Successful Chronic Total Occlusion Recanalization Research Articles

TCT-168 TIcaGrEloR and ABSORB Bioresorbable Vascular Scaffold implantation for recovery of vascular function after successful Chronic Total Occlusion recanalization

Coronary vascular function of a chronic coronary total occlusion (CTO) immediately after recanalization is demonstrated to be poor. We aim to explore role of Ticagrelor vs. Clopidogrel in improving vascular function in this context. The TIGER BVS is a prospective, double-randomized, open-label, two

Case Report: RETROGRADE APPROACH FOR CTO LESIONS: SERIAL CASE

Chronic total occlusion recanalization still represents the final frontier in percutaneous coronary intervention. Successful revascularization is associated with improved long-term survival, reduced symptoms, improved left ventricular function and reduced need for coronary bypass surgery. Retrograde chronic total occlusion recanalization has recently become an essential complement to the classic antegrade approach. Retrograde approach through the collateral channel has been recently proposed and has the potential to improve the success rate of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lession of the coronary arteries. We report several cases of successful CTO recanalization procedure using retrograde approach in Soetomo Hospital.

Comparison of Benefit of Successful Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients With Versus Without Reduced (≤40%) Left Ventricular Ejection Fraction

Successful recanalization of chronic total occlusions (CTO) has been associated with improved survival. Data on outcomes in patients with left ventricular (LV) systolic dysfunction undergoing percutaneous coronary intervention for CTO, however, are scarce. Between January 2005 and December 2013, a total of 2,002 consecutive patients undergoing elective CTO percutaneous coronary intervention at a tertiary care center were divided into patients with (LV ejection fraction ≤ 40%) and without (LV ejection fraction > 40%) LV systolic dysfunction as defined by transthoracic echocardiography. The primary end point was all-cause mortality. Median follow-up was 2.6 (1.1 to 3.1) years. A total of 348 (17.4%) patients had LV dysfunction. All-cause mortality was higher in patients with LV dysfunction (30.2%) than in those with normal LV function (8.2%, p <0.001), and associations remained significant after adjustment for baseline differences (adjusted hazard ratio [HR] 3.39, 95% confidence interval [CI] 2.57 to 4.47, p <0.001). Successful CTO recanalization was independently associated with reduced all-cause mortality, with similar relative risk reductions in both the preserved (6.6% vs 16.9%, adjusted HR 0.48, 95% CI 0.34 to 0.70, p <0.001) and the reduced LV function groups (26.2% vs 45.2%, adjusted HR 0.63, 95% CI 0.41 to 0.98, p = 0.04, interaction p = 0.28). In conclusion, irrespective of LV function, successful CTO recanalization is associated with a clear survival benefit.

Outcomes of patients with periprocedural atrial fibrillation undergoing percutaneous coronary intervention for chronic total occlusion

Successful CTO recanalization has been associated with clinical benefit. Outcomes of patients with atrial fibrillation undergoing CTO PCI have not been investigated, yet. This study sought to evaluate the association between atrial fibrillation and outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Consecutive patients undergoing CTO PCI between January 2005 and December 2013 were divided into patients with and without atrial fibrillation, and propensity-matched models used to adjust for baseline differences between groups. The primary outcome was all-cause mortality at a median follow-up of 3.2 (interquartile range 3.1-4.5) years. Of 2002 patients undergoing CTO PCI, atrial fibrillation was present in 169 (8.4%) patients. Patients with atrial fibrillation were older, and more frequently had hypertension, left ventricular systolic dysfunction, and chronic kidney disease. Before matching, all-cause mortality was 39.6 and 14.5% in the atrial fibrillation and the sinus rhythm groups (HR 2.92, 95% CI 2.23-3.82, p<0.001). In the propensity-matched model, atrial fibrillation remained associated with an increased risk of mortality (HR 1.62, 95% CI 1.06-2.47, p=0.03). In the unmatched patient cohort, all-cause mortality was significantly reduced in patients with procedural success, both in the atrial fibrillation (34.9 versus 55.0%, adjusted HR 0.99, 95% CI 0.97-1.00, p=0.02) and the sinus rhythm groups (12.8 versus 23.0%, adjusted HR 0.70, 95% CI 0.53-0.92, p=0.01). Although atrial fibrillation is independently associated with mortality after CTO PCI, substantial survival benefit of successful CTO recanalization is observed in both patients with and without atrial fibrillation.

