Percutaneous Coronary Intervention Attempt Research Articles

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.

Contemporary Management Before Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system. We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates. Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]). Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.

Abstract 10553: Staged Percutaneous Coronary Intervention For Chronic Total Occlusion of Non-Infarct Related Artery: A Meta-Analysis

Background: Chronic total occlusion (CTO) of a non-infarct related artery (nIRA) is associated with adverse outcomes following acute myocardial infarction (AMI). The current study aimed to evaluate the impact of successful staged percutaneous coronary intervention (PCI) of nIRA CTO lesions on clinical outcomes. Methods: PubMed, EMBASE, Google Scholar and Scopus databases were queried for studies comparing outcomes between AMI patients who underwent successful staged PCI of nIRA CTO lesions (CTO PCI group) and AMI patients with medical management of nIRA CTO lesions or failed CTO PCI attempt (No CTO PCI group). The primary meta-analysis outcome was major adverse cardiovascular events (MACE). The main summary estimate was the random effects risk ratio (RR) with 95% confidence intervals (CIs). Results: Eleven studies (1 randomized, 10 observational) with 2,788 patients were included. Compared with the No CTO PCI group, the CTO PCI group demonstrated a lower incidence of MACE (Figure A, RR 0.55 [0.46, 0.66], p&lt;0.001), all-cause mortality (Figure B, RR 0.47 [0.33, 0.66], p&lt;0.001), cardiac mortality (Figure C, RR 0.4 [0.28, 0.59], p&lt;0.001), stroke (Figure D, RR 0.38 [0.22, 0.66], p=0.0007) and heart failure (HF) hospitalization (RR 0.61 [0.41, 0.9], p=0.01). There was no significant difference in rates of any repeat revascularization (Figure E, RR 0.98 [0.69, 1.4], p=0.92) or target vessel revascularization (Figure F, RR 0.81 [0.48, 1.37], p=0.43) between the two groups. Conclusion In patients with AMI, staged PCI of nIRA CTO lesions was associated with a significantly lower incidence of MACE, all-cause mortality, cardiac mortality, stroke and HF hospitalization.

Impact of Subintimal Plaque Modification on Reattempted Chronic Total Occlusions Percutaneous Coronary Intervention.

Predictors of success in reattempted chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures remain obscure, mainly owing to the lack of consecutive angiograms and procedural records of initial attempts in the same cohort. This study sought to investigate the factors predicting the success of reattempted CTO PCI procedures. A total of 208 consecutive patients who underwent a failed CTO PCI attempt and received reattempted procedure at the same cardiac center were retrospectively analyzed. Predictors of the success of reattempted procedures were evaluated. The overall technical success rate of reattempted CTO PCI procedures was 71.2%. Subintimal plaque modification (SPM) was implemented in 35 (16.8%) procedures in initial attempts. The reattempted technical success rate was 93.3% in cases in which SPM with guidewire (GW) crossing was achieved in the initial attempt; however, the success rate was 55.0% for procedures involving SPM without GW crossing. SPM with GW crossing (OR: 11.21; 95%CI: 1.31-96.16; P=0.028), referral to high-volume operators (OR: 2.38; 95%CI: 1.14-4.98; P=0.021), and a bidirectional approach (OR: 2.31; 95%CI: 1.12-4.79; P=0.024) were positive independent predictors of technical success in the subsequent reattempt. The time interval for reattempt (per 90-day increment) was negatively correlated with the technical success of the reattempted procedures (OR: 0.85; 95%CI: 0.73-0.98; P=0.030). This study identified independent predictors of success in reattempted CTO PCI procedures. SPM with GW crossing achieved in the initial attempt is associated with a higher success rate in the subsequent reattempt.

Cost-Effectiveness in Patients Undergoing Revascularization of Chronic Total Occluded Coronary Arteries-A Cohort Study.

