomes of CTO PCIs performed at 47 United States and non-United States centers between 2012 and 2023. Of the 12,164 patients who underwent CTO PCI during the study period, 3,475 (29%) had previous CABG. Previous CABG patients were older, more likely to be men, and had more comorbidities and lower left ventricular ejection fraction and estimated glomerular filtration rate. Their CTOs were more likely to have moderate/severe calcification and proximal tortuosity, proximal cap ambiguity, longer lesion length, and higher Japanese CTO scores. The first and final successful crossing strategy was more likely to be retrograde. Previous CABG patients had lower technical (82.1% vs 88.2%, p <0.001) and procedural (80.8% vs 86.8%, p <0.001) success, higher in-hospital mortality (0.8% vs 0.3%, p <0.001), acute myocardial infarction (0.9% vs 0.5%, p=0.007) and perforation (7.0% vs 4.2%, p <0.001) but lower incidence of pericardial tamponade and pericardiocentesis (0.1% vs 1.3%, p <0.001). At 2-year follow-up, the incidence of major adverse cardiac events, repeat PCI and acute coronary syndrome was significantly higher in previous CABG patients, whereas all-cause mortality was similar. In conclusion, patients with previous CABG who underwent CTO PCI had more complex clinical and angiographic characteristics and lower success rate, higher perioperative mortality, and myocardial infarction but lower tamponade, and higher incidence of major adverse cardiac events with similar all-cause mortality during follow-up.

Atrial fibrillation and chronic total occlusion percutaneous coronary intervention outcomes: insights from the Progress-CTO registry.

We examined the effect of atrial fibrillation on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the baseline characteristics and procedural outcomes of 9,166 CTO PCIs performed at 39 US and non-US centers between 2012 and 2023. Atrial fibrillation was present in 1122 (12%) patients. These patients were older and had a higher incidence of comorbidities, such as hypertension, dyslipidemia, heart failure, cerebrovascular disease, and peripheral arterial disease, lower left ventricular ejection fraction, and lower eGFR. Their CTOs were more likely to have moderate to severe calcification and longer lesion length. They also had higher mean J-CTO and PROGRESS-CTO complications (Acute MI, MACE, Mortality, Perforation, and Pericardiocentesis) scores. Patients with atrial fibrillation had higher prevalence of uncrossable and undilatable CTO lesions and required longer procedure (107 vs 119 min; P less than .001) and fluoroscopy (40 vs 43 min; P=.005) time. Technical success and MACE, including procedural/in-hospital bleeding, were similar in patients with and without atrial fibrillation. Although the crude incidence of MACE on follow-up (median 61 days) was significantly higher in patients with atrial fibrillation, the latter was not independently associated with adverse events on Cox proportional hazards analysis. Patients with atrial fibrillation undergoing CTO PCI are older, have more comorbidities, higher lesion complexity, and longer procedure time, but similar technical success and in-hospital MACE. They have higher MACE and mortality during follow-up, but the difference is not significant after adjusting for potential confounding variables.

Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention of the Left Anterior Descending Artery

The left anterior descending artery (LAD) subtends a large myocardial territory. The outcomes of LAD chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. We performed a retrospective analysis of all patients who underwent LAD CTO PCI at a high-volume single center. Outcomes included in-hospital and long-term major adverse cardiovascular events (MACEs) and changes in left ventricular ejection fraction (LVEF). We performed a subgroup analysis of patients with ischemic cardiomyopathy, defined as an LVEF of 40% or less. From December 2014 to February 2021, 237 patients underwent LAD CTO PCI. The technical success rate was 97.4%, and the in-hospital MACE rate was 5.4%, A landmark analysis after hospital discharge showed an overall survival of 92% and 85% MACE-free survival at 2years. There was no difference in overall survival or MACE-free survival between those who had ischemic cardiomyopathy versus those who did not. In patients with ischemic cardiomyopathy, LAD CTO PCI was associated with significant improvement in LVEF (10.9% at 9months), which was further pronounced when these patients had a proximal LAD CTO and were on optimal medical therapy (14% at 6months). In a single high-volume center, LAD CTO PCI was associated with 92% overall survival at 2years, with no difference in survival between patients with or without ischemic cardiomyopathy. LAD CTO PCI was associated with an absolute 10% increase in LVEF at 9months in patients with ischemic cardiomyopathy.

Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention After a Previous Failed Attempt

The impact of a previous failure on procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We examined the clinical and angiographic characteristics and procedural outcomes of 9,393 patients who underwent 9,560 CTO PCIs at 42 United States and non-United States centers between 2012 and 2022. A total of 1,904 CTO lesions (20%) had a previous failed PCI attempt. Patients who underwent reattempt CTO PCI were more likely to have a family history of coronary artery disease (37% vs 31%, p <0.001) and dyslipidemia (87.9% vs 84.3%, p <0.001) but were less likely to have heart failure (25.1% vs 29.5%; p <0.001) and cerebrovascular disease (8.7% vs 10.4%, p=0.04). Patients with previous failure had a higher Japanese CTO (3.33 ± 1.16 vs 2.12 ± 1.19, p <0.001) score and required longer procedure (120 vs 111minutes, p <0.001) and fluoroscopy (46.9 vs 40.4minutes, p <0.001) times and higher air kerma radiation dose (2.3 vs 2.1 gray, p=0.013). Technical success rates (84.3% vs 86.5%, p=0.011) were lower in patients with a previous failure compared with patients who underwent first-attempt CTO PCI with no significant difference in in-hospital major adverse cardiac events. After adjusting for potential confounders, a previous failure was not associated with technical failure. Operators performing >30 CTO PCIs annually were more likely to achieve technical success in patients with previous failure. In conclusion, a previous failed CTO PCI attempt was associated with higher lesion complexity, longer procedure time, and lower technical success; however, the association with lower technical success did not remain significant in multivariable analysis.

Impact of lesion length on the outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

The impact of occlusion length on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We examined the clinical and angiographic characteristics and procedural outcomes of 10,335 CTO PCIs at 42 US and non-US centers between 2012 and 2022. The cohort was divided into two groups based on lesion length (≥20 mm vs. <20 mm). Long lesions were present in 7208 (70%) patients. Comorbidities were more common in patients with long CTOs. Compared with short lesions, long lesions had higher J-CTO score (2.8 ± 1.1 vs. 1.3 ± 1; p < 0.001) and retrograde wiring was more often the initial (15.5% vs. 4.0%; p < 0.001) and successful (22.8% vs. 8.2%; p < 0.001) crossing strategy. Long lesions were more likely to require longer procedure (123 vs. 91 min; p < 0.001) and fluoroscopy (47.1 vs. 32.2 min; p < 0.001) time, larger contrast volume (218 vs. 200 mL; p < 0.001) and higher air kerma radiation dose (2.4 vs. 1.7 Gy; p < 0.001). After adjusting for potential confounders, long lesions were associated with lower technical success (odds ratio [OR]: 0.91 per 10 mm increase; 95% confidence interval [CI]: 0.88, 0.94) and higher major adverse cardiovascular events (MACE) (OR: 1.08 per 10 mm increase; 95% CI: 1.02, 1.15). CTO PCI of long occlusions is independently associated with lower rates of technical success and higher rates of in-hospital MACE.

Impact of target vessel on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention.

There is limited information on the impact of the target vessel on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 11,580 CTO PCIs performed between 2012 and 2022 at 44 centers. The most common CTO target vessel was the right coronary artery (RCA) (53.1%) followed by the left anterior descending artery (LAD) (26.0%) and the left circumflex artery (LCX) (19.8%). RCA CTOs were longer and more complex, with a higher Japanese CTO score compared with LAD or LCX CTOs. Technical success was higher among LAD (88.8%) lesions when compared with RCA (85.7%) or LCX (85.8%) lesions (P less than .001). The incidence of major adverse cardiovascular events (MACE) was overall 1.9% (n = 220) and was similar among target vessels (P=.916). There was a tendency toward more frequent utilization of the retrograde approach for more proximal occlusions in all 3 target vessels. When compared with all other RCA lesions combined, distal RCA lesions had higher technical success (87.7% vs 85.3%; P=.048). Technical success was similar between various locations of LAD CTOs (P=.704). First/second/third obtuse marginal branch had lower technical success when compared with all other LCX lesion locations (82.7% vs 86.8%; P=.014). There was no association between MACE and CTO location in all 3 target vessels. LAD CTO PCIs had higher technical and procedural success rates among target vessels. The incidence of MACE was similar among target vessels and among various locations within the target vessel.

Impact of impaired renal function on outcomes of chronic total occlusion undergoing revascularization: a systemic review and meta-analysis.

