Undergoing Chronic Total Occlusion Percutaneous Coronary Intervention Research Articles

Optical coherence tomography findings after chronic total occlusion interventions: Insights from the "AngiographiC evaluation of the everolimus-eluting stent in chronic Total occlusions" (ACE-CTO) study (NCT01012869).

There is limited information on optical coherence tomography (OCT) findings after percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). OCT allows high resolution imaging that can enhance understanding of the vascular response after stenting of chronically occluded vessels. The Angiographic Evaluation of the Everolimus-Eluting Stent in Chronic Total Occlusions (ACE-CTO) study collected angiographic and clinical outcomes from 100 patients undergoing CTO PCI with the everolimus-eluting stent (EES). OCT was performed 8-months post stenting in 62 patients. Every third frame was analyzed throughout the course of the stented arterial segment. Lumen contours were semi-automatically traced and stent struts were manually delineated, with automatic measurement of the strut to lumen distance. Struts on the luminal side of the lumen contour were classified as malapposed if the distance to the lumen contour exceeded 0.108mm. A total of 44,450 struts in 6047 frames were analyzed, of which 4113 9.3%, 95% confidence intervals [CI] 9.0% to 9.5%) were malapposed and 1230 (2.8%, 95% CI 2.6% to 2.9%) were uncovered. Fifty-five of 62 patients (88.7%, 95% CI 78.5% to 98.4%) had at least one malapposed stent strut and 50 patients (80.7%, 95% CI 69.2% to 88.6%) had at least one uncovered stent strut. Mean strut-intimal thickness of the apposed and malapposed struts was 0.126±0.140mm and -0.491±0.440mm, respectively. High rates of stent strut malapposition and incomplete stent strut coverage were observed after CTO PCI using EES, highlighting unique challenges associated with stent implantation in CTOs.

Impact of crossing technique on the incidence of periprocedural myocardial infarction during chronic total occlusion percutaneous coronary intervention.

We sought to evaluate the impact of crossing strategy on the incidence of periprocedural myocardial infarction (PMI) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The optimal technique for crossing coronary CTOs remains controversial. We retrospectively examined the incidence of PMI among 184 consecutive patients who underwent CTO PCI at our institution between 2012 and 2015. Creatine kinase-myocardial band fraction (CK-MB) and troponin were measured before and after PCI in all patients. PMI was defined as CK-MB increase ≥3× upper limit of normal (ULN). Mean age was 65 ± 8 years, 98% of patients were men, 57% had diabetes mellitus, 36% were current smokers, 38% had prior heart failure, 31% had prior coronary artery bypass graft surgery (CABG), and 55% had prior PCI. The retrograde approach was used in 38% of cases. As compared with antegrade wire escalation and antegrade dissection/re-entry, use of the retrograde approach was associated with higher J-CTO (Multicenter CTO Registry of Japan) scores (P < 0.0001), higher frequency of moderate or severe calcification (P = 0.0061), longer CTO length (P < 0.0001), more frequent proximal cap ambiguity (P < 0.0001), and lower technical (P = 0.0007) and procedural (P = 0.0014) success. The frequency of PMI for the antegrade-only and retrograde cases was 10% and 33%, respectively (P = 0.0001). On multivariate analysis, use of the retrograde approach and moderate/severe calcification were independently associated with higher incidence of PMI. As compared with antegrade-only crossing techniques, the retrograde approach is used in patients with more complex anatomy but may carry higher risk for PMI. © 2016 Wiley Periodicals, Inc.

Correlates and outcomes related to periprocedural myocardial injury during percutaneous coronary intervention for chronic total occlusion: Results from a prospective, single center PCI registry.

There is increasing interest in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Periprocedural myocardial injury (PMI) post CTO PCI is not uncommon, but true incidence and implications of PMI are not well understood. This study aimed to investigate risk factors for PMI post CTO PCI and its implications for the 1-year clinical outcome of a Chinese population. Baseline characteristics, procedure features, and major adverse cardiac events (MACE) at 1 year were assessed in 629 consecutive patients who underwent CTO PCI. PMI was diagnosed as an elevation of creatine kinase MB ≥3 times ULN 12-24 hr post procedure. Multivariate analysis was performed to determine the correlates of PMI and MACE at 1-year follow-up. In total, PMI was detected in 115 patients (18.3%). Compared with patients without PMI, those with PMI had a higher percentage of previous coronary artery bypass grafting (CABG), right coronary occlusion and side branch occlusion, and technical success was lower in the PMI group (90.4% vs. 96.7%, P = 0.003). One-year MACE-free survival was reduced in the PMI group (87.8% vs. 95.9%, P = 0.001). The final TIMI flow 0-1 (OR 2.23, 95%CI 1.06-4.87, P = 0.02), side branch occlusion (OR 2.67, 95%CI 1.19-7.11, P = 0.009), retrograde PCI (OR 1.35, 95%CI 1.10-2.74, P = 0.04), and history of prior CABG (OR 2.41, 95%CI 1.38-5.91, P = 0.01) were independent risk factors for the occurrence of PMI. In this unique Chinese cohort, PMI post CTO PCI was associated with several clinical and angiographic factors and exerts an adverse effect on 1-year clinical outcomes.