BackgroundRevascularization of patients with chronic total occluded coronary arteries (CTO) is recommended if they have symptoms despite medical treatment. The cost-effectiveness of treatment with percutaneous coronary intervention (PCI) was investigated in this cohort study.Materials and MethodsThe study was designed as a cohort study enrolling all patients undergoing PCI for a CTO in the Central Region of Denmark and recorded in the EUROCTO database. Major adverse cardio- and cerebrovascular events (MACCE) and admissions for cardiac symptoms were collected in the Western Denmark Heart Registry and through medical Journal Audits. Exposure was defined as successful revascularization of all CTO lesions compared with having one or more remaining CTOs after PCI attempt(s). Cost-effectiveness was evaluated as the net benefit (NB) at the patient level 3 years after treatment and through cost-effectiveness planes. The cost was defined as the cumulative cost of the index procedure and admissions due to MACCE and cardiac symptoms. Effectiveness was defined as the difference in MACCE for the primary analysis and the difference in death and symptomatic admissions for the secondary.ResultsBetween 2009 and 2019, 441 patients with ≥ 3 years of follow-up were treated with PCI for at least one CTO lesion (342 in the successful arm and 99 in the unsuccessful arm). The technical success rate was 85.4%. In total, 155 MACCE and 184 symptomatic admissions occurred in the follow-up period. The mean total cost was EUR 11.719 (11.034; 12.406) in the successful group vs. EUR 13.565 (11.899; 15,231) (p = 0.02) in the unsuccessful group. Net-benefit was EUR 1.846 (64; 3,627) after successful revascularization for MACCE. The adjusted analysis found an NB of EUR 1,481 (–118; 3,079). Bootstrap estimates showed cost-effectiveness planes in favor of successful revascularization.ConclusionPatients fully revascularized for all CTO lesions had a more cost-efficient treatment. However, results need confirmation in a randomized controlled trial due to the risk of residual confounding after adjustment.

Conus branch artery utilization in percutaneous coronary intervention for chronic total occlusion

Data on the prevalence of conus branch artery (CBA) is scarce, and its utilization in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is non-existing. The present study examined carefully in a large cohort the angiographic prevalence of CBA, its role as a collateral channel for the occlusion, and the potential usage of CBA in contemporary CTO PCI. We retrospectively examined consecutive CTO PCIs from our database between 2016 and 2019. All CTO PCIs were evaluated and the results with complications were recorded to determine the prevalence and utilization of CBA. From January 2016 to December 2019, a total of 556 CTO PCI attempts in 546 patients by high-volume operators were enrolled. The clinical, angiographic, and procedural details were collected. CBA was identifiable in 85.3% of these patients, and CBA providing visible collaterals connected to CTO distal lumen was found in 27.8% of patients. 84 CBA were used for balloon anchoring, 17 for selective distal true lumen visualization, and 9 as actual retrograde interventional collateral channel during CTO PCI. Only 1 patient suffered from chest pain during CBA balloon anchoring, and no other procedural complication such as arrhythmia or perforation occurred.CBA is frequently seen in coronary CTO. Its existence provided potential for various CTO PCI technique applications, without increase in risk.

Characteristics and outcomes of unsuccessful percutaneous coronary intervention.

To examine predictors and outcomes of unsuccessful percutaneous coronary intervention (PCI) cases in a contemporary Australian registry cohort. With improvements in techniques and pharmacotherapy in PCI, more complex lesions in older patients are now being attempted. In the context of PCI performance assessment, there are limited data regarding the characteristics and outcomes of unsuccessful PCI. We prospectively collected data on patients undergoing single-lesion PCI between 2013 and 2017 who were enrolled in the multi-center Victorian Cardiac Outcomes Registry. Procedures were divided into two groups by whether or not PCI was deemed successful at the end of the procedure using a pre-specified definition. There were 34,383 single-lesion PCI performed, of which 18,644 (54.2%) were for acute coronary syndromes. Of the study cohort, 2080 patients (6.0%) had an unsuccessful PCI - these patients were older, more likely to have previous stroke, PCI, severe left ventricular dysfunction and chronic kidney disease (all p <0.001). The procedure was also more likely to be performed for stable angina (p <0.001). Chronic total occlusion PCI made up 31% of unsuccessful PCI cases. Unsuccessful PCI was itself associated with higher in-hospital and 30-day mortality and MACE (all p <0.001). 4.9% of unsuccessful PCIs led to unplanned in-hospital bypass surgery (compared to 0.2% in successful PCIs, p <0.001). Our study highlights that even in contemporary PCI practice, more than 1 in 20 PCI attempts are unsuccessful. Lack of procedural success has a strong influence on patient outcomes. Monitoring rates of unsuccessful cases is an important quality assurance tool.