Predicting Successful Recanalization in Patients with Native Coronary Chronic Total Occlusion: The Busan CTO Score

Background: The optimal strategy to manage chronic total occlusion (CTO) remains unclear. The Japanese CTO multicenter registry (J-CTO) score is an established tool for predicting successful recanalization. However, it does not take into account nonangiographic predictors for final technique success. In the present study, we designed and tested a scoring model called the Busan single-center CTO registry (B-CTO) score combining clinical and angiographic characteristics to predict successful CTO recanalization in Korean patients. Methods: Prospectively enrolled CTO patients (n = 438) undergoing coronary intervention (1999-2015) were assessed. The B-CTO score comprises 6 independent predictors: age 60-74 years and lesion length ≥20 mm were assigned 1 point each, while age ≥75 years, female gender, lesion location in the right coronary artery, blunt stump, and bending >45° were assigned 2 points each. For each predictor, the points assigned were based on the associated odds ratio by multivariate analysis. The lesions were classified into 4 groups according to the summation of points scored to assess the probability of successful CTO recanalization: easy (score 0-1), intermediate (score 2-3), difficult (score 4-5), and very difficult (score ≥6). CTO opening was designated as the primary endpoint regardless of the interventional era or the skill of the operator. Results: The final success rate for B-CTO was 81.1%. The probability of successful recanalization for patient groups classified as easy (n = 64), intermediate (n = 148), difficult (n = 134), and very difficult (n = 92) was 95.3, 86.5, 79.1 and 65.2%, respectively (p for trend <0.001). When compared to the J-CTO, the B-CTO score demonstrated a significant improvement in discrimination as indicated by the area under the receiver-operator characteristic curve (AUC 0.083; 95% CI 0.025-0.141), with a positive integrated discrimination improvement of 0.042 and a net reclassification improvement of 56.0%. Conclusions: The B-CTO score has been designed and validated in Korean patients with native coronary CTO and is an improved tool for predicting successful recanalization. Wider application of the B-CTO score remains to be explored.

Randomized Multicenter Trial Investigating Angiographic Outcomes of Hybrid Sirolimus-Eluting Stents With Biodegradable Polymer Compared With Everolimus-Eluting Stents With Durable Polymer in Chronic Total Occlusions: The PRISON IV Trial

ObjectivesThe aim of this study was to investigate the efficacy and safety of the hybrid ultrathin-strut sirolimus-eluting stent (SES) with biodegradable polymer compared with the thin-strut everolimus-eluting stent (EES) with durable polymer in successfully recanalized chronic total occlusions (CTOs). BackgroundThe introduction of drug-eluting stents revolutionized the treatment of CTOs. However, limited data are available on new-generation drug-eluting stents with biodegradable polymer in CTOs. MethodsIn this multicenter trial, patients were randomized, after successful CTO recanalization, to either SES or EES. The primary noninferiority endpoint was in-segment late lumen loss (noninferiority margin 0.2 mm). Secondary endpoints included in-stent late lumen loss and clinical endpoints. ResultsOverall, 330 patients were included. At 9 months, angiography was available in 281 patients (85%). Duration of occlusion ≥3 months was 92.5%, with mean stent length of 52.4 ± 28.1 mm versus 52.3 ± 26.5 mm in the SES and EES groups. The primary noninferiority endpoint, in-segment late lumen loss, was not met for SES versus EES (0.13 ± 0.63 mm vs. 0.02 ± 0.47 mm; p = 0.08, 2-sided; difference 0.11 mm; 95% confidence interval: −0.01 to 0.25 mm; pnoninferiority = 0.11, 1-sided). In-stent late lumen loss was comparable between SES and EES (0.12 ± 0.59 mm vs. 0.07 ± 0.46 mm; p = 0.52). The incidence of in-stent and in-segment binary restenosis was significantly higher with SES compared with EES (8.0% vs. 2.1%; p = 0.028), with comparable rates of reocclusions (2.2% vs. 1.4%; p = 0.68). Clinically indicated target lesion and target vessel revascularization (9.2% vs. 4.0% [p = 0.08] and 9.2% vs. 6.0% [p = 0.33]), target vessel failure (9.9% vs. 6.6%; p = 0.35), and definite or probable stent thrombosis (0.7% vs. 0.7%; p = 1.00) were comparable between the SES and EES groups. ConclusionsThis randomized trial failed to show noninferiority of hybrid SES relative to EES in terms of in-segment late lumen loss in successfully recanalized CTOs. Furthermore, a statistically significantly higher rate of binary restenosis was found with SES.