Patients with chronic kidney disease (CKD) have an associated burden of coronary artery disease, including chronic total occlusions (CTO). It is unclear how the presence of CKD affects the outcomes of CTO revascularization. Previous reviews have not taken into account all relevant published studies that examined the association of CKD with outcomes of CTO revascularization. A systematic search was conducted using PubMed, Scopus, and Google Scholar databases for studies investigating patients with or without CKD who also had coronary chronic total occlusion undergoing revascularization procedures Statistical analysis was performed using STATA software. Effect sizes were reported as pooled relative risk (RR). A total of 13 studies were included. CKD patients showed elevated risk of in-hospital mortality (RR 4.25, 95% CI 2.64, 6.82) and mortality at latest follow-up (RR 3.24, 95% CI 2.56, 4.11), elevated risk of major cardio or cerebrovascular events (RR 1.65, 95% CI 1.38, 1.98), major bleeding (RR 2.85, 95% CI 1.96, 4.13), and contrast-induced acute kidney injury (RR 3.06, 95% CI 1.70, 5.52). CKD patients also showed lower chances of technical success (RR 0.95, 95% CI 0.91, 1.00). The presence of CKD increases the risk of mortality, complications and adversely affects the success of CTO revascularization. Patients with CKD undergoing revascularization should have their kidney function comprehensively evaluated and these patients should be carefully monitored.

Drug-coated balloon for the management of coronary chronic total occlusions.

There is a higher rate of successful recanalization of patients with coronary chronic total occlusions, nevertheless, the rate of patients referred for revascularization remains low. In addition, there is a greater need to improve long-term outcomes of chronic total occlusions after percutaneous coronary intervention, and although the implantation of new-generation drug-eluting stents has been optimized with coronary imaging guidance, the rate of stenting failure remains a major issue and long-term vessel patency could be improved. We reviewed clinical data regarding the benefit of treating chronic total occlusions and the use of drug-coated balloons as an alternative therapeutic modality in this setting. Although clinical data is limited, the initial evidence and the daily clinical practice point towards a synergistic hybrid treatment strategy based on the combination of drug-coated balloons plus drug-eluting stents, reducing the total stent length and maintaining the scaffolding properties of stents where it is mandatory. Additionally, drug-coated balloons allow natural enlargement of the open vessel after percutaneous coronary intervention (PCI), which is a major limitation of stents in chronic total occlusion (CTO).

Outcomes of chronic total occlusion percutaneous coronary intervention in patients with prior coronary artery bypass graft surgery: Insights from the LATAM CTO registry.

To evaluate the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in patients with and without prior coronary artery bypass graft (CABG) surgery. Data on the outcomes of CTO PCI in patients with versus without CABG remains limited and with scarce representation from developing regions like Latin America. We evaluated patients undergoing CTO PCI in 42 centers participating in the LATAM CTO registry between 2008 and 2020. Statistical analyses were stratified according to CABG status. The outcomes of interest were technical and procedural success and in-hospital major adverse cardiac and cerebrovascular events (MACCE). A total of 1662 patients were included (n=1411 [84.9%] no-CABG and n=251 [15.1%] prior-CABG). Compared with no-CABG, those with prior-CABG were older (67 ± 11 vs. 64 ± 11 years; p < 0.001), had more comorbidities and lower left ventricular ejection fraction (52.8 ± 12.8% vs. 54.4 ± 11.7%; p=0.042). Anatomic complexity was higher in the prior-CABG group (J-CTO score 2.46 ± 1.19 vs. 2.10 ± 1.22; p < 0.001; PROGRESS CTO score 1.28 ± 0.89 vs. 0.91 ± 0.85; p < 0.001). Absence of CABG was associated with lower risk of technical and procedural failure (OR: 0.60, 95% CI: 0.43-0.85 and OR: 0.58, 95% CI: 0.40-0.83, respectively). No significant differences in the incidence of in-hospital MACCE (3.8% no-CABG vs. 4.4% prior-CABG; p=0.766) were observed between groups. In a contemporary multicenter CTO-PCI registry from Latin America, prior-CABG patients had more comorbidities, higher anatomical complexity, lower success, and similar in-hospital adverse event rates compared with no-CABG patients.

Outcomes of successful vs. failed contemporary chronic total occlusion percutaneous coronary intervention.