Cardiac and sudden death after chronic total occlusion percutaneous coronary intervention: Prognostic role of the target vessel.

The role of the target vessel in percutaneous revascularization of chronic total occlusion (CTO) is unclear. We sought to assess the long-term results of percutaneous coronary intervention (PCI) for CTO lesions in each coronary artery and to investigate the impact of successful revascularization and previous myocardial infarction (MI) in the territory of the target vessel. Cohort observational study on 1,124 patients who have undergone CTO PCI attempt: 371 on left anterior descending artery (LAD), 485 right coronary artery, and 268 left circumflex. Patients were further stratified by successfully revascularized and not-revascularized CTO (CTO-NR). Vessels affected by a previous MI were defined as infarct-related artery (IRA). The primary endpoint was cardiac death; the secondary endpoint was the combined rate of sudden cardiac-death and sustained ventricular-arrhythmias (SCD/SVAs). Propensity score-matching was performed to evaluate LAD versus NON-LAD CTO. Up to 12-year follow-up, the clinical benefit associated with successful PCI was consistent across the three groups. CTO-NR had the greatest association with cardiac death and SCD/SVAs in each coronary artery and in IRA-CTO patients. Unsuccessful percutaneous CTO revascularization was associated with lower cardiac survival and freedom from SCD/SVAs, irrespective of the vessel treated. This result was mainly driven by patients with an IRA CTO.

Abstract 16977: Coronary Chronic Total Occlusions: Insights on Upstream Management

Introduction: Percutaneous coronary intervention (PCI) of coronary artery chronic total occlusions (CTO) has increased over time, despite representing higher procedural risk than traditional PCI. While guidelines for stable ischemic heart disease recommend antianginal therapy prior to attempted revascularization, the frequency with which this occurs for CTO PCI remain unknown. We propose to assess the frequency and variability in upstream use of antianginal therapy prior to CTO PCI attempt over time. Methods: This study identified all patients who underwent a CTO PCI attempt from January 2012 to September 2018 across the Veterans Affairs Healthcare System using the Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) program. Patients were categorized by upstream management: (A) &lt;2 antianginal medications prescribed in year prior to CTO PCI, (B) ≥ 2 antianginals (C) Stress testing within 3 months of CTO PCI attempt and (D) ≥2 antianginals AND stress testing. Antianginal medications included beta blockers, nitrates, calcium channel blockers, and ranolazine. Multivariable logistic regression was used to estimate the propensity for receiving each category of treatment over time. Results: During the study period, 4250 patients underwent CTO PCI, with 1716 (40%) on ≥2 antianginal medications, 2534 (60%) on &lt;2 antianginals, 1023 (24%) with stress testing, and 338 (8%) on ≥2 antianginals with stress testing. Trends in upstream medical management of patients undergoing CTO PCI were unchanged over each fiscal year (Figure 1A) while odds of preprocedural stress testing decreased across fiscal years (Figure 1B). Conclusions: The majority of patients were on low intensity antianginal medical therapy prior to CTO PCI. Utilization of preprocedural stress testing decreased over time while patterns of upstream medical management remained constant, suggesting an opportunity to improve guideline compliance among patients undergoing attempted CTO PCI.

Safety and Feasibility of Transradial Approach for Coronary Artery Bypass Graft Intervention