Everolimus-eluting bioresorbable vascular scaffolds versus second generation drug-eluting stents for percutaneous treatment of chronic total coronary occlusions: Technical and procedural outcomes from the GHOST-CTO registry.

We aimed at comparing the acute performance of bioresorbable scaffolds (BRS) and second-generation drug-eluting stents (DES) for the treatment of chronic total occlusions (CTO). There is a lack of knowledge regarding the use of BRS in CTO. Key outcomes of interest were technical and procedural success. Technical success was defined as successful stent delivery and implantation, postprocedural residual diameter stenosis <30% within the treated segment, and restoration of thrombolysis in myocardial infarction (TIMI) grade 3 flow. Procedural success was defined as technical success with no in-hospital major adverse cardiac events (MACE). Between May 2013 and May 2014, 32 patients underwent CTO percutaneous coronary intervention (PCI) with the Absorb BRS (Abbott Vascular, Santa Clara, CA) and were compared with a historical control group of 54 patients who had undergone CTO PCI with second-generation DES. Baseline characteristics were similar between the BRS and DES groups, with the exception of a larger mean reference vessel diameter in the BRS group (2.92±0.34 vs 2.50±0.68; P<0.001). Technical success was less likely to be achieved in the BRS group compared with the DES group (78.1% vs 96.3%, P=0.012). Procedural success rates were 78.1% and 94.4% in the BRS and DES group, respectively (P = 0.035). Compared with second-generation DES for PCI of CTO lesions, BRS were associated with lower rates of technical and procedural success. © 2016 Wiley Periodicals, Inc.

Abstract 14955: Factors Associated With High Contrast Utilization During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry

Background: High contrast utilization during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) may lead to peri-procedural complications, in particular contrast-induced nephropathy (CIN). Methods: We examined the association between several clinical and angiographic variables and contrast volume utilization during CTO PCI among 950 consecutive procedures performed at 10 experienced US centers between May 2012 and March 2015. Results: Mean age was 65±10 years, 87% of patients were men, and 34% had prior coronary artery bypass graft surgery (CABG). Technical and procedural success was 91% and 90%, respectively. The median contrast volume utilization was 260 (IQR:195, 360) mL. Approximately 33% of patients received &gt;310mL of contrast (high contrast utilization). On univariable analysis male gender (p=0.017), moderate or severe calcification (p=0.002) and tortuosity (p=0.004), proximal cap ambiguity (p=0.002), distal cap at a bifurcation (p=0.001), side branch at proximal cap (p=0.02), blunt/no stump (p=0.003), occlusion length (p&lt;0.0001), high J-CTO score (p=0.012), guide catheter size (&gt;7F) (p&lt;0.0001), retrograde approach (p=0.006), ad-hoc CTO PCI (p&lt;0.0001) and dual arterial access (p&lt;0.0001) were associated with higher contrast administration, whereas history of diabetes mellitus (p=0.008) and in-stent restenosis (p=0.049) were associated with less contrast use. On multivariable analysis proximal cap ambiguity (p=0.030), bigger guide catheter size (p=0.007), ad-hoc CTO PCI (p&lt;0.0001) and dual arterial access (p=0.002) were independently associated with higher contrast use during CTO PCI. On the other hand, in-stent restenosis (p=0.027) and presence of interventional collaterals (p&lt;0.0001) were associated with lower contrast use. Conclusions: Approximately 1 in 3 patients undergoing CTO PCI receive high contrast volume (&gt;310 mL). Several baseline clinical and angiographic characteristics can help predict the likelihood of high contrast volume administration. This knowledge could be used pre-procedurally and intra-procedurally to guide and intensify efforts to reduce contrast utilization and reduce the risk of contrast-induced complications during CTO PCI.

