CTO Revascularization Research Articles

The evaluation of combined fractional flow reserve and dynamic SPECT in chronic total occlusion

BackgroundChronic total occlusion (CTO) is the most challenging subset in percutaneous coronary intervention (PCI), but the optimal selection of patients and indication for such procedures remain a subject of debate. We sought to investigate the role of physiological function in treatment decisions of CTO PCI by measuring fractional flow reserve (FFR) and Dynamic SPECT imaging in this study. MethodsAll the FFR of CTO vessel were measured before and immediately after CTO revascularization, and Dynamic SPECT imaging were detected before PCI in patients with an identified CTO. ResultsA total of 53 patients with single-vessel CTO lesions were included in this cohort study. The mean FFR value was 0.34 ± 0.09 at baseline. Immediately after successful CTO PCI, the FFR value significantly increased to 0.79 ± 0.11. The regional coronary flow reserve (CFR) of CTO vessels was 1.62 ± 0.64, which was significantly and positively correlated with the baseline FFR value (r = 0.607, p = 0.005). The area under the ROC curve of the baseline FFR for the detection of ischemia was 0.923 (p < 0.001). The diagnostic performance in terms of sensitivity and specificity was 83.3 % and 85.7 % for baseline FFR with a ROC-optimized cutoff value of 0.35. ConclusionsA significant correlation was found between the CFR derived from dynamic SPECT and baseline FFR. An FFR of <0.35 before CTO PCI can be taken as the cutoff for the presence of inducible ischemia, which was a useful index for therapy options.

Effects of a prior failed attempt on the outcomes of subsequent chronic total occlusion‐percutaneous coronary intervention

AbstractObjectivesPatients undergoing a prior failed attempt of chronic total occlusion‐percutaneous coronary intervention (CTO‐PCI) represent a challenging subgroup across all patients undergoing CTO‐PCI. There are limited data on the effects of a prior failed attempt on the outcomes of subsequent CTO‐PCI. We aimed to compare the procedural results and 24‐month outcomes of prior‐failed‐attempt CTO‐PCI with those of initial‐attempt CTO‐PCI.MethodsPatients who underwent attempted CTO‐PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 24‐month major adverse cardiac events (MACE) between patients who underwent prior‐failed‐attempt and initial‐attempt CTO‐PCI. MACE was defined as a composite of cardiac death, target vessel‐related myocardial infarction, and ischemia‐driven target vessel revascularization (TVR) during follow‐up.ResultsIn total, 484 patients who underwent CTO‐PCI (prior‐failed‐attempt, n = 49; initial‐attempt, n = 435) were enrolled during the study period. After propensity score matching (1:3), 147 patients were included in the initial‐attempt group. The proportion of the Japanese‐CTO (J‐CTO) score ≥2 was higher in the patients who underwent prior failed attempt than in those who underwent initial attempt (77.5% vs. 38.8%, p &lt; 0.001). The retrograde approach was more often adopted in the prior‐failed‐attempt group than in the initial‐attempt group (32.7% vs. 3.4%, [P&lt; 0.001). Successful CTO revascularization rates were significantly lower in the prior‐failed attempt‐group than in the initial attempt group (53.1% vs. 83.3%, P &lt; 0.001). The multivariate analysis revealed that J‐CTO score ≥2 [odds ratio (OR), 0.359; 95% confidence interval (CI), 0.159–0.812; P = 0.014], intravascular ultrasound procedure (OR, 4.640; 95% CI, 1.380–15.603; P = 0.013), and prior failed attempt (OR, 0.285; 95% CI, 0.125–0.648; P = 0.003) were the independent predictors for successful CTO revascularization. There were no significant differences in major procedural complications (2.0% vs. 0.7%, p = 0.438) and MACE rates (4.1% vs. 8.8%, p = 0.438) between the groups, mainly due to the TVR rate (4.1% vs. 8.2%, P = 0.522).ConclusionsCompared with initial‐attempt CTO‐PCI, prior‐failed‐attempt CTO‐PCI deserves more attention, since it is associated with a lower successful CTO revascularization rate. Prior failed attempt, J‐CTO score ≥2, and IVUS procedure are the determining factors for predicting successful CTO revascularization. There are no significantly different unfavorable outcomes between patients who undergo prior‐failed‐attempt and initial‐attempt CTO‐PCI.