&#x0D; Background &amp; Objective: To compare the safety and feasibility of using radial versus femoral access during coronary artery intervention of patients who had previously undergone coronary artery bypass graft (CABG) surgery.&#x0D; Methods: The study was conducted in Ibrahim Cardiac Hospital &amp; Research Institute (ICHRI), Dhaka from January 2013 to December 2015. During the period a total of 380 patients with past CABG surgery underwent diagnostic coronary angiogram (CAG) and percutaneous coronary intervention (PCI) at our institution. We retrospectively evaluated 98 consecutive patients who underwent graft intervention via the transradial (TRA, n=54) or transfemoral approach (TFA, n=44) route. Baseline clinical characteristics, angiographic characteristics and complications between the two study groups were observed.&#x0D; Result: The baseline clinical characteristics between the two study groups were similar. No significant difference was observed in terms of angiographic characteristics between the two groups. Contrast volume in between the groups was pretty similar (p = 0.267). Procedure time (40±20 min vs. 41±7 min, p=0.36) and fluoroscopy time (11.1±6.5 min vs. 12.5±8.7 min, p=0.19) were almost similar in both access for graft intervention. All PCI attempts were successful in both groups. Stent deployment was significantly more common in the TR access group. No significant difference was observed between the groups in terms of target vessel intervention. There was no major adverse cardiac event during hospitalization. However, the vascular access site complications were significantly lower (p=0.003) in the TRA group.&#x0D; Conclusion: The TRA for coronary artery bypass graft intervention is safe and feasible.&#x0D; Ibrahim Card Med J 2019; 9 (1&amp;2): 23-28

Echocardiographic assessment of left ventricular function recovery post percutaneous coronary intervention of chronic total occlusions in patients with low and mid-range left ventricular ejection fractions.

Coronary chronic total occlusion (CTO) is a frequent condition encountered in cardiac catheterization laboratory with a prevalence of about 20%. Through literature, data are scarcely reported regarding the left ventricular (LV) function recovery post CTO percutaneous coronary intervention (PCI) in patients with low (<40%) and mid-range (40%-49%) LV ejection fraction (LVEF). The aim of this study was to assess the echocardiographic outcomes of CTO patients with low and mid-range LVEF successfully revascularized at 6-month follow-up. This prospective study included 75 patients with at least one CTO of an epicardial coronary artery proved by previous diagnostic coronary angiography with PCI attempt indication, and successfully revascularized. They were equally divided according to LVEF into three groups, and echocardiographic remodeling indices were assessed at baseline and 6months post PCI. Our study showed significant improvement of LVEF, S-wave velocity by tissue doppler imaging (TDI), LV wall-motion score (LVWMS), and LV systolic sphericity index (LVSIS) 6months post CTO PCI in low LVEF group, and a significant improvement in LVEF, S-wave velocity, and LVWMS in mid-range LVEF group (P<.05). The delta change in LVEF was significantly more in low LVEF group, compared to the other two groups (F=4.739, P<.05). Successful CTO PCI in patients with low and mid-range LVEF is associated with significant improvement of LVEF and other indices of myocardial remodeling after 6months of follow-up.

Outcomes of subintimal plaque modification in chronic total occlusion percutaneous coronary intervention.

When crossing into the distal true lumen fails during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification (SPM) is often performed to restore antegrade flow and facilitate subsequent lesion recanalization. Between January 2012 and May 4, 2019, 4,659 CTO PCIs were included in the PROGRESS-CTO registry, of which 935 (20%) had a prior unsuccessful attempt. Of those 935 patients, 119 (13%) had prior SPM. We analyzed the outcomes of the 58 SPM procedures for which data were available, as well as the outcomes of the 60 subsequent CTO PCI attempts. Mean patient age was 67 ± 9 years and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%) diabetes (48%), prior PCI (61%), and prior coronary artery bypass graft surgery (47%). The target CTO lesions often had proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J-CTO score (mean 3.2 ± 1.1). The technical and procedural success of subsequent CTO PCI were high (83% for both) with an acceptable rate of in-hospital major adverse cardiovascular events (3.3%). Technical and procedural success were higher for repeat attempts that were performed ≥60 days after the index CTO PCI (94% vs. 69%, p = .015). Median (interquartile range) subsequent procedure time was 147 (100, 215) min, contrast volume was 185 (150, 260) ml, and air kerma radiation dose was 2.5 (1.4, 4.2) Gray. Repeat CTO PCI attempts after SPM are associated with high likelihood for successful revascularization with acceptable risks.

Patient Characteristics Associated With Antianginal Medication Escalation and De-Escalation Following Chronic Total Occlusion Percutaneous Coronary Intervention.

