Total Occlusion Research Articles

Ten-Year Outcome of Recanalization or Medical Therapy for Concomitant Chronic Total Occlusion After Myocardial Infarction.

The EXPLORE (Evaluating Xience and Left Ventricular Function in PCI on Occlusions After STEMI) trial was the first and only randomized trial investigating chronic total occlusion (CTO) percutaneous coronary intervention (PCI) early after primary PCI for ST-segment-elevation myocardial infarction, compared with medical therapy for the CTO. We performed a 10-year follow-up of EXPLORE to investigate long-term safety and clinical impact of CTO PCI after ST-segment-elevation myocardial infarction, compared with no-CTO PCI. In EXPLORE, 302 patients post-ST-segment-elevation myocardial infarction with concurrent CTO were randomized to CTO PCI within ≈1 week or no-CTO PCI. We performed an extended clinical follow-up for the primary end point of major adverse cardiac events, consisting of cardiovascular death, coronary artery bypass grafting, or myocardial infarction. Secondary end points included all-cause death, angina, and dyspnea. Median follow-up was 10 years (interquartile range, 8-11 years). The primary end point occurred in 25% of patients with CTO PCI and in 24% of patients with no-CTO PCI (hazard ratio [HR], 1.11 [95% CI, 0.70-1.76]). Cardiovascular mortality was higher in the CTO PCI group (HR, 2.09 [95% CI, 1.10-2.50]), but all-cause death was similar (HR, 1.53 [95% CI, 0.93-2.50]). Dyspnea relief was more frequent after CTO PCI (83% versus 65%, P=0.005), with no significant difference in angina. This 10-year follow-up of patients post-ST-segment-elevation myocardial infarction randomized to CTO PCI or no-CTO PCI demonstrated no clinical benefit of CTO PCI in major adverse cardiac events or overall mortality. However, CTO PCI was associated with a higher cardiovascular mortality compared with no-CTO PCI. Our long-term data support a careful weighing of effective symptom relief against an elevated cardiovascular mortality risk in CTO PCI decisions. URL: https://www.trialregister.nl; Unique identifier: NTR1108.

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion

PurposeThis retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting. MethodsThis treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1–P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter. ResultsForty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period. ConclusionThe endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

Procedural Results and Long-term Outcome of Chronic Total Occlusion Percutaneous Coronary Intervention in a UK Non-surgical Centre.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has evolved a great deal over recent years, with increased procedural success and lower complication rates being reported. This study aims to evaluate the feasibility, safety and success of a dedicated CTO programme in a large UK PCI centre without on-site cardiothoracic surgery facilities. Clinical and procedural data were retrospectively collected for consecutive unselected patients undergoing CTO PCI between 2015 and 2019 from the local database and regional electronic patient records. In-hospital outcomes and long-term major adverse cardiovascular events (all-cause mortality, MI, stroke and target vessel revascularisation) were recorded. A total of 170 patients underwent 191 CTO procedures during the study period. The mean age was 63 ± 10 years and 80.6% of patients were male (n=137). The clinical indications were: stable chronic coronary syndromes in 88.5% (n=169) of patients; staged procedures in the context of acute coronary syndromes in 1.6% (n=3); and presentation with acute coronary syndrome in 9.9% (n=19). The procedural success rate was 50.0% (n=25) for general interventional cardiologists and 90.1% (n=127) for dedicated CTO operators. In-hospital major adverse cardiovascular events occurred once (0.5%) and interhospital transfer for emergency salvage cardiac surgery was not required. Long-term follow-up data at a median duration of 3.8 years revealed 4 (2.4%) cardiac deaths, 14 (8.3%) spontaneous MI events and 10 (5.9%) target vessel revascularisations. These data suggest CTO PCI using contemporary techniques is both safe and effective when undertaken in a high-volume non-surgical centre by experienced operators.

Retrograde Peroneal Artery Approach to Treat Infra-Inguinal Arterial Chronic Total Occlusions: A Multicentre Experience and Technical Considerations.

