Successful Chronic Total Occlusion Recanalization Research Articles

Improvement of left ventricular function after successful chronic total occlusion recanalization in patients with evidence of ischemia by stress myocardial perfusion imaging

Backgroud: Several observational studies have suggested survival advantages after successful chronic total occlusion (CTO) recanalization by percutaneous coronary intervention (PCI). However, controversy persists and it is unclear whether CTO recanalization ameliorates left ventricular ejection fraction (LVEF), generally considered to be a predictor of mortality in patients with ischemic heart disease. Method: Enrolled were 88patients (67.5±8.6years old, 67males) having CTO lesions on their coronary arteries. In each patients, stress myocardial perfusion imaging (MPI) using Thallium-201 were performed before PCI. LVEF was assessed echocardiographically before and 6 months after PCI procedure. According to the results of PCI and preexisting ischemia, patients were divided into 4 groups as the followings; 1) recanalization(+) ischemia(+) group (n=55), 2) recanalization(+) ischemia(-) group (n=12), 3) recanalization(-) ischemia(+) group (n=7), 4) recanalization(-) ischemia(-) group (n=14) groups. Result: In the recanalization(+) ischemia(+) group, LVEF increased significantly 6 months after PCI (61.3±12.0%), compared with baseline (56.9±11.8%). However, such improvement of LVEF was not observed in the other three groups. View this table: Result of LVEF at baseline and follow up Conclusion: Stress MPI could be a good indicator of appropriate PCI to CTO lesions. It should be notified that recanalization of CTO site not responsible for myocardial ischemia dose not contribute to the left ventricular functional recovery.

Reversal of ischemia of donor artery myocardium after recanalization of a chronic total occlusion

Case reports have shown that an intermediate stenosis in the donor artery collateralizing the myocardium of a chronic total occlusion (CTO) can produce an ischemic fractional flow reserve (FFR) value which may revert to non-ischemic with CTO revascularization. A consecutive series of patients with severe angina in which a donor artery with intermediate stenosis (30-70%) had FFR measured before and after successful CTO recanalization were studied. Fourteen of 50 consecutive CTO patients with successful PCI fulfilled the study criteria. Eight had CTO of the right coronary artery (RCA), three circumflex (LCx), and three RCA and LCx. Left anterior descending artery was the donor artery in 13 and LCx in 1 patient. Of nine donor ischemic FFR patient's pre-PCI, six reverted to non-ischemic (FFR pre-PCI 0.76 ± 0.04 and 0.86 ± 0.03 post-PCI). Five patients had normal FFR in the donor artery pre- and post-CTO PCI. In patients with a CTO and an intermediate donor artery stenosis, the frequency of ischemia in the donor artery territory is relatively high and often normalized by successful CTO recanalization. These data recommend recanalizing the CTO first whenever possible as a preferred therapeutic strategy to avoid the need for PCI to the donor artery or multivessel bypass surgery.

ASSA13-15-9 A Meta-Analysis of Percutaneous Coronary Intervention For Chronic Total Coronary Occlusions Recanalization

<h3>Background</h3> Despite advances in procedural techniques and expertise, PCI for CTO recanalization in select patients remains a challenge. <h3>Objective</h3> To perform an evaluation (meta-analysis) on short-term and long-term prognosis of percutaneous coronary intervention (PCI) for patients with chronic total occlusions (CTO) recanalization. <h3>Methods</h3> Data sources included published studies from a search of PUBMED, ELSEVIER, and CLINICAL.COM from January 2000 to July 2012. Selected studies were either observational studies or randomised clinical trials that compared PCI treatment of CTO recanalization to medical management. The endpoints were analysed using pooled estimates for death, myocardial infarction (MI), coronary artery bypass surgery (CABG), angina symptoms, repeat revascularization, and major adverse cardiac events (MACE). <h3>Results</h3> Sixteen observational studies comparing outcomes after failed or successful CTO recanalization with PCI were included in the current analysis. Collectively, these studies enrolled 10,256 patients who were observed at an average follow-up period of 5 years. Patients with successful CTO recanalization demonstrated significantly reduced rates of all-cause death (P &lt; 0.00001), cardiac death (P &lt; 0.00001), MACE (P &lt; 0.0001), MI (P = 0.003), subsequent CABG (P &lt; 0.00001), and long-term repeat revascularization (P = 0.03). In addition, successful CTO improved quality of life (P = 0.0001), reduced both MACE (P &lt; 0.00001) and mortality (P = 0.004) in patients with multivessel disease, and resulted in a lower death rate in patients with single vessel disease (SVD; P = 0.02); although there was no difference in MACE events in patients with SAD. <h3>Conclusions</h3> PCI should be considered an effective option for the patients with CTO lesions.

Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: A meta‐analysis comparing successful versus failed percutaneous intervention for chronic total occlusion

Chronic total occlusions (CTOs) represent the most complex and challenging coronary lesions for percutaneous coronary intervention (PCI). PCI for a CTO is a high-risk procedure and the long-term benefits of a successful percutaneous CTO recanalization over the medical management (as a result of failed PCI) are not clear, as the studies have shown conflicting results in the past. The goal of this analysis was to clarify this issue by performing a meta-analysis of the available literature. Using major electronic databases, we searched for studies (randomized or observational) comparing death, major adverse cardiovascular events (MACE), myocardial infarction (MI), and target vessel revascularization (TVR) between patients who underwent PCI recanalization of CTOs versus those treated with medical management as a result of failed PCI attempts. We identified 23 observational studies comparing the desired clinical parameters between patients with successful CTO recanalization and those managed conservatively as a result of attempted but failed PCI. The total number of patients observed in all of the studies was 12,970 and the mean time of follow up was 3.7 ± 2.1 years. Our results indicated that successful recanalization of a CTO results in improved all-cause mortality (relative risk [RR] of 0.54, 95% confidence interval [CI] (0.45-0.65), P-value < 0.001), lower rates of MACE (RR of 0.70, 95% CI 0.60-0.83, P-value < 0.001) and reduced needs for subsequent bypass surgery (RR of 0.25, 95% CI (0.21-0.30), P-value < 0.001). The difference in long-term mortality remained statistically significant even after the adjustment for procedure related complications and in-hospital deaths. As compared to conservative management (as a result of failed intervention), successful PCI recanalization of a CTO appears to be associated with improved long-term clinical outcomes; however, randomized controlled trials (RCTs) are needed to further confirm these results.

Transient Impairment of Vasomotion Function After Successful Chronic Total Occlusion Recanalization

The aim of our study was to assess coronary vasomotion after successful revascularization of chronic total occlusion (CTO). It is largely unknown whether the recovery of anterograde flow after CTO recanalization with drug-eluting stent implantation affects vascular function in distal coronary segments. One hundred consecutive CTOs successfully treated with drug-eluting stents underwent coronary diameter measurement after intracoronary nitroglycerin injection 5, 20, and 35 mm distal to the stented coronary segment using 3-dimensional quantitative coronary angiography. In a subgroup of 14 patients, coronary vasomotion was tested in distal segments: incremental atrial pacing for endothelium-dependent cases; and intracoronary nitroglycerin injection for endothelium-independent cases. In another subgroup of 13 patients, distal vessels were assessed by intracoronary ultrasounds. Vessel diameters significantly increased at follow-up as compared to baseline values (2.0 ± 0.52 mm vs. 2.25 ± 0.50 mm, 1.76 ± 0.49 mm vs. 2.05 ± 0.58 mm, 1.54 ± 0.53 mm vs. 2.04 ± 0.58 mm, at each segment analyzed; p < 0.001). At baseline, distal segments failed to respond to both endothelium-dependent and -independent stimuli. At follow-up, atrial pacing induced vasoconstriction, whereas nitroglycerine administration resulted in significant vasodilation (p < 0.05). Intracoronary ultrasounds failed to show changes of the cross-sectional area of distal segments at follow-up angiography. Recanalization of CTO is followed by a hibernation of vascular wall at distal coronary segments that fail to respond to endothelium-dependent and -independent stimuli. Distal vessel diameter increases over time in the absence of positive remodeling and in spite of persistent endothelial dysfunction. This severe impairment of vasomotor tone after CTO reopening suggests that intracoronary ultrasound assessment is of paramount importance for the selection of stent size.