CLINICAL UTILITY OF THE J-CTO SCORE IN CORONARY CHRONIC TOTAL OCCLUSION INTERVENTIONS: RESULTS FROM A MULTICENTER REGISTRY

We sought to validate the clinical utility of the J-CTO score in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The records of 650 patients who underwent CTO PCI using the “hybrid” approach at six experienced CTO PCI centers were reviewed. Baseline characteristics and

Procedural outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National Cardiovascular Data Registry).

The aim of this study was to describe contemporary frequency, predictors, and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in the United States. CTO PCI can provide significant clinical benefits, yet there is limited information on its success and safety in unselected patient populations. We analyzed the frequency and outcomes of CTO PCI compared with non-CTO PCI in elective patients, and of successful versus failed CTO PCI between July 1, 2009, and March 31, 2013, in the National Cardiovascular Data Registry CathPCI Registry. Generalized estimating equations logistic regression modeling was used to generate independent variables associated with procedural success and procedural complications. During the study period, CTO PCI represented 3.8% of the total PCI volume for stable coronary artery disease (22,365 of 594,510). Overall, patients undergoing CTO PCI required greater contrast volume and longer fluoroscopy time and had lower procedural success (59% vs. 96%, p < 0.001) and higher major adverse cardiac event (1.6% vs. 0.8%, p < 0.001) rates than non-CTO PCI patients. On multivariable analysis, several parameters (including older age, current smoking, previous myocardial infarction, previous coronary artery bypass graft, previous peripheral arterial disease, previous cardiac arrest, right coronary artery CTO target vessel, and less operator experience) were associated with a lower likelihood of CTO PCI procedural success, whereas operators' annual CTO PCI volume was associated with improved success without a significant increase in major complications. CTO PCI is currently performed infrequently in the United States for stable coronary artery disease and is associated with lower procedural success and higher complication rates compared with non-CTO PCI. Procedural success was associated with several patient factors and operator experience.

Effect of a successful percutaneous coronary intervention for chronic total occlusion on parameters of ventricular repolarization.

Coronary collaterals may be insufficient for restoring blood flow to normal levels in patients with chronic total occlusions (CTO), leading to myocardial ischemia and electrical inhomogeneity in the ventricles. We evaluated the effect of percutaneous CTO revascularization on parameters of ventricular repolarization, including the T wave peak-to-end interval (TpTe) interval, the TpTe/QT ratio, and QT dispersion. A total of 114 patients who underwent CTO percutaneous coronary intervention (PCI) of any major coronary artery were divided into two groups: the successful CTO PCI group (n=90) and the failed CTO PCI group (n=24). Patients' 12-lead ECGs were analyzed within 24 h before revascularization and 24-48 h after the procedure for the following parameters: corrected QT interval (QTc) dispersion, TpTe interval (V2 and V5), and TpTe/QT ratio (V2 and V5). Subsequently, the successful CTO PCI group was divided into subgroups according to the Rentrop class, number of diseased vessels, and target vessels for further evaluation. There was no significant difference between the successful and the failed CTO PCI groups in terms of any baseline demographic or angiographic characteristic, or ventricular repolarization parameter. The post-PCI values of TpTe (85.3±12.8 vs. 74.8±10.4; P<0.001), the TpTe/QT ratio (0.21±0.02 vs. 0.19±0.02; P<0.001), and QTc dispersion (65.6±9.8 vs. 53.4±11.6; P<0.001) were significantly decreased compared with the pre-PCI values after successful CTO PCI. The patients in Rentrop class 1 and patients with multivessel disease had higher pre-PCI values for TpTe and the TpTe/QT ratio than those in the other groups (P<0.05). No significant differences were detected when the preprocedure values of TpTe, the TpTe/QT ratio, and QTc dispersion were compared according to the target vessel. In patients with CTO, a poor coronary collateral status and multivessel disease may further impair electrical homogeneity. Our results indicate that successful CTO PCI reduces the arrhythmic vulnerability of the myocardium on the basis of an analysis of the TpTe, the TpTe/QT ratio, and QTc dispersion.