Durable polymer versus bioabsorbable polymer drug eluting stents in right coronary artery chronic total occlusions: Eighteen months (median) results of a single-center experience

Objective: There are a few data regarding the long-term clinical outcomes of durable polymer (DP) drug-eluting stents (DES) versus bio absorbable polymer (BP) drug-eluting stents treatment in patients with right coronary artery (RCA) chronic total occlusion (CTO). The aim of this study was to compare the clinical outcomes of these stents according to their polymer-based difference. Methods: Between June 2013 and August 2016, 66 RCA CTO patients enrolled in the study. Fortyseven patients with successful CTO recanalization of RCA via ante grade or retrograde approach using either DP (n=25) and BP (n=22) were scheduled for 6, 12, and 18 months clinical follow-up. Primary clinical outcomes were cardiac death and major adverse cardiac events (MACE). Results: RCA CTO success rate was 71%. There was no difference in Japanese-CTO (JCTO) scores between two groups. Total stent length was longer in BP group, and it was statistically significant (p=0.015). The incidence of cardiac death was not significant between the two groups. After propensity score matching, TVR rates were 12.0% for DP group and 9.1% for BP group at the end of the 18th month (hazard ratio [HR]=0.815; 95% confidence interval [CI]=0.123–5.418; p=0.832) and composite MACE rates were 16.0% for DP group and 15.0% for BP group (hazard ratio [HR]=0.926; 95% confidence interval [CI]=0.182–4.718; p=0.927). Conclusion: This study shows that the efficacy of BP-DES is comparable to that second-generation DP-DES treatment for RCA CTO over 18-month follow-up.

TCT-61 Long-term Outcomes of Patients with Left Ventricular Dysfunction Undergoing Percutaneous Coronary Intervention for Chronic Total Occlusion

We assessed long-term outcomes in patients with left ventricular dysfunction undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Background: Successful CTO recanalization has been associated with improved survival. Data on outcomes in high-risk patients with left

Long-Term Follow-Up of Patients With Previous Coronary Artery Bypass Grafting Undergoing Percutaneous Coronary Intervention for Chronic Total Occlusion

Successful revascularization of chronic total occlusions (CTOs) has been associated with clinical benefit. Data on outcomes in patients with previous coronary artery bypass grafting (CABG) undergoing percutaneous coronary intervention (PCI) for CTO, however, are scarce. A total of 2,002 consecutive patients undergoing PCI for CTO from January 2005 to December 2013 were divided into patients with and without previous CABG, and outcomes were retrospectively assessed. The primary outcome measure was all-cause mortality. Median follow-up was 2.6 years (interquartile range 1.1 to 3.1). A total of 292 patients (15%) had previous CABG; they were older and had a greater prevalence of comorbidities. Procedural success was achieved in 75% and 84% of patients in the previous CABG and the non-CABG groups (p <0.001), respectively. All-cause mortality was 16% and 11% in the previous CABG and the non-CABG groups (p= 0.002), and differences were mitigated after adjustment for baseline characteristics (adjusted hazard ratio [HR] 1.22, 95% confidence interval [CI] 0.86 to 1.74, p= 0.27). All-cause death was significantly reduced in patients with procedural success, both in the previous CABG (11% vs 32%, adjusted HR 0.43, 95% CI 0.24 to 0.77, p= 0.005) and the non-CABG groups (10% vs 20%, adjusted HR 0.63, 95% CI 0.45 to 0.86, p= 0.004), with similar mortality benefits associated with successful revascularization in both groups (interaction p= 0.24). In conclusion, the relative survival benefit of successful recanalization of CTO is independent of previous CABG. However, owing to a greater baseline risk, the absolute survival benefit of successful CTO procedures is more pronounced in patients with previous CABG than in non-CABG patients.

Impact of the Intracoronary Rendezvous technique on coronary angioplasty for chronic total occlusion.