Efficacy of virtual reality reducing anxiety during CTO revascularization: the ReViCTO trial design

Efficacy of virtual reality reducing anxiety during CTO revascularization: the ReViCTO trial design

Morphological Aspects and Treatment Strategies for Chronic Total Occlusions of the Coronary Arteries.

Coronary total occlusions are routinely found in patients suffering from chronic coronary artery disease. Their prevalence is between 20-50% and is higher in patients with prior coronary artery bypass surgery. Patients with CTOs have a higher risk profile, higher Syntax scores and in approximately 80% of the cases, a multi-vessel disease. Advances in technology that supports CTO-PCI and the increasing operator experience in high volume centers has raised important questions about the revascularization strategy. In the majority of cases, the treatment strategy for this group of patients should aim at achieving full revascularization. In this context CABG should be considered the first choice and percutaneous coronary intervention can be considered for patients with less advanced disease. It is not clear, whether successful CTO revascularization (CABG or PCI) have an impact on long-term outcomes. For these reasons, the treatment of patients in the presence of CTOs should be based on the current evidence on the treatment of multivessel coronary disease.

Antegrade revascularization of long-segment femoropopliteal chronic total occlusion

Although revascularization of a femoropopliteal (CTO) always remains challenging through a retrograde or contralateral crossover approach, we report a case of successful revascularization of a long-segment femoropopliteal CTO through antegrade femoral puncture which stands as the crux of the procedure. In routine peripheral intervention, long-segment femoropopliteal occlusion is usually approached from a contralateral femoral artery or ipsilateral brachial artery, antegrade revascularization of femoropopliteal CTO is not adapted by many in routine practice. Here, we describe the technique and the tips and tricks of antegrade puncture of common femoral artery. We will also discuss the literature review of antegrade technique versus retrograde and crossover technique for revascularization of femoropopliteal CTO which may be useful for budding young interventionists. Our case carries another important learning point about management of popliteal disease where revascularization with a stent is of concern due to high knee joint mobility.

Abstract 13895: Impact of Coronary Revascularization on Cardiopulmonary Performance in Patients With Coronary Chronic Total Occlusion

Background: —CTO PCI represents the tip of iceberg in interventional cardiology, however owing to lack of enough data, there is still debate about its benefit. CPET combines measurement of gas indices with standard exercise and ECG parameters giving a comprehensive way for patient evaluation also there is plenty of data about its use in many cardiovascular diseases and about its prognostic value in many occasions. So we thought of using CPET in evaluating value of CTO PCI on various CPET parameters. Hypothesis: CTO PCI improves cardiopulmonary performance evaluated by CPET. Methods: fifty nine patients underwent successful CTO PCI and CPET at baseline and at12 month follow up, of whom nine patients had suboptimal results in control angiography which is a higher than usual incidence of re-stenosis, we compared the results of the CPET pre and post-PCI in both groups. Results: In patent group, CPET at follow up revealed a significant increase of peak oxygen consumption (Peak VO 2 ) (13.47±1.53 ml/kg/min vs. 17.84±0.99 ml/kg/min p &lt;0.0001), VO 2 at anaerobic threshold (AT) (11.63 ± 1.14 ml/kg/min vs. 10.35 ±1.01ml/kg/min ( p &lt; 0.0001), peak oxygen pulse ( 16.02 ±1.34 vs. 11.15 ± 1.36, p &lt; 0.0001) and significant increase in peak cardiac index (3.78 ± 0.5 vs. 2.98 ±0.6, p &lt; 0.0001). Also there was significant decrease of Peak VE/VCO 2 (32.98 ± 3.2 vs. 42.98 ± 6.2, p &lt; 0.0001).In patients with re-stenosis, CPET at follow up revealed a significant decrease of peak oxygen consumption (Peak VO 2 ) (13.36±1.48 ml/kg/min vs. 12.41±0.97 ml/kg/min, p =0.02) and a significant increase of Peak VE/VCO 2 (42.73 ± 4.33 vs. 43.27 ± 3.29, p =0.01)also there was worse numerical values of other parameters despite not being statistically significant. Conclusions: CTO revascularization improves cardiopulmonary performance assessed by CPET in addition patients with re-occlusion after successful procedure had worse parameters even than their own baseline. CPET can provide a way for non-invasive follow-up of patients after PCI and earlier detection of in-stent re-stenosis that is more common in CTO.