Background Prior research has shown that providers may infrequently adjust antianginal medications (AAMs) following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Patient characteristics associated with AAM titration and the variation in postprocedure AAM management after CTO PCI across hospitals have not been reported. We sought to determine the frequency and potential correlates of AAM escalation and de-escalation after CTO PCI. Methods and Results Using the 12-center OPEN CTO registry (Outcomes, Patient Health Status, and Efficiency iN Chronic Total Occlusion Hybrid Procedures), we assessed AAM use at baseline and 6 months after CTO PCI. Escalation was defined as any addition of a new class of AAM or dose increase, whereas de-escalation was defined as a reduction in the number of AAMs or dose reduction. Angina was assessed 6 months after the index CTO PCI attempt using the Seattle Angina Questionnaire Angina Frequency domain. Potential correlates of AAM escalation (vs no change) or de-escalation (vs no change) were evaluated using multivariable modified Poisson regression models. Adjusted variation across sites was evaluated using median rate ratios. AAMs were escalated in 158 (17.5%), de-escalated in 351 (39.0%), and were unchanged at 6-month follow-up in 392 (43.5%). Patient characteristics associated with escalation included lung disease, ongoing angina, and periprocedural major adverse cardiac and cerebral events (periprocedural myocardial infarction, stroke, death, emergent cardiac surgery, or clinically significant perforation), whereas de-escalation was more frequent among patients taking more AAMs, those treated with complete revascularization, and after treatment of non-CTO lesions at the time of the index procedure. There was minimal variation in either escalation (median rate ratio, 1.11; P=0.36) or de-escalation (median rate ratio, 1.10; P=0.20) compared to no change of AAMs across sites. Conclusions Escalation or de-escalation of AAMs was less common than continuation following CTO PCI, with little variation across sites. Further research is needed to identify patients who may benefit from AAM titration after CTO PCI and develop strategies to adjust these medications in follow-up. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02026466.

Hybrid coronary revascularization: Midterm outcomes of robotic multivessel bypass and percutaneous interventions

ObjectiveThe purpose of this study was to investigate the outcomes of patients undergoing advanced hybrid coronary revascularization, defined as robotic beating-heart multivessel totally endoscopic coronary artery bypass combined with percutaneous coronary intervention. MethodsThis is a retrospective study. Among 308 consecutive patients who underwent totally endoscopic coronary artery bypass, 57 who underwent advanced hybrid coronary revascularization (mean age, 65.6 years) from July 2013 to September 2017 were included. Midterm survival and freedom from major adverse cardiac events, including death, myocardial infarction, and repeat revascularization, were analyzed. ResultsMultivessel totally endoscopic coronary artery bypass was successfully performed without conversion to thoracotomy. Bilateral internal thoracic artery grafting was used in 50 patients (87.7%). The mean operative time was 318.4 ± 51.0 minutes. The mean length of hospital stay was 3.0 ± 1.3 days. There was no 30-day mortality. Percutaneous coronary intervention was planned after totally endoscopic coronary artery bypass in 51 patients (89.4%). The target lesions were the right coronary artery only in 38 patients, the left circumflex artery only in 4 patients, and multiple lesions in 13 patients. Eventually, 2 patients did not receive percutaneous coronary intervention. Percutaneous coronary intervention attempt was unsuccessful in 8 lesions. Patency of the left/right internal thoracic artery was 95.2% (60/63) and 95.7% (45/47), respectively. Graft patency was 95.2% (40/42) in the left circumflex artery and 93.3% (14/15) in the diagonal branch. Three-year survival was 92.8%, and 3-year freedom from major adverse cardiac events was 80.2%. ConclusionsAdvanced hybrid coronary revascularization is a safe and less-invasive approach with short hospital stay and good midterm outcomes.

Interventional Management of "Balloon-Uncrossable" Coronary Chronic Total Occlusion: Is There Any Way Out?