Abstract 17010: The Coronary Arteries Chronic Total Occlusion Recanalization Reduces Symptoms in Patients with Stabile Angina in Short- and Long-Term Observation

Objectives: Despite the ongoing technological progress and the introduction of more advanced equipment, chronic total occlusions (CTO) remains a challenge. Technical difficulties imply higher exposure to contrast media and radiation but clinical benefits of this procedure are not well defined. The goal of the study was to assess the influence of a successful recanalization of the coronary arteries chronic total occlusion on the reduction of angina symptoms and risk of major cardiovascular events (death, myocardial infarction, further revascularizations) in stable ischemic heart disease. Methods: The study group consists of 401 patients (72.8% men), age 65.5±10.0 years, who underwent the PCI of the CTO in I Department of Cardiology, Medical University of Gdansk, Poland. We analyzed frequency of major adverse cardiac events (MACE) and CCS angina class in patients with successful procedure (group 1) and failure (group 2). The data from the 6-months and 18-months follow up was collected over the phone calls and clinical visits. Results: There was significant difference in the prevalence of the angina symptoms between both groups in 6-month follow up (group 1 vs. group 2: 178 vs. 33, p&lt;0.01) and 18-month observation (group 1 vs. group 2: 145 vs. 11, p&lt;0.05). Moreover, the patients with ineffective recanalization of the CTO had to undergo the CABG much more often than the patients with effective recanalization in 6- and 18-months follow up (4.2% vs. 0,4%, p&lt;0,01 and 9.1% vs. 1.2%, p&lt;0,01, respectively). However there were no differences between the group 1 and group 2 in death, myocardial infarction and TVR or TLR frequency in 6-month follow up (respectively: 0 vs. 0; 2.3% vs. 1.4%; 13.6% vs.11.2%, all p=NS) and 18-month follow up (respectively: 1.9% vs. 2.1%; 3.9% vs. 2.8% and 23.6% vs. 14.7%, all p=NS). Conclusions: Successful recanalization of the coronary arteries CTO considerably decrease angina intensity. The patients with the successful recanalization of the CTO had less frequent CABG. There is no influence of CTO recanalization results on the mortality, risk of myocardial infarction and new revascularizations during 6- and 18-month observation.

Improved cardiac survival, freedom from mace and angina-related quality of life after successful percutaneous recanalization of coronary artery chronic total occlusions

BackgroundMost percutaneous recanalizations of coronary artery chronic total occlusion (CTO) are not attempted because of the skepticism on their long-term clinical benefit. We assessed the effect of percutaneous CTO recanalization procedures on long-term cardiac survival, freedom from MACE and angina-related quality of life (AQL). MethodsAll consecutive patients who underwent attempt of percutaneous native coronary artery CTO recanalization between 2003 and 2009 were included in the study. MACE was defined as combined cardiac death, myocardial infarction (MI) and target vessel revascularization (TVR). AQL was assessed by the Seattle Angina Questionnaire-UK-version (SAQ-UK). ResultsAmong 302 patients who received an attempt of percutaneous CTO recanalization, 237 (78%) had a successful procedure while in 65 (22%) the procedure failed. Overall intra-hospital complication rate was 3.0%, with no difference between the two groups. Median follow-up was 4.0years, during which 13 patients had a fatal cardiac event. Patients in whom the CTO recanalization procedure failed had a higher risk of cardiac death (HR 3.39; 95% CI 1.14–10.1;p=0.03; after propensity score adjustment, HR 2.83; 95% CI 0.89–8.96;p=0.07) and MACE (HR 5.40; 95% CI 2.71–10.5;p<0.001; adjusted HR 3.34; 95% CI 1.47–7.58;p=0.003) compared to patients with successful procedure. CTO recanalization significantly improved the AQL during follow-up: patients with successful procedure experienced less physical activity limitation (p=0.01), rarer angina episodes (p<0.001) and greater treatment satisfaction (p=0.03) compared to patients with failed procedure. ConclusionsPatients with successful CTO recanalization had a trend towards better cardiac survival and significant lower risk of MACE and improvement of AQL compared to patients with failed procedures.

Effectiveness of recanalization of chronic total occlusions: A systematic review and meta-analysis

Chronic total occlusion (CTO) recanalizations remain extremely challenging procedures. With improvements in technology and techniques, success rates for recanalization of CTO continue to improve. However, the clinical benefits of this practice remain unclear. The aim of the study was to determine the effectiveness of CTO recanalization on clinical outcomes. We performed a systematic review and meta-analysis of published studies comparing CTO recanalization to medical management. Data were extracted in duplicate and analyzed by a random effects model. We did not identify any randomized controlled trials or observational studies comparing CTO recanalization to a planned medical management. We did identify 13 observational studies comparing outcomes after successful vs failed CTO recanalization attempt. These studies encompassed 7,288 patients observed over a weighted average follow-up of 6 years. There were 721 (14.3%) deaths of 5,056 patients after successful CTO recanalization compared to 390 deaths (17.5%) of 2,232 patients after failed CTO recanalization (odds ratio [OR] 0.56, 95% CI 0.43-0.72). Successful recanalization was associated with a significant reduction in subsequent coronary artery bypass graft surgery (CABG) (OR 0.22, 95% CI 0.17-0.27) but not in myocardial infarction (OR 0.74, 95% CI 0.44-1.25) or major adverse cardiac events (OR 0.81, 95% CI 0.55-1.21). In the 6 studies that reported angina status, successful recanalization was associated with a significant reduction in residual/recurrent angina (OR 0.45, 95% CI 0.30-0.67). In highly selected patients considered for CTO recanalization, successful attempts appear to be associated with an improvement in mortality and with a reduction for the need for CABG as compared to failed recanalization. However, given the observational nature of the reviewed evidence, randomized clinical trials are needed to confirm these findings.

Practical use of duplex echo-guided recanalization of chronic total occlusion in the iliac artery

Although endovascular therapy for peripheral arterial disease has undergone tremendous changes, chronic total occlusion (CTO) remains a significant challenge for interventionalists. Failed CTO recanalization is predominately due to unsuccessful guidewire crossing. In particular, the unique characteristics of tortuous and deeply located large vessels in the retroperitoneal cavity create challenging endovascular procedures. Real-time guidance based on external direct vessel visualization might be a promising tool for successful recanalization of noncalcific CTO. Here, we describe the practical use of duplex echo-guidance during the procedural course of iliac CTO recanalization.

Novel high-frequency vibration approach for recanalization of difficult coronary and peripheral chronic total occlusions

Chronic total occlusions (CTOs) continue to be quite prevalent and still present as some of the most challenging lesions for the coronary and/or peripheral interventionalist. Recanalization success rates have been historically low and the potential for adverse events are typically higher than the more common procedures of angioplasty and stenting. At present, there are two paths to successful CTO recanalization; the subintimal approach and the central lumen approach. The subintimal approach tracks a standard guidewire around the occlusion and through the subintimal plane, while the luminal approach attempts to recanalize the occlusion through the central lumen of the artery. After failure to stay in the true lumen, a bypass is essentially created around the occlusion through the adventitia. This may lead to adverse events. A central luminal approach may provide increased safety and more therapeutic options to the clinician and may ultimately deliver enhanced longer-term outcomes owing to the optimization ...

Quantifying the Early Health Status Benefits of Successful Chronic Total Occlusion Recanalization

Data on the health status benefits of percutaneous coronary intervention for coronary chronic total occlusions (CTOs), a principal indication for the procedure, are lacking. In the FlowCardia Approach to CTO Recanalization (FACTOR) trial, patients (n=125) completed the Seattle Angina Questionnaire (SAQ) at baseline and 1 month after percutaneous coronary intervenion. One-month health status outcomes were compared by multivariable analysis, adjusting for group differences between those whose CTO was successfully and unsuccessfully recanalized. These changes were also analyzed according to baseline symptoms. Procedural success was 55% (n=64) and independently associated with angina relief (difference between those with successful and unsuccessful percutaneous coronary intervention [Delta] in SAQ angina frequency=9.5 points; 95% confidence interval, 1.6 to 17.5; P=0.019), improved physical function (Delta in SAQ physical limitation=13.1 points; 95% confidence interval, 5.1 to 21.1; P=0.001), and enhanced quality of life (Delta in SAQ quality of life [QoL]=20.3 points; 95% confidence interval, 11.9 to 28.6; P<0.001). The benefit of successful percutaneous coronary intervention was greatest in symptomatic patients as compared with asymptomatic patients although statistically significantly so only for QoL (DeltaSAQ angina frequency domain=10.3 versus 4.3 points, P=0.51, Deltaphysical limitation =15.9 versus 6.3 points, P=0.25; DeltaQoL=27.3 versus 8.5 points, P=0.047). Successful CTO recanalization is associated with significant early improvements in patient symptoms, function, and QoL but only among symptomatic patients. Percutaneous treatment of a CTO offers the potential to provide significant health status benefits in symptomatic patients.

The Efficacy of a Bilateral Approach for Treating Lesions With Chronic Total Occlusions: The CART (Controlled Antegrade and Retrograde subintimal Tracking) Registry

The aim of this study was to evaluate the safety and feasibility of a new concept for chronic total occlusion (CTO) recanalization-using a bilateral approach that utilizes a Controlled Antegrade and Retrograde subintimal Tracking (CART) technique. Successful percutaneous recanalization of coronary CTOs results in improved long-term outcomes. The recanalization of CTOs in native coronary arteries no doubt represents one of the most technically challenging of interventional procedures. A total of 224 consecutive patients (mean age 61 +/- 9 years; 86.2% men) were enrolled in this prospective multicenter registry. This technique combines the simultaneous use of antegrade and retrograde approaches. A subintimal dissection is created in both antegrade and retrograde fashion, thereby limiting the extension of the subintimal dissection within the CTO portion. Of 224 CTO lesions (>3 months in duration) undergoing attempted recanalization using the CART technique, 145 cases (64.7%) had undergone previous CTO recanalization attempts. The success rates of crossing in a retrograde fashion with a wire and a balloon were 87.9% and 79.9%, respectively. The overall technical and procedural success rates achieved in this registry were 92.4% and 90.6%, respectively. A bilateral approach for CTO lesions using the CART technique is feasible, safe, and has a higher success rate than previous approaches. These results indicate that a bilateral technique can solve a major dilemma that commonly affects CTO procedures.

One-year follow-up of myocardial perfusion and function evaluated by gated SPECT MIBI in patients with earlier myocardial infarction and chronic total occlusion

Optimal treatment for chronic total occlusion (CTO) in the infarct-related coronary artery is not clear. Our aim was to assess myocardial perfusion, left ventricular ejection fraction (EF), and left ventricular size using gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging with 99mTc-methoxy-isobutyl-isonitrile in patients with CTO before and 1 year after recanalization. Thirty patients with earlier myocardial infarction and at least one CTO underwent percutaneous coronary intervention (PCI) as well as nitrate-enhanced gated SPECT myocardial perfusion and dobutamine stress echocardiography before and 11 +/- 1 months after recanalization. They were divided into three groups based on the outcome of the follow-up angiography: (i) successful recanalization with no evidence of in-stent restenosis (n=13); (ii) successful recanalization with in-stent restenosis (n=7) and (iii) unsuccessful recanalization (n=10). Overall success of recanalization for CTO was 74%. In group 1, myocardial viability was preserved in 11 of 13 (85%) patients at baseline. Gated SPECT at 1 year showed a significant decrease in perfusion abnormalities (29 +/- 12 to 23 +/- 14%, P < 0.05) and left ventricular end-diastolic volume (EDV) (168 +/- 47 to 151 +/- 47 ml, P < 0.05). Improvement in EF (51 +/- 11 to 54 +/- 13%, P > 0.05) and reduction in left ventricular end-systolic volume (ESV) (84 +/- 37 to 77 +/- 40 ml, P > 0.05) did not reach the level of significance. Myocardial viability was preserved in only two of seven patients (28%) in group 2. Neither mean perfusion abnormalities (37 +/- 24 to 35 +/- 22%, P > 0.05) nor global left ventricular parameters (EF 41 +/- 15 vs. 42 +/- 19%, EDV 298 +/- 33 vs. 299 +/- 57 mL, ESV 197 +/- 12 vs. 195 +/- 32 ml; P > 0.05) changed at the follow-up. In group 3, myocardial viability was preserved in seven of 10 patients (70%) at baseline, but no significant changes in perfusion (40 +/- 18 vs. 41 +/- 19%, P > 0.05) and left ventricular function (EF 42 +/- 17 vs. 44 +/- 14%, EDV 228 +/- 101 vs. 227 +/- 81 ml, ESV 143 +/- 87 vs. 146 +/- 8 ml; P > 0.05) were seen at the follow-up. Myocardial perfusion and EDV may significantly improve 1 year after PCI provided recanalization of CTO was successful. Our preliminary findings suggest that successful recanalization of CTO may have favorable outcome on left ventricular perfusion and function, particularly in patients with viable myocardium before PCI. The gated SPECT myocardial perfusion imaging with 99mTc-methoxy-isobutyl-isonitrile may be useful for monitoring long-term functional outcome of PCI in patients with CTO.

Abstract 2520: Drug-Eluting Stents for the Treatment of Chronic Total Occlusion: A Comparison with Sirolimus, Paclitaxel, Zotarolimus, EPC Capture and Everolimus-Eluting Stent: Multicenter Registry in Asia

The aim of this study is to compare the safety and efficacy of Sirolimus (SES), Paclitaxel (PES), Zotarolimus (ZES), EPC capture (ECS) and Everolimus-eluting stent (EES) on the outcome of patients with chronic total occlusion (CTO). A prospective analysis of 1149 patients with 1183 CTOs (396 SES, 526 PES, 177 ZES, 41 ECS, 43 EES) in five high volume Asian centers after successful recanalization of CTO was performed. The study endpoints were 30 days and 9 months major adverse cardiac events (MACE), 9 months angiographic restenosis and target lesion revascularization (TLR). See table for clinical results. The use of drug-eluting stents in patients with CTO was safe with low acute complication. Patients treated with SES and EES showed lesser rate of restenosis compared with other drug-eluting stents.

Abstract 3420: Effects on Myocardial Perfusion at 3 and 15 Months in Recanalized Chronic Total Occlusions - Randomized Comparison of Blood-Derived Progenitor Cells and Inactive Serum

Background: MRI is an excellent diagnostic tool for serial assessment of changes in myocardial perfusion, left ventricular function, and infarct size. In chronic total occlusions (CTO) the effects of recanalization on perfusion and function are contradictory and might depend primarily on viability. Circulating progenitor cells (CPC) injected intracoronarily after successful CTO recanalization might improve perfusion and function. Methods and results: Twenty-eight patients with reperfused CTO were randomized to either CPC’s or inactive serum (control), which were infused into the target vessel. First-pass myocardial perfusion MRI at rest and stress using adenosine at standard dose revealed a significant improvement of the myocardial perfusion reserve index (MPRI) in the affected segments. The baseline MPRI in affected segments was 1.50±0.17 in CPC versus 1.46±0.16 in control (p=0.62). In CPC the MPRI improved to 1.76±0.16 (p&lt;0.001) at 3 and 1.82±0.20 (p&lt;0.001) at 15 months; in control the change was 1.58±0.10 (p=0.01) at 3 and 1.61±0.08 (p=0.004) at 15 months follow-up. However, the MPRI recovery was significantly better in CPC as compared to control at 3 (p=0.004) and 15 months (p=0.005). In remote myocardium the MPRI was 1.70±0.30 and 1.69±0.25 (p&lt;0.01 versus affected segments), respectively. At follow-up there was no significant improvement for both groups. The change in MPRI at 3 and 15 months was correlated with a change in overall infarct size for CPC (3 months: r=−0.68, p&lt;0.02; 15 months: r=−0.81, p=0.001), whereas in control there was no correlation (r=−0.38, p=0.26; 15 months: r=−0.21, p=0.56). Infarct transmurality influenced MPRI improvement at follow-up. CPC patients had a trend towards more improved segments in particular those with higher transmurality (p=0.06). Conclusions: Analysis of serial contrast-enhanced MRI suggests that intracoronary application of CPC post recanalization of CTO is associated with improved myocardial perfusion and subsequent improved recovery of left ventricular function as compared to a control group at mid- and long-term follow-up. Further investigations of the pathophysiological CPC effects on macro- and microvascular function are required.