Background/Objectives: Retrograde access of the peroneal artery (PA) is considered technically challenging and at risk of bleeding. The aim of this multicentre retrospective study was to assess the safety, feasibility, and technical success of this access route for infrainguinal endovascular recanalizations. Methods: We retrospectively analyzed 186 consecutive patients treated over a 7-year period (May 2014-August 2021) who underwent endovascular recanalization of infra-inguinal lesions using a PA access route. In all cases, retrograde PA access was obtained following a failed attempt to cross the occlusion via the antegrade route. Results: Among the 186 patients, 120 were males (60.5%) and the mean age was 76.8 ± 10.7 years old (44-94 years). One hundred and thirteen patients (60.7%) suffered from chronic limb threatening ischemia (CLTI). All patients presented with chronic total occlusions (CTO) and a failed conventional antegrade recanalization attempt. Retrograde access was performed under angiographic guidance in 185 cases (99.5%). It was successfully established in 171 cases (91.9%). The total rate of retrograde puncture-related complications was 2.1% (two puncture site bleedings of which one necessitated fasciotomy and two cases of arteriovenous fistulas managed conservatively). The Major Adverse Event (MAE) rate at 30 days was 1.6% (3/186). Conclusions: Retrograde recanalization of challenging infra-inguinal lesions via PA is safe and effective in experienced hands.

Double set up technique as a bailout of diagonal branch coronary perforation: a case report

Coronary artery perforation is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). A 55-year-old male with a history of implanted stent on the left main ostium to the proximal left circumflex artery (LCX) and distal right coronary artery, and chronic total occlusion (CTO) on ostium left anterior descending (LAD). PCI was performed using a stiff wire to cross the CTO body in LAD. We performed an injection and confirmed the presence of extravasation. We successfully managed to stop the bleeding by placing the tips of floppy wire that were cut into pieces. A drainage pathway was made through thoracotomy for pericardial effusion. Angiography showed persisting extravasation at the wire insertion site. We then made our own covered stent. We implanted on the osteal LAD until proximal LCX. Repeated angiography showed no contrast extravasated from the perforation site, and the patient was stabilized and discharged.

Quantitative coronary computed tomography assessment for differentiating between total occlusions and severe stenoses

BackgroundsThe impact of quantitative assessment to differentiate total occlusions (TOs) from severe stenoses on coronary computed tomography angiography (CCTA) remains unknown. ObjectiveThis study investigated whether quantitative characteristics assessed on CCTA could help differentiate a TO from a severe stenosis on invasive coronary angiography (ICA). MethodsThis study is a sub-analysis of the FASTTRACK CABG (NCT04142021) in which both CCTA and ICA were routinely performed. Quantitative analysis was performed with semi-automated CCTA plaque-analysis software. Blinded analysts compared TOs on CCTA, defined as a complete lack of contrast opacification within the coronary occlusion, with corresponding ICA. ResultsEighty-four TOs were seen on CCTA in 59 of the 114 patients enrolled in the trial. The concordance in diagnosing a TO between ICA and CCTA was 56.0% (n ​= ​47). Compared to severe stenoses, TOs had a significantly longer lesion length (25.1 ​± ​23.0 ​mm vs 9.4 ​± ​11.2 ​mm, P ​< ​0.001). The best cut-off value to differentiate a TO from severe stenosis was a lesion length of 5.5 ​mm (area under the curve 0.77, 95% CI: 0.66–0.87), with a 91.1% sensitivity and 61.1% specificity. Dense calcium percentage atheroma volume (PAV) was significantly higher in TOs compared to severe stenoses (18.7 ​± ​19.6% vs. 6.6 ​± ​13.0%, P ​< ​0.001), whilst the opposite was seen for fibro-fatty PAV (31.3 ​± ​14.2% vs. 19.5 ​± ​10.5%, P ​< ​0.001). On a multivariable logistic regression analysis, lesion length (>5.5 ​mm) was the only parameter associated with differentiating a TO from a severe stenosis. ConclusionIn quantitative CCTA analysis, a lesion length >5.5 ​mm was the only independent predictor differentiating a TO from a severe stenosis. NCT registration numberNCT04142021.

The Impact of Radial Vs Femoral Access on Vascular Complications and Patients Outcomes in Complex PCI

Background: Percutaneous coronary intervention (PCI) is a primary treatment modality for coronary artery disease, particularly in complex cases involving multivessel disease, chronic total occlusions, or bifurcation lesions. The choice of vascular access site—radial versus femoral—can significantly impact patient outcomes and the incidence of vascular complications. Recent trends favor radial access due to its potential advantages in safety and recovery. Objective: To evaluate the impact of radial versus femoral access on vascular complications and patient outcomes in complex PCI. Methods: This randomized control trial was conducted at the Chaudhary Pervaiz Elahi Institute of Cardiology, Wazirabad, Pakistan, over a six-month period from September 2023 to February 2024. A total of 350 patients undergoing complex PCI were enrolled, with 210 assigned to radial access and 140 to femoral access. Baseline characteristics, including age, BMI, and prevalent comorbidities (dyslipidemia, hypertension, and diabetes mellitus), were recorded. Major outcomes measured included periprocedural myocardial infarction, in-hospital mortality, and stent thrombosis. Statistical analysis was performed using SPSS Version 26. Results: The mean age of participants was 52.90 ± 8.07 years. No significant differences were found in BMI and comorbid conditions between the groups. In-hospital mortality was 1.4% in the radial group compared to 4.3% in the femoral group (P=0.05). Rates of periprocedural myocardial infarction were similar between groups (0.5% radial vs 0.7% femoral, P=0.77). Stent thrombosis was observed in 0.5% of the radial group and was absent in the femoral group. Conclusion: Radial access in complex PCI was associated with lower in-hospital mortality compared to femoral access, with similar rates of myocardial infarction and stent thrombosis. These findings suggest that radial access may provide a safer alternative, supporting its increasing use in clinical practice.

Same-day discharge after large-bore access in percutaneous coronary intervention of chronic total coronary occlusions.

Same-day discharge (SDD) in patients undergoing percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is appealing because of the increased patient comfort. However, data on SDD following large-bore vascular access are scarce. We investigated the feasibility and safety of SDD in patients undergoing large-bore CTO PCI. Between 2013 and 2023, 948 patients were prospectively enrolled in a single-centre CTO registry and underwent CTO PCI. SDD was pursued in all patients. Large-bore access was defined as the use of ≥7 French (Fr) sheaths in ≥1 access site. A logistic regression analysis was used to identify predictors for non-SDD. Clinical follow-up was obtained at 30 days. SDD was observed in 62% of patients. Large-bore access was applied in 99% of the cohort. SDD patients were younger and more often male, with lower rates of renal insufficiency and prior coronary artery bypass grafting. Local access site bleeding (odds ratio [OR] 8.53, 95% confidence interval [CI]: 5.24-13.87) and vascular access complications (OR 7.23, 95% CI: 1.98-26.32) made hospitalisation more likely, with vascular access complications occurring in 3%. At 30 days, the hospital readmission rate was low in both SDD and non-SDD patients (5% vs 7%; p=non-significant). Finally, SDD was not a predictor for major adverse cardiovascular events (MACE) at follow-up. Same-day discharge can be achieved in the majority of patients undergoing CTO PCI with large-bore (≥7 Fr) access. Similar low hospital readmission and MACE rates between SDD and non-SDD patients at 30 days demonstrate the feasibility and safety of SDD.