It has been estimated that coronary chronic total occlusion (CTO) is encountered in 15 to 20% patients referred for coronary angiography (CAG). The success of percutaneous coronary intervention (PCI) of CTO can be attributed to the vast array of hardware that has now become available and also to the vastly enhanced operator expertise. It is however realistic to state that despite the tremendous increase in the rate of success, there then comes a subset of CTO where PCI attempts fail. The reason for such failures given that other variables remain constant is the inability to cross the CTO lesion. This can be due to a failure to cross the lesion with a guide wire (despite guide wire escalation). The second cause of failure is the inability to cross the lesion with a balloon (balloon-uncrossable [BU] CTO). This can occur despite the successful placement of a guidewire in the distal true lumen. The BU lesions contribute 2% to 10% of CTO PCI failure cases. The author attempts to present a creative solution to assist crossing such lesions.

Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients With Low Left Ventricular Ejection Fraction

ObjectivesThe study sought to assess the outcome of percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) in patients with low left ventricular ejection fraction (LVEF) (≤35%). BackgroundData regarding the outcome of PCI in patients with low LVEF affected by CTO are scarcely reported. MethodsThe authors performed a prospective longitudinal multicenter study including consecutive patients undergoing elective PCI of CTOs. Patients were subdivided into 3 groups: group 1 (LVEF ≥50%), group 2 (LVEF 35% to 50%), and group 3 (LVEF ≤35%). ResultsA total of 839 patients (mean 64.6 ± 10.5 years of age, 87.7% men) underwent CTO PCI attempts. Baseline LVEF ≤35% was present in 72 (8.6%) patients. The angiographic success was high (overall 93.6%) and similar among the 3 groups (93.5% vs. 94.4% vs. 91.7%, respectively; all p = NS). In group 3, no periprocedural complications of CTO PCI were observed. Mean clinical follow-up of 16.3 ± 8.2 months duration was available in 781 (93.1%) patients including those with LVEF ≤35%. At 2 years, major cardiac and cerebrovascular events (MACCE) free survival was similar in the 3 groups (86% vs. 82.8% vs. 75.2%; all p = NS). In patients with LVEF ≤35%, LVEF improved significantly in the presence of a successful CTO PCI from 29.1 ± 3.4% to 41.6 ± 7.9% (p < 0.001). ConclusionsIn CTO patients with low LVEF, PCI could represent a safe and effective revascularization strategy achieving good midterm outcome and LVEF improvement.

Accuracy of J-CTO Score Derived From Computed Tomography Versus Angiography to Predict Successful Percutaneous Coronary Intervention

ObjectivesThe aim of this study was to compare the ability of conventional versus computed tomography angiography (CTA) to predict procedural success and 30-min wire crossing rates in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. BackgroundCoronary CTA can be used to assess the morphology of CTO lesions. MethodsWe examined 205 consecutive patients (218 CTO lesions) who underwent coronary CTA pre-PCI. The J-CTO (Multicenter CTO Registry of Japan) score (the sum of the following 5 binary parameters: blunt proximal cap, calcification, bending >45°, and length of occluded segment >20 mm plus previously failed PCI attempt) was calculated using both CTA and conventional coronary angiography and compared. ResultsThe median patient age was 69 years (interquartile range: 62 to 75 years), 82.4% were male, and a retrograde approach was attempted in 72 (33.0%) cases. The procedural success rate of the CTO-PCI procedures was 82.6%, and 29.4% of cases achieved 30-min wire crossing. The areas under the curve of the CTA-derived J-CTO score for predicting procedural success and 30-min wire crossing were significantly greater than those derived from conventional angiography (0.855 vs. 0.698; p < 0.001 for procedural success and 0.812 vs. 0.692; p < 0.001, for 30-min wire crossing). In addition, the areas under the curve of CTA-derived evaluations of calcification, bending, and occlusion length were significantly higher than those of derived from angiography for predicting procedural success. ConclusionsThe CTA-derived J-CTO score was a more useful predictor of both procedural success and 30-min wire crossing than the J-CTO score derived from conventional angiography.

Further validation of the hybrid algorithm for CTO PCI; difficult lesions, same success.