Pericardial tamponade after chronic total occlusion revascularization: a case report and literature review

Pericardial tamponade is a complication of percutaneous coronary intervention (PCI) with extremely high mortality. The rupture of coronary artery causes hypotension and shock, eventually resulting in death due to pericardial tamponade. Because of the complex operation in revascularization of chronic total occlusion (CTO-PCI) lesion, the incidence of pericardial tamponade increases. Usually, we use coronary angiogram to identify the rupture of coronary artery after PCI by the contrast agent. We presented a 67-year-old woman with pericardial tamponade after CTO revascularization. She had chest pain and out of breath for nearly two years. The coronary angiogram showed three branch lesion and CTO lesion of the right coronary artery (RCA). After revascularization of the RCA CTO lesion, the pericardial effusion and low blood pressure occurred, but we didn't find the leak of contrast agents during the final angiography. Then the patient was transferred to cardiac surgery department for emergency thoracotomy. They found the hematoma on the surface of the RCA and finally discharged without any symptoms. Our case approved: (I) there was still the possibility of coronary artery rupture even the coronary angiogram showed no contrast agent leakage from the coronary artery after PCI; (II) the combined use of IVUS and coronary angiogram may improve the accuracy and safety of CTO revascularization procedure.

Management and outcomes of coronary artery perforations treated with the block and deliver technique

Coronary artery perforation (CAP) is a potentially life-threatening complication during percutaneous coronary interventions (PCI) and the best strategy for its management is yet to be proved. We aimed to analyze the safety, efficacy, and long-term clinical outcomes of the block and deliver (BAD) technique, as only anecdotal cases are reported in literature. From January 2016 to January 2020, all consecutive patients treated with the BAD technique at five high-volume centers in Italy were retrospectively identified. 25 CAPs treated with the BAD technique were included. The most frequently perforated artery was the left anterior descending artery (32%) and spring-coil wires with a hydrophilic coating were the most common culprit wires (68%). Mean sealing time was 46.9 ± 60.1min, with no significant differences between CTO-PCIs and non-CTO PCIs (p=.921). Acute successful sealing of the CAP was achieved in 96% of the cases. Immediate cardiac tamponade occurred in 28% of patients, four during CTO PCI and three during non-CTO PCI (p=.55). Two patients required pericardiocentesis during hospitalization, one patient developed acute kidney injury, and one patient underwent cardiac surgery due to severe mitral regurgitation. At 1-year follow-up no significant differences were observed between groups in terms of POCE (25 vs 25%, p=.628) and its individual components. The BAD technique proved to be effective for the management of CAP, showing high successful sealing rates. Rates of in-hospital events and at 1-year follow-up did not significantly differ between patients suffering CAP during CTO revascularization or during non-CTO PCI.

P966Clinical impact of target vessel on long term cardiac survival in patients with chronic total occlusion treated by percutaneous coronary intervention

Abstract Background Chronic total occlusions (CTOs) occur in 15–35% of patients with significant coronary artery disease who undergo coronary angiography. The rationale of percutaneous CTO revascularization is the improvement in survival and in quality of life, mainly reducing angina symptoms and increasing LVEF. The clinical impact of target vessel has been investigated in previous studies, with controversial results. Purpose The aim of this study, based on a large scale single-center registry, is to determine the impact of different target vessel successful CTO percutaneous coronary intervention (PCI) on long-term survival in a “real world” population. Methods All consecutive patients who attempted a CTO-PCI from 2004 to 2015 in our Hospital department were included in a CTO-PCI Registry. CTO was defined as a coronary obstruction with TIMI flow grade 0 with an estimated duration of &gt;3 months. Patients with multiple CTO were excluded. Long-term mortality was assessed by Kaplan-Meier and Cox multivariable analysis. Results A total of 1235 patients attempted PCI for CTO; patients were stratified into two main groups according to the CTO carrying vessel: LAD-CTO (n=360) and not-LAD CTO (n=875). Cardiac survival rate at 5 years was lower in LAD-CTO patients compared with not-LAD CTO patients (85±3% vs. 90±2%; p=0.001), but when a successful CTO-PCI was achieved, there was no statistical difference between the two groups (89±3% vs. 93±1%; p=0.095). On the other side, a failure of the CTO PCI in LAD vessel was associated with a worse outcome (67±8% vs. 85±4%; p=0.001). Completeness of revascularization carried a significant survival benefit independently from the target vessel CTO (LAD CTO group 94±2% vs. not-LAD CTO group 95±1%; p=0.256), but an incomplete revascularization was associated with a worse outcome in LAD-CTO patients (67±6% vs. 81±4%; p&lt;0.001). By multivariable Cox analysis, age &gt;75 years, diabetes, left ventricular ejection fraction &lt;40%, complete revascularization and LAD-CTO were independently related to death. Conclusions In a “real world” population, LAD-CTOs were associated with a lower cardiac survival rate when compared to other vessel CTOs; however, this survival gap was no longer significant when a successful CTO PCI was performed. The survival benefit was even greater when a complete coronary revascularization was achieved.

