Revascularization Of Coronary Total Occlusions Research Articles

Clinical and Angiographic Outcomes With Sirolimus-Eluting Stents in Total Coronary Occlusions: The ACROSS/TOSCA-4 (Approaches to Chronic Occlusions With Sirolimus-Eluting Stents/Total Occlusion Study of Coronary Arteries-4) Trial

We sought to examine angiographic and clinical outcomes with sirolimus-eluting stents (SES) in total coronary occlusion (TCO) revascularization. Despite evaluation of drug-eluting stents beyond approved indications, few studies have evaluated their clinical benefit in TCO revascularization. Among 15 centers in North America, 200 consecutive TCO patients (78.8% >6 weeks TCO age) were enrolled for treatment with SES. The primary end point was 6-month angiographic binary restenosis within the treated segment. Patient characteristics included: diabetes, 24.5%; prior infarction, 33.5%; and stent length, 45.9 mm median (quartile 1, 30.2 mm; quartile 2, 62.1 mm). A total of 199 patients (99.5%) were treated with SES, and procedural success was 98.0%. The 6-month binary restenosis rates were 9.5% in-stent, 12.4% in-segment, and 22.6% in-"working length" representing the entire treatment segment. Rates of 1-year target lesion revascularization, myocardial infarction, and target vessel failure were 9.8%, 1.0%, and 10.9%, respectively. Stent thrombosis occurred in 2 patients (1.0%). Using logistic regression modeling with propensity score adjustment, the absolute reduction in binary restenosis with SES compared with a historical bare-metal stent control was 37.7% (95% confidence interval [CI]: 27.2% to 48.3%, p < 0.001; odds ratio: 0.17, 95% CI: 0.09 to 0.30, p < 0.0001). Among 32 patients (16%) identified with stent fracture, target lesion revascularization was more common than patients without fracture (25.0% vs. 6.7%, p = 0.005). Despite greater lesion complexity than prior TCO trials, percutaneous revascularization with SES appears safe and results in substantial reductions in angiographic restenosis and failed patency and a low rate of repeat revascularization. These findings support the use of SES in TCO revascularization. (The ACROSS/TOSCA Trial; NCT00378612).

Angiographic suitability for catheter revascularization of total coronary occlusions in patients from a community hospital setting

To assess the frequency of totally occluded coronary arteries and their angiographic suitability for catheter-based revascularization in an unselected patient population, all coronary angiograms showing ≥50% diameter stenosis obtained from patients in a community hospital setting, were reviewed during a 1-year period. There were 112 totally occluded arteries in 101 patients (35%). Based on coronary morphologic variables previously identified as predictive of successful revascularization, 52 (46%) totally occluded arteries were judged suitable for coronary angioplasty. Totally occluded arteries with unfavorable features for coronary angioplasty were present in 29% of patients with multivessel coronary artery disease and were more commonly present in the right coronary artery. Thus totally occluded coronary arteries are found in approximately one third of patients with suspected or known coronary artery disease studied by means of coronary arteriography in a community hospital setting. Approximately one half of the total occlusions have features favoring successful coronary angioplasty.

New option for balloon recanalization of total coronary occlusions

In 9 out of 12 patients with a total coronary occlusion but definite signs of viable myocardium a new approach for the recanalization procedure was successfully employed: Following recanalization using an on-the-wire 2.0 or 2.5 mm angioplasty catheter, a standard coronary guidewire was placed along the angioplasty catheter. After withdrawal of the catheter, over-the-wire angioplasty with an appropriately sized balloon was performed for final dilatation. Pending further studies in a larger patient population, this new method may offer an alternative approach for revascularization of total coronary occlusions.