To evaluate the success rates and outcome of the hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) by a single operator in two different clinical settings. We compared 279 consecutive CTO PCIs performed by a single, high-volume operator using the hybrid algorithm in two different clinical settings. Data were collected through the PROGRESS CTO Registry. We compared 145 interventions performed in a community program (cohort A) with 134 interventions performed in a referral center (cohort B). Patient in cohort B had more complex lesions with higher J-CTO (3.0 vs. 3.41; p<0.001) and Progress CTO (1.5 vs.1.8, P=0.003) scores, more moderate to severe tortuosity (38% vs. 64%; p<0.001), longer total occlusion length (25 vs. 40mm; p<0.001) and higher prevalence of prior failed CTO PCI attempts (15% vs. 35%; p=0.001). Both technical (95% vs. 91%; p=0.266) and procedural (94% vs. 88%; p=0.088) success rates were similar between the two cohorts despite significantly different lesion complexity. Overall major adverse cardiovascular events were higher in cohort B (1.4% vs. 7.8%; p=0.012) without any significant difference in mortality (0.7% vs. 2.3%, p=0.351). In spite of higher lesion complexity in the setting of a quaternary-care referral center, use of the hybrid algorithm for CTO PCI enabled similarly high technical and procedural success rates as compared with those previously achieved by the same operator in a community-based program at the expense of a higher rate of MACE.

Effect of Previous Failure on Subsequent Procedural Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention (from a Contemporary Multicenter Registry)

We sought to examine the impact of previous failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 1,213 consecutive patients who underwent 1,232 CTO PCIs from 2012 to 2015 at 12 US centers. Mean age was 65 ± 10years, and 84.8% of patients were men. A previously failed attempt had been performed in 215 patients (17.5%). As compared with patients without previous CTO PCI failure, patients with previous failure had higher Multicenter CTO Registry in Japan CTO score (2.40 ± 1.13 vs 3.28 ± 1.29, p<0.0001) and were more likely to have in-stent restenosis (10.5% vs 28.4%, p <0.0001) and to undergo recanalization attempts using the retrograde approach (41% vs 50%, p= 0.011). Technical (90% vs 88%, p= 0.390) and procedural (89% vs 86%, p= 0.184) success were similar in the 2 study groups; however, median procedure time (125 vs 142minutes, p=0.026) and fluoroscopy time (45 vs 55minutes, p= 0.015) were longer in the previous failure group. In conclusion, a previously failed CTO PCI attempt is associated with higher angiographic complexity, longer procedural duration, and fluoroscopy time, but not with the success and complication rates of subsequent CTO PCI attempts.

Comparison of procedural complications and in-hospital clinical outcomes between patients with successful and failed percutaneous intervention of coronary chronic total occlusions: a meta-analysis of observational studies.

Multiple attempts to pass guidewires and balloons across totally occluded segments may result in significant mechanical trauma and higher rates of coronary complications in patients undergoing PCI (percutaneous coronary intervention) for CTOs (chronic total occlusion). It is unknown whether these procedural complications affect short-term survival and in-hospital clinical outcomes after the PCI. The goal of this analysis was to clarify this issue by comparing the rates of adverse in-hospital clinical outcomes between successful and failed CTO-PCI groups. We performed a meta-analysis of 25 studies (16,490 patients) to determine the rates of in-hospital death, myocardial infarction (MI), major adverse cardiovascular events (MACE), and urgent CABG (coronary artery bypass grafting) for the successful and failed CTO-PCI groups. Compared to successful CTO PCI, failed CTO PCI procedures were associated with higher in-hospital mortality (1.44% versus 0.5%) [relative risk (RR) of 2.88, 95% confidence interval [CI] (1.96-4.24), P<0.001], a higher risk of in-hospital MACE (8.88% versus 3.75%) [RR of 2.25, CI (1.69-2.98), P<0.001], slightly higher risk of in-hospital MI (3.17% versus 2.4%) [RR of 1.35, CI (1.03-1.78), P=0.03] and increased need for urgent CABG (4.0% versus 0.5%) [RR of 6.67, CI (4.26-10.43), P<0.001]. Furthermore, higher rates of coronary perforations [RR of 5.0, CI (3.93-6.59), P<0.001] and cardiac tamponade [RR of 5.0, CI (1.97-12.69), P<0.001] were observed in the unsuccessful PCI arm. As compared to successful interventions, failed PCI attempts for CTOs appear to be associated with higher risk of adverse short-term clinical outcomes.