The Rendezvous technique, which requires bidirectional wiring, is one of the useful methods for improving the success rate of recanalization for chronic total occlusion (CTO) in the field of peripheral intervention. Recently, advanced new devices for percutaneous coronary intervention have enabled us to perform the Rendezvous technique for peripheral as well as for coronary CTO lesions. We used the Intracoronary Rendezvous technique to perform angioplasty for coronary CTO. "Intracoronary Rendezvous" means that Rendezvous was achieved within the CTO lesion. From March 2009 to November 2015, 189 patients underwent CTO angioplasty at our institute, and we treated 10 patients with the Intracoronary Rendezvous technique. This technique involves crossing the Gaia series guidewire to the contralateral Corsair microcatheter located inside the plaque of CTO lesions. The majority of the CTO sites examined were in the proximal RCA (60%). Lesion length of the occlusion was relatively long (64.4±12.2mm). Using the biplane imaging system, we were able to control the Gaia guidewires in a specific direction. Furthermore, if the antegrade and retrograde wires can be advanced into contiguous space inside the CTO lesion, we intentionally entered either wire into the contralateral Corsair microcatheter, followed by successful CTO crossing. CTO recanalization was completed for all patients without controlled antegrade retrograde subintimal tracking (CART) or reverse CART. No major complications occurred during hospitalization. These results indicate that the Rendezvous technique, assisted by new devices and a biplane imaging system, represents one of the primary options to achieve successful coronary CTO recanalization.

CMR Guidance for Recanalization of Coronary Chronic Total Occlusion

ObjectivesThis study explored whether cardiac magnetic resonance (CMR) could help select patients who could benefit from revascularization by identifying inducible myocardial ischemia and viability in the perfusion territory of the artery with chronic total occlusion (CTO). BackgroundThe benefit of revascularization using percutaneous coronary intervention (PCI) in CTO is controversial. CMR offers incomparable left ventricular (LV) systolic function assessment in addition to potent ischemic burden quantification and reliable myocardial viability analysis. Whether CMR guided CTO revascularization would be helpful to such patients has not yet been explored fully. MethodsA prospective study of 50 consecutive CTO patients was conducted. Of 50 patients undergoing baseline stress CMR, 32 (64%) were selected for recanalization based on the presence of significant inducible perfusion deficit and myocardial viability within the CTO arterial territory. Patients were rescanned 3 months after successful CTO recanalization. ResultsAt baseline, myocardial perfusion reserve (MPR) in the CTO territory was significantly reduced compared with the remote region (1.8 ± 0.72 vs. 2.2 ± 0.7; p = 0.01). MPR in the CTO region improved significantly after PCI (to 2.3 ± 0.9; p = 0.02 vs. baseline) with complete or near-complete resolution of CTO related perfusion defect in 90% of patients. Remote territory MPR was unchanged after PCI (2.5 ± 1.2; p = NS vs. baseline). The LV ejection fraction increased from 63 ± 13% to 67 ± 12% (p < 0.0001) and end-systolic volume decreased from 65 ± 38 to 56 ± 38 ml (p < 0.001) 3 months after CTO PCI. Importantly, despite minimal post-procedural infarction due to distal embolization and side branch occlusion in 8 of 32 patients (25%), the total Seattle Angina Questionnaire score improved from a median of 54 (range 45 to 74) at baseline to 89 (range 77 to 98) after CTO recanalization (p < 0.0001). ConclusionsIn this small group of patients showing CMR evidence of significant myocardial inducible perfusion defect and viability, CTO recanalization reduces ischemic burden, favors reverse remodeling, and ameliorates quality of life.

Reducing radiation in chronic total occlusion percutaneous coronary interventions.

The field of percutaneous intervention for chronic total occlusion (CTO) has enjoyed significant innovations in the recent years. Novel techniques and technologies have revolutionized the field and have resulted in considerably higher success rates even in patients with high anatomical complexity. Successful CTO recanalization is associated with significant clinical benefits, such as the improvement of angina and quality of life, reduced rates of surgical revascularization, improvement of left ventricular function and decreased mortality rates. However, complex CTO procedures often require prolonged x-ray exposure which have been associated with adverse long term outcomes.