There are limited contemporary data on the impact of success vs. failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We conducted a systematic review and a meta-analysis of contemporary studies that compared the outcomes in patients who underwent successful vs. failed contemporary (2010 onwards) CTO PCI. We performed a sensitivity analysis limited to studies that started enrollment after the publication of the hybrid algorithm in 2012. We included five studies with a total of 6,084 patients (successful CTO PCI n = 4,861, failed CTO PCI n = 1,223). During a median follow-up time of 12months (range 6-60months), successful CTO PCI was associated with a lower risk of major adverse cardiovascular events [OR: 0.61, 95% CI (0.41, 0.92), p = 0.02, I2 = 63%] and all-cause death [OR: 0.57, 95% CI (0.33, 0.99), p = 0.05, I2 = 60%]. Both groups had similar risk of myocardial infarction (MI) [OR 0.69, 95% CI (0.43, 1.10), p = 0.38, I2 = 80%], target vessel revascularization (TVR) [OR: 0.56, 95% CI (0.25, 1.27), p = 0.17, I2 = 80%], and stroke [OR: 0.52, 95% CI (0.14, 1.91), p = 0.33, I2 = 0%]. In contemporary practice, successful CTO PCI was associated with a lower incidence of MACE driven by lower all-cause mortality compared with failed CTO PCI at a median follow-up of 1year.

Angiographic characteristics and long-term outcomes of single-vessel chronic total occlusion percutaneous coronary intervention in patients with and without previous myocardial infarction.

This study evaluated the angiographic characteristics and clinical outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) among patients with and without a history of myocardial infarction (MI). The pathogenesis of CTO and myocardial viability are different in cases with or without previous MI. However, the lesion characteristics and clinical outcomes are unclear for these two groups. We reviewed consecutive patients who underwent single-vessel CTO PCI from 2010 to 2013. Patients were classified according to their history of MI. Acute procedural results were classified as optimal recanalization, suboptimal recanalization, or technical failure. The primary endpoint was the 5 year rate of cardiac death. We identified 2,191 eligible patients, including 859 patients (39.2%) with previous MI. The overall technical success rate was 74.4%. Relative to the non-MI group, the MI group had a larger reference vessel diameter (3.0 ± 0.5 vs. 2.9 ± 0.4 mm, p = .002), a lower proportion of Werner grade ≥ 1 collateral circulation (65.4 vs. 79.2%, p < .001), a higher proportion of optimal recanalization (63.1 vs. 58.6%, p = .006), and a higher 5-year rate of cardiac death (3.9 vs. 2.1%, p = .02). In the MI group, suboptimal recanalization was associated with a significantly higher 5-year rate of spontaneous MI, relative to optimal recanalization and technical failure (11.7 vs. 4.6 vs. 4.1%, p = .006). Patients with CTO and previous MI had a larger reference vessel diameter, lower level of collateral circulation, and higher proportion of optimal recanalization. However, suboptimal recanalization in these patients was associated with an increased risk of spontaneous MI.

Chronic total occlusion percutaneous coronary intervention in octogenarians and nonagenarians.

The outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in octogenarians and nonagenarians have received limited study. We compared in-hospital outcomes of CTO PCI between patients ≥80 vs. <80-years-old in 6233 CTO PCIs performed between 2012 and 2020 at 33 U.S. and international centers. There were 415 octogenarians and nonagenarians in our study (7% of the total population). Compared with younger patients, octo- and nonagenarians were less likely to be men (73% vs. 83.2%, p< 0.0001) and more likely to have atrial fibrillation (27% vs. 12%, p< 0.0001) and prior coronary artery bypass graft surgery (CABG) (43% vs. 29%, p< 0.0001). They were more likely to have CTOs with moderate/severe calcification (71% vs. 46%, p< 0.0001), but had similar mean J-CTO scores (2.5± 1.3 vs. 2.4± 1.3, p= 0.08). They had lower technical and procedural success (82.2% vs. 86.3%, p= 0.0201; 80.3% vs. 84.8%, p= 0.016, respectively) and higher incidence of in-hospital major adverse cardiovascular events (3.4% vs. 1.8%, p= 0.021). On multivariable analysis PCI in octo- and nonagenarians was not independently associated with technical and procedural success or with in-hospital MACE. CTO PCI is feasible in octo- and nonagenarians, although success rates are lower, and the risk of complications is higher compared with younger patients, likely related to more comorbidities and higher coronary lesion complexity.