D-52 | Role of controlled antegrade and retrograde subintimal tracking (CART) in contemporary chronic total occlusion recanalization

D-52 | Role of controlled antegrade and retrograde subintimal tracking (CART) in contemporary chronic total occlusion recanalization

Determinants of right coronary artery occlusion in patients with inferior wall myocardial infarction: A cross-sectional study from Western India

ABSTRACT Introduction: In acute inferior wall myocardial infarction (IWMI) and occlusion of the right coronary artery (RCA), the most important element is to recognize the culprit artery and the location and size of the infarct, which is essential in the treatment. Adequate knowledge about clinical determinants can aid in prompt and effective management. Materials and Methods: A cross-sectional study was conducted to find determinants of RCA occlusion among 103 subjects with IWMI from rural western India. Results: About 86.4% of subjects were male. Females experienced IWMI at a later age than males (62.4 ± 10.3 vs. 58.6.1 ± 11.8 years). Bradycardia was more prevalent than tachycardia (44.66% vs. 15.53%). Males had a 5.17 times higher odds of having RCA involvement in IWMI. Subjects with deranged lipid profiles had 2.37 times higher odds of involvement of RCA. RCA involvement was significantly associated with bradycardia (P = 0.006, aOR = 15.31, 95% confidence interval [CI] = 2.21–105.7) but not with tachycardia (P = 0.903). Proximal site occlusion was significantly associated (P = 0.027; aOR = 0.103; 95% CI = 0.013–0.772) with bradycardia compared to distal sites. Triple-vessel disease had significantly (P &lt; 0.05) 12.9 times higher odds than single-vessel disease. Total occlusion of RCA was 2.9 times higher than obstructive coronary artery disease. Conclusion: These findings suggest determinants associated with RCA involvement in IWMI, including gender, lipid profile, cardiac rhythm disturbances (particularly bradycardia), and the extent and site of coronary artery occlusion. Incorporating these factors into clinical practice, clinicians can better predict the underlying pathophysiology of IWMI, anticipate its hemodynamic and electrophysiologic consequences, and tailor management strategies accordingly.

Controlled antegrade and retrograde subintimal tracking (CART) for recanalisation of chronic total occlusions.

Controlled antegrade and retrograde subintimal tracking (CART) is rarely performed in contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to analyse the indications, procedural characteristics, and outcomes of CART at a high-volume CTO programme. We included all patients undergoing a retrograde CTO PCI in which CART was performed at our institution between January 2019 and November 2023. The primary endpoint was technical success. Of 1,582 CTO PCI, the retrograde approach was performed in 603 procedures (38.1%), and CART was used in 45 cases (7.5%). The mean age was 69.1±10.3 years, 93.3% were male, and prior coronary artery bypass graft surgery was present in 68.9%. The most common target CTO vessel was the right coronary artery (48.9%). Anatomical complexity was high (Multicentre CTO Registry of Japan [J-CTO] score of 3.6±0.9). The most common collateral used for CART was a saphenous vein graft (62.2%). Advanced calcium modification was required in 15.6% of cases. CART was successful in 73.3%. Technical and procedural success was 82.2%. Coronary perforation was diagnosed in 4 subjects (8.9%), but only 1 patient (2.2%) suffered tamponade and required pericardiocentesis. No other in-hospital major adverse cardiac events were diagnosed. CART is a useful technique in selected, very complex CTOs tackled with the retrograde approach. Success rates were high, while complication rates were low, considering the high anatomical complexity and baseline patient risk.

Regional wall motion abnormalities in transthoracic echocardiography in patients with significant coronary artery disease and coronary collateral circulation in adults

BackgroundCoronary collateral circulation is a common finding in patients with chronic total occlusions (CTOs) resulting from chronic coronary artery disease (CAD). Regional wall motion abnormalities (RWMA) on transthoracic echocardiography (TTE) can be used for the diagnosis of CAD. However, little work has been done to investigate the impact of collateral vessels on the diagnostic accuracy of resting TTE for CAD. MethodsA retrospective chart review was conducted of adults who received a resting TTE and cardiac catheterization within 30 days over a 4-year period at the Temple Baylor Scott & White echocardiography laboratory. Exclusion criteria included catheterization without coronary angiography and prior history of CAD, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). We analyzed RWMA on TTE in patients with CAD and coronary collateral circulation on cardiac catheterization to assess for correlation. ResultsOf the 753 patients were included in this study, 453 had CAD, 272 had both CAD and RWMA, 111 had collateral circulation, and 73 had collateral circulation and RWMA. There was no significant difference in RWMA in patients with CAD with and without collateral circulation. There was no significant difference in the sensitivity (60.0 % vs 59.2 %) and specificity (78.4 % vs 73.9 %) after collateral-adjusted interpretation of RWMA and CAD (p = 0.3). DiscussionOur results suggest the average coronary collateral system is of insufficient clinical significance to prevent the development of RWMA on resting TTE.

A-46 | Crude and Propensity Matched In-Hospital Outcomes of Acute ST Elevation Myocardial Infarction in patients with & without Chronic Total Occlusion of Coronaries

A-46 | Crude and Propensity Matched In-Hospital Outcomes of Acute ST Elevation Myocardial Infarction in patients with & without Chronic Total Occlusion of Coronaries

C-31 | Impact of Frailty on Prognosis in Chronic Total Occlusion Interventions: A Comprehensive Analysis of In-Hospital Mortality and Readmission Rates Following Percutaneous Coronary Intervention

C-31 | Impact of Frailty on Prognosis in Chronic Total Occlusion Interventions: A Comprehensive Analysis of In-Hospital Mortality and Readmission Rates Following Percutaneous Coronary Intervention

D-35 | Ranolazine and Chronic Total Occlusion Percutaneous Coronary Intervention

D-35 | Ranolazine and Chronic Total Occlusion Percutaneous Coronary Intervention

Retrograde Coronary Chronic Total Occlusion Intervention (JR-CTO) Score: From the Japanese CTO-PCI Expert Registry

BackgroundDespite the effectiveness of the retrograde approach for chronic total occlusion (CTO) lesions, there are no standardized tools to predict the success of retrograde percutaneous coronary intervention (PCI). ObjectivesThe aim of this study was to develop a prediction tool to identify CTO lesions that will achieve successful retrograde PCI. MethodsThis study evaluated data from 2,374 patients who underwent primary retrograde CTO-PCI and were enrolled in the Japanese CTO-PCI Expert Registry between January 2016 and December 2022 (NCT01889459). All observations were randomly assigned to the derivation and validation cohorts at a 2:1 ratio. The prediction score for guidewire failure in retrograde CTO-PCI was determined by assigning 1 point for each factor and summing all accrued points. ResultsThe JR-CTO score (moderate–severe calcification, tortuosity, Werner collateral connection grade ≤1, and nonseptal collateral channel) demonstrated a C-statistic for guidewire failure of 0.72 (95% CI: 0.67-0.76) and 0.71 (95% CI: 0.64-0.77) in the derivation and validation cohorts, respectively. Patients with lower scores had higher guidewire and technical success rates and decreased guidewire crossing time and procedural time (P < 0.01). ConclusionsThe JR-CTO (Japanese Retrograde Chronic Total Occlusion) score, a simple 4-item score that predicts successful guidewire crossing in patients undergoing retrograde CTO-PCI, has the potential to support clinical decision-making for the retrograde approach.

D-57 | Outcomes of chronic total occlusion percutaneous coronary intervention in young patients

D-57 | Outcomes of chronic total occlusion percutaneous coronary intervention in young patients

D-45 | J-CTO score as a predictor for outcomes after percutaneous coronary intervention of chronic total occlusions

D-45 | J-CTO score as a predictor for outcomes after percutaneous coronary intervention of chronic total occlusions

OR4-2 | Percutaneous Coronary Intervention Versus Robotic-Assisted Coronary Artery Bypass for Left Anterior Descending Artery Chronic Total Occlusion

OR4-2 | Percutaneous Coronary Intervention Versus Robotic-Assisted Coronary Artery Bypass for Left Anterior Descending Artery Chronic Total Occlusion

D-36 | Chronic Lung Disease in Chronic Total Occlusion Percutaneous Coronary Intervention

D-36 | Chronic Lung Disease in Chronic Total Occlusion Percutaneous Coronary Intervention