Role of CT Coronary Angiography in Recanalization of Chronic Total Occlusion

Chronic total occlusion (CTO) is considered as the most challenging frontier in interventional cardiology and the last one to be conquered. With availability of state of the art hardware, wires and catheters in particular and increased skills of the operators, the success rate for recanalization of CTO by percutaneous catheter intervention (PCI) has improved. Yet the complications rate and longterm adverse events are high, mostly due to failure in tracking or navigation of hardware through the occluded CTO segment, prolonged exposure to radiation and high doses of contrast used. Therefore, proper selection of patient is of utmost importance. One of the major challenges for successful CTO recanalization is satisfactory visualization of the occluded CTO segment. Conventional invasive catheterization fails to fill the gap and the shortcomings and handicaps of such invasive imaging can be resolved with the use of non-invasive CT coronary angiography (CTCA). CTCA helps to better define the morphological features of the occluded CTO segment, which are established predictors of success, like the actual length of the occluded segment and any calcification or tortuosity in its course. Integration of reconstructed three-dimensional CT coronary images with twodimensional fluoroscopic images, offers directional guide to select the best angiographic plane for visualization of angiographically “missing segment”. With advances in CT technology, CTCA has now become an established technology for pre-procedure evaluation of CTO segment, thereby help in planning and execution of successful PCI.

In-hospital and long-term outcomes after percutaneous coronary intervention for chronic total occlusion in elderly patients: A consecutive, prospective, single-centre study

Elderly patients are increasingly referred for complex percutaneous coronary interventions (PCI), including recanalization of chronic total occlusion (CTO). To assess the feasibility, safety and clinical benefits associated with CTO-PCI in elderly patients. Consecutive patients (n=356) who underwent CTO-PCI in our institution between January 2008 and December 2011 were prospectively included. The short-term outcomes of CTO-PCI were assessed by comparing the rates of successful recanalization and postoperative complications in patients aged ≥ 75 years and those < 75 years. The clinical effect of successful recanalization was evaluated in a 20-month follow-up analysis in patients ≥ 75 years. Although patients ≥ 75 years (n = 93) had more complex coronary artery disease, the procedural success rate was similar to that in younger patients (78.2% vs. 74.3%, respectively; P = 0.41). Postoperative complications were more frequent in older patients (5.4% vs. 0.4%; P = 0.005). Major adverse cardiac event-free survival analysis at 20 months revealed that successful revascularization was indicative of a better prognosis in older patients (hazard ratio: 0.43, 95% confidence interval: 0.19-0.96; P = 0.039). Elderly patients have more complex coronary disease and are at a higher risk of postoperative complications. Nevertheless, we observed a similar success rate for CTO-PCI in elderly patients as for younger patients. Successful CTO recanalization improved the event-free survival rate at 20 months. Thus, CTO-PCI constitutes an alternative strategy for treating selected elderly patients.

Improvement of regional and global left ventricular function in magnetic resonance imaging after recanalization of true coronary chronic total occlusions.

Successful recanalization of true chronic total occlusion (CTO) has been linked to a decrease in cardiac mortality. We evaluated the effect of CTO recanalization on LVEF and regional wall motion using paired cardiac magnetic resonance imaging (cMRI) studies. 43 patients underwent contrast enhanced cMRI prior to and 9 months after successful recanalization of a true CTO defined as thrombolysis in myocardial infarction flow 0 and duration of occlusion of more than 3 months. Regional wall motion was analyzed using the AHA model. For each segment the wall thickness (WT) was measured over the duration of one heart cycle and segmental wall thickening (SWT) was calculated. Left ventricular ejection fraction (LVEF) and volumes were measured. LVEF significantly increased by 2.4 ± 6.0% (p = 0.01). The increase was confined to patients with baseline LVEF below the median of 49.3% (4.1 ± 7.0%, p = 0.01) compared to 0.6 ± 4.0 (p = 0.48) in patients with baseline LVEF higher than the median. Segmental wall motion analysis was performed in 706 myocardial segments. SWT significantly increased in segments within the perfusion territory of the CTO vessel (5.1 ± 30.4%, p = 0.01), especially in dysfunctional segments at baseline with SWT(init) <45% (13.3 ± 24.3%, p < 0.001). In addition, SWT significantly increased in segments of non-CTO vessels (4.1 ± 32.1%, p < 0.01). In conclusion, in patients with successful recanalization of CTO left ventricular ejection fraction and regional wall motion are significantly improved, especially in patients with decreased LVEF and in dysfunctional segments.