Surgical Revascularization of Chronically Occluded Coronary Arteries-What You See Is What You Get?

Revascularization strategy in coronary artery bypass grafting (CABG) surgery usually depends on coronary dimension and stenosis severity. Little is known about the relation of preoperative evaluation of scarcely or invisibly chronic occluded coronary arteries (chronic total occlusion [CTO]) and revascularization rate or anastomosis quality. We aimed to evaluate the success rates of CTO revascularization in CABG surgery and determine the influence of coronary lumen visibility and collateralization in preoperative angiograms on revascularization rates, bypass blood flow, and target vessel diameter. Preoperative coronary angiograms were evaluated for 938 consecutive patients who underwent isolated CABG surgery between 2014 and 2016 and screened for occluded coronary arteries. The occluded vessels were scored for visibility using the Rentrop grading of collateral filling. Intraoperatively, dimensions of the occluded arteries were measured using conventional vessel probes, and anastomosis quality was assessed by transit time flow measurement. A total of 404 (43.1%) patients were identified with at least one CTO. Revascularization rates differed from 96.2% in the left anterior descending artery, to 85.0% in left circumflex artery-dependent vessels, and 78.8% in right coronary artery territory. Coronary visibility and grade of collateralization in the preoperative angiogram had no influence on intraoperatively measured coronary diameter. Bypass blood flow in grafts revascularizing CTOs lacking collateralization were not significantly lower than those grafts leading to CTOs with higher Rentrop scores. Preoperative coronary assessment often differs from intraoperative findings. Our study confirms that even patients with scarcely collateralized CTOs and impaired visibility in the coronary angiogram have a high chance of complete revascularization during CABG surgery.

TCTAP C-090 Complete Revascularization of LAD Long CTO by Segmented and Staged Canalization

### Patient Initials or Identifier Number Mr. Xu ### Relevant Clinical History and Physical Exam The 51-year-old Mr. Xu had type 2 DM and HTN, hyperlipidemia and smoking history, he had palpitation for 10 years, and reduced exercise for 1 year. He received health exam with 256 slice coronary CT

Bioresorbable vascular scaffolds for percutaneous treatment of chronic total coronary occlusions: a meta-analysis

BackgroundBRS represent a new approach to treating coronary artery disease. Beneficial properties of BRS regarding the restoration of vasomotility after resorption make them attractive devices in CTO revascularization. However, experience in this setting is limited.MethodsWe systematically searched Medline, Scholar, and Scopus for reports of at least 9 patients with CTO undergoing BRS implantation. Patients’ and procedural characteristics were summarized. The primary outcome of interest was target lesion revascularization (TLR). Pooled estimates were calculated using a random-effects meta-analysis. The study protocol was registered in PROSPERO (CRD42017069322).ResultsThirteen reports for a total of 843 lesions with a median follow-up of 12 months (IQR 6–12) were included in the analysis. At short-term, the summary estimate rate of TLR was 2.6% (95% CI: 1 to 4%, I2 = 0%, P = 0.887) while at mid to long-term it was 3.8% (95% CI: 2 to 6%, I2 = 0%, P = 0.803). At long-term follow-up (≥12 months), the summary estimate rate of cardiac death was 1.1% (95% CI: 0 to 2%, I2 = 0%, P = 0.887). The summary estimate rates of scaffold thrombosis and clinical restenosis were respectively 0.9% (95% CI: 0 to 2%, I2 = 0%, P = 0.919) and 1.8% (95% CI: 0 to 4%, I2 = 0%, P = 0.448). Finally, the summary estimate rate of target vessel revascularization was 6.6% (95% CI: 0 to 11%, I2 = 0%, P = 0.04).ConclusionsImplantation of BRS in a population with CTO is feasible, although further longer-term outcome studies are necessary.