Dissection and Re-Entry Techniques and Longer-Term Outcomes Following Successful Percutaneous Coronary Intervention of Chronic Total Occlusion

New techniques involving dissection of the subintimal space and re-entry into the true lumen increase success rates in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). However, their long-term safety and efficacy were unknown. This study included a series of consecutive patients who underwent CTO PCI. All patients who did not present events were contacted 12 to 18months after their PCI. The combined incidence of cardiac death, myocardial infarction, ischemia-driven target-vessel revascularization (TVR), or reocclusion was assessed as our primary outcome. From January 2010 to January 2013, of 212 CTOs treated in our CTO program, 192 (91%) were successfully opened (in 179 patients). Follow-up data were available for 187 CTOs (97.4%), with 82 (44%) that were opened with dissection re-entry and 105 (56%) with conventional wire escalation techniques. At a median follow-up of 398days, the primary outcome occurred in 18 of 179 CTOs treated (10.7%), driven by TVR. No patient died from cardiac causes. Eleven CTOs (15.2%) treated with dissection re-entry versus 7 CTOs (7.3%) treated with wire escalation presented with the primary outcome (p= 0.17). With multivariate adjustment, dissection re-entry techniques had no significant impact on outcomes. However, treatment of an in-stent occlusion was independently associated with TVR (hazards ratio >6.0, p <0.001). In conclusion, dissection re-entry techniques have minimal impact on long-term outcomes after CTO PCI, which are favorable in most patients. However, treatment of an in-stent occlusion and use of sirolimus-eluting stent were predictors of subsequent adverse outcomes.

Percutaneous Intervention of Circumflex Chronic Total Occlusions Is Associated With Worse Procedural Outcomes: Insights From a Multicentre US Registry

BackgroundWe sought to determine whether outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) vary according to CTO target vessel: left anterior descending artery (LAD), left circumflex artery (LCX), and right coronary artery (RCA). MethodsWe evaluated the clinical and angiographic characteristics and procedural outcomes of 636 patients who underwent CTO PCI at 6 high-volume centres in the United States between January 2012 and March 2014. ResultsThe CTO target vessel was the RCA in 387 cases (61%), LAD in 132 (21%), and LCX in 117 (18%). LCX lesions were more tortuous and RCA lesions had greater occlusion length and Japanese Chronic Total Occlusion (J-CTO) score, but were less likely to have a side branch at the proximal cap and had more developed collateral circulation. The rate of procedural success was lower in LCX CTOs (84.6%), followed by RCA (91.7%), and LAD (94.7%) CTOs (P = 0.016). Major complications tended to occur more frequently in LCX PCI (4.3% vs 1.0% for RCA vs 2.3% for LAD; P = 0.07). LCX and RCA CTO PCI required longer fluoroscopy times (45 [interquartile range (IQR), 30-74] minutes vs 45 [IQR, 21-69] minutes for RCA vs 34 [IQR, 20-60] minutes for LAD; P = 0.018) and LCX CTOs required more contrast administration (280 [IQR, 210-370] mL vs 250 [IQR, 184-350] mL for RCA and 280 [IQR, 200-400] mL for LAD). ConclusionsIn a contemporary, multicentre CTO PCI registry, LCX was the least common target vessel. Compared with LAD and RCA, PCI of LCX CTOs was associated with a lower rate of procedural success, less efficiency, and a nonsignificant trend for higher rates of complications.

The efficacy of “hybrid” percutaneous coronary intervention in chronic total occlusions caused by in‐stent restenosis: Insights from a US multicenter registry

ObjectivesTo examine the success and complication rates in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) caused by in‐stent restenosis (ISR).BackgroundPCI for in‐stent total occlusive disease has traditionally been associated with low success rates. We sought to examine angiographic and procedural outcomes of patients who underwent CTO PCI due to ISR using the novel “hybrid” algorithm, and compare them with patients with de novo CTOs.MethodsWe examined 521 consecutive patients who underwent CTO PCI at five high‐volume PCI centers in the United States using the “hybrid” approach. Clinical, angiographic, and procedural outcomes were compared between CTOs due to ISR and de novo CTOs.ResultsThe target CTO was due to ISR in 57 of 521 patients (10.9%). Compared to patients with de novo CTOs, those with CTO due to ISR had higher frequency of diabetes (56.1% vs. 39.6%, P = 0.02) and less calcification (5.3% vs. 16.2%, P &lt;0.001), but longer occlusion length [38 (29–55) vs. 30 (20–51), P = 0.04]. Technical success in the ISR and de novo group was 89.4% and 92.5% (P = 0.43), respectively; procedural success was 86.0% and 90.3% (P = 0.31), respectively; and the incidence of major adverse cardiac events was 3.5% and 2.2% (P = 0.63), respectively.ConclusionsUse of the “hybrid” approach to CTO PCI was associated with similarly high procedural success and similarly low major complication rates in patients with