Avoid overtreatment in the setting of chronic total occlusions: The role of blood flow restoration in positive vascular remodeling

A coronary chronic total occlusion (CTO) promotes negative remodeling in distal segments by negative vascular wall remodeling and plaque growth [ [1] Park J.J. Chae I.H. Cho Y.S. et al. The recanalization of chronic total occlusion leads to lumen area increase in distal reference segments in selected patients: an intravascular ultrasound study. JACC Cardiovasc. Interv. Aug 2012; 5: 827-836 Crossref PubMed Scopus (31) Google Scholar ]. As a result, epicardial coronary segments located distal to a CTO appear often as diffusely diseased arteries [ [2] Werner G.S. Schwarz G. Prochnau D. et al. Paclitaxel-eluting stents for the treatment of chronic total coronary occlusions: a strategy of extensive lesion coverage with drug-eluting stents. Catheter. Cardiovasc. Interv. 2006; 67: 1-9 Crossref PubMed Scopus (46) Google Scholar ]. It is unknown if these lesions are related to clinical events at follow-up and if they require percutaneous coronary intervention (PCI) with stenting, because blood flow restoration by recanalisation potentially leads to positive vascular remodeling in the distal reference segments [ [3] Gasparini G.L. Rossi M.L. Presbitero P. Follow-up improvement of distal vessel diameter after successful chronic total coronary occlusion recanalization. JACC Cardiovasc. Interv. Apr 2014; 7: e31-e33 Crossref PubMed Scopus (4) Google Scholar ]. Few data have been published to investigate the role of blood flow restoration in remodeling process after successful CTO PCI. A study of Park et al. [ [1] Park J.J. Chae I.H. Cho Y.S. et al. The recanalization of chronic total occlusion leads to lumen area increase in distal reference segments in selected patients: an intravascular ultrasound study. JACC Cardiovasc. Interv. Aug 2012; 5: 827-836 Crossref PubMed Scopus (31) Google Scholar ] showed that recanalization of a CTO led to lumen area increase in two-thirds of the patients. Independent predictors of lumen area increase were occlusion duration, a poor collateral flow and statin use. The degree of collateral flow might reflect the magnitude of hemodynamic stimuli deprivation, whereas the CTO duration correlates with the time in which vessels undergo a negative remodeling process. In a study of Galassi et al. [ [4] Galassi A.R. Tomasello S.D. Crea F. et al. Transient impairment of vasomotion function after successful chronic total occlusion recanalization. J. Am. Coll. Cardiol. Feb 21 2012; 59: 711-718 Crossref PubMed Scopus (70) Google Scholar ] authors have suggested that improvement of distal vessel diameter after CTO recanalization can be explained by an impaired endothelium-dependent and/or -independent vasomotion immediately after CTO recanalization, that improves at follow-up, or by a positive remodeling or by a combination of both. Gomez-Lara et al. [ [5] Gomez-Lara J. Teruel L. Homs S. et al. Lumen enlargement of the coronary segments located distal to chronic total occlusions successfully treated with drug-eluting stents at follow-up. EuroIntervention. Feb 2014; 9: 1181-1188 Crossref PubMed Scopus (32) Google Scholar ] have documented a notable late lumen enlargement between baseline and follow-up. These findings can be explained either by the absence of vasomotor response to non-endothelium-mediated stimuli immediately after the procedure and plaque regression. At follow-up, endothelium-independent response was restored in most patients, showing a remarkable luminal gain compared to the index procedure.

TCT-191 Health-related quality of life, Functional status and Myocardial ischemia in patients with successful chronic total occlusion recanalization

TCT-191 Health-related quality of life, Functional status and Myocardial ischemia in patients with successful chronic total occlusion recanalization

RETRACTED ARTICLE: Meta-analysis of the effect of percutaneous coronary intervention on chronic total coronary occlusions

Background and purposeCoronary chronic total occlusion (CTO) is the last stage of coronary artery atherosclerosis. Percutaneous coronary intervention (PCI) is a therapeutic procedure used to recanalize vessels with total occlusion. However, successful recanalization of CTO is still not optimal, and the key influence factors are still uncertainty. Therefore, a scientific evaluation on the effective of PCI for CTO treatment is necessary.MethodsRelevant studies of PCI treatment for CTO were examined. Data were extracted and assessed by two independent clinical experts. Embase, PubMed and Medline et al. were used as database. The main research key words include “CTO”, “PCI”, “Stent”, “Reopen”, “long-term”, “follow-up” and “outcome”. Quality assessment was carried out according to the Cochrane Handbook. The selected data were pooled and analyzed using fixed-effect model and random-effect model. Heterogeneity was assessed using the I2 test, Q test, L’abbe and Galbraith. Comprehensive Meta -Analysis 2.0 and Metanalysis 1.0 were used for statistics analysis in this research.ResultsA total of 16 articles involving 6695 cases in successful CTO recanalization (CTO success group) and 2370 cases in failed CTO recanalization(CTO failure group) were included in this research. Low CTO success was associated with elder age, previous coronary artery bypass graft surgery (CABG) history, multi-vessel diseases and right coronary artery disease lesion. Six follow-up variables including major adverse cardiac events (MACE), recurrent myocardial infarction (MI), all-cause death, incidence of angina, subsequent CABG and cumulative survival rate were found significantly reduced associated with CTO success.ConclusionsClinical baseline characteristics such as age, previous CABG history and lesion baseline characteristics such as lesion length, multi-vessel diseases might be important factors influencing the successful rate of CTO recanalization. Compared to CTO failure patients, all six follow-up variables showed advantage for CTO success patients.

Evaluation of the effect of concurrent chronic total occlusion and successful staged revascularization on long-term mortality in patients with ST-elevation myocardial infarction.

Aims. To investigate the impact of chronic total occlusion (CTO) in non-infarct-related artery (IRA) on the long-term prognosis and evaluate the clinical significance of staged revascularization in patients with ST-segment elevation myocardial infarction (STEMI). Methods. 1266 STEMI patients with primary percutaneous coronary intervention (PCI) were categorized as single-vessel disease (SVD), multivessel disease (MVD) without and with CTO. We study the clinical outcomes of patients after primary PCI in the following 3 years. Additionally, patients with CTO received staged revascularization, and major adverse cardiac events (MACE) during 3-year follow-up were recorded. Results. Presence of CTO was a predictor of both early mortality [hazard ratio (HR) 3.4, 95% confidence interval (CI) 2.4–4.5, P < 0.01] and late mortality (HR 1.9, 95% CI 1.4–3.6, P < 0.01), whereas MVD without CTO was only a predictor of early mortality (HR 1.7, 95% CI 1.3–2.3, P < 0.05). In CTO group, 100 patients had successful CTO recanalization, and 48 patients failed. During 3-year follow-up, patients with failed procedure had higher cardiac mortality (22.9% versus 9.0%, P = 0.020) and lower MACE-free survival (50.0% versus 72.0%, P = 0.009) compared to patients with successful procedure. Conclusion. The presence of CTO and not MVD alone is associated with long-term mortality. Successful revascularization of CTO in the non-IRA is associated with improved clinical outcomes in patients with STEMI undergoing primary PCI.

慢性期内頚動脈完全閉塞に対する脳血管内治療

EC-IC bypass based on the inclusion criteria of Japanese EC-IC Bypass Trial (JET study) is recommended for chronic total occlusion (CTO) of the internal carotid artery (ICA). But patients who do not meet the inclusion criteria of the JET study are also entitled to the best possible medical treatment. Recently several authors have reported the successful endovascular recanalization of CTO of the ICA. We report 10 cases of symptomatic CTO of the ICA that did not meet the inclusion criteria of the JET study that were treated by endovascular recanalization. Cerebral angiogram showed complete occlusion of the ICA and opacification of the cavernous segment of ICA or the more proximal portion of the ICA via collateral channels. Xenon CT (Xe-CT) showed hemodynamic compromise in all cases. The endovascular procedure was performed by proximal balloon protection of the common carotid arery and the external carotid artery via transfemoral route under local anesthesia. The occlusion of the ICA was recanalized successfully in all cases. Carotid artery stenting (CAS) was performed in eight cases identified as occlusion at the cervical ICA, and percutaneous transluminal angioplasty (PTA) with stenting using coronary stents was performed in two cases identified as occlusion at the cavernous or petrous ICA. Neither new ischemic symptoms nor hyperperfusion syndrome appeared after treatment. Endovascular recanalization of symptomatic CTO of the ICA can be considered as an alternative treatment for patients who do not meet the inclusion criteria of the JET study.