TCT-685 The improvement of left ventricular function after CTO revascularization—a strain echocardiography based study

TCT-685 The improvement of left ventricular function after CTO revascularization—a strain echocardiography based study

The effect of revascularization of a chronic total coronary occlusion on electrocardiographic variables. A sub-study of the EXPLORE trial

IntroductionChronic total coronary occlusions (CTOs) have been associated with a higher prevalence of ventricular arrhythmias compared to patients without a CTO. We evaluated the effect of CTO revascularization on electrocardiographic (ECG) variables. MethodsWe studied a selection of ST-elevation myocardial infarction patients with a concomitant CTO enrolled in the EXPLORE trial. ECG variables and cardiac function were analysed at baseline and at 4 months follow-up. ResultsPatients were randomized to percutaneous coronary intervention (PCI) of their CTO (n = 77) or to no-CTO PCI (n = 81). At follow-up, median QT dispersion was significantly lower in the CTO PCI group compared to the no-CTO PCI group (46 ms [33–58] vs. 54 ms [37–68], P = 0.043). No independent association was observed between ECG variables and cardiac function. ConclusionRevascularization of a CTO after STEMI significantly shortened QT dispersion at 4 months follow-up. These findings support the hypothesis that CTO revascularization reduces the pro-arrhythmic substrate in CTO patients.

TCTAP C-157 Challenging Revascularization of Coronary In-stent CTO: Never Celebrate Too Early

TCTAP C-157 Challenging Revascularization of Coronary In-stent CTO: Never Celebrate Too Early

Retrograde revascularization of ostial left main CTO using internal mammary artery byepass graft: A case report

Retrograde revascularization of ostial left main CTO using internal mammary artery byepass graft: A case report

Rationale and indications for coronary chronic total occlusion interventions

AbstractChronic total occlusions (CTOs) are commonly found in patients with coronary artery disease and are considered the “final frontier” of coronary intervention. Despite growing interest in percutaneous coronary intervention (PCI) of CTOs along with advances in techniques and equipment, attempt rates remain low. This is most likely due to the fact that CTO PCI remains technically challenging and requires higher resource utilization. Furthermore, there remains controversy regarding the actual clinical benefit of successful CTO PCI. However, there have been a growing number of studies reporting short‐ and long‐term outcomes of CTO revascularization. We therefore sought to review the evidence and potential clinical benefits of successful CTO PCI.Answer questions and earn CME: https://www.wileyhealthlearning.com/Activity2/3691380/Activity.aspx

The haemodynamic effects of collateral donation to a chronic total occlusion: Implications for patient management

Physiological lesion assessment in the form of Fractional Flow Reserve (FFR) is now well established for the purpose of guiding multi-vessel revascularization. Chronic total coronary occlusions are frequently associated with multi-vessel disease and the collateral dependent myocardium distal to the occlusion is often supplied by a collateral supply from another epicardial coronary artery. The haemodynamic effect of collateral donation upon collateral donor vessel flow may have important implications for the vessel's FFR; rendering it unreliable at predicting ischaemia should the CTO be revascularized. As a consequence, in the setting of multi-vessel disease, optimal revascularization strategy might be altered. There is a paucity of work in the medical literature directly examining this phenomenon. We endeavoured to review the existing literature related to it, to summarise from current knowledge of coronary physiology what is known about the potential effects of CTO revascularization on both collateral flow and collateral donor vessel physiology, and to highlight where further studies might inform practice.

TCTAP C-102 Usefulness of Guide-Extension Device in Retrograde Approach for Coronary Chronic Total Occlusion

### Patient initials or identifier number HT ### Relevant clinical history and physical exam A 60’s gentleman referred to our hospital for revascularization of RCA CTO. He had undergone PCI for proximal LAD due to unstable angina 5 months before. His coronary risk factors were hypertension,

TCTAP C-083 Is Retrograde the Only Hope of Revascularization of CTO After Failed Antegrade Attempt?

### Patient initials or identifier number 6044270 ### Relevant clinical history and physical exam This 61-year-old patient has a history of hypertension and dyslipidemia. He suffered from angina and CAG at other hospital showed a 1-vessel disease but RCA total occlusion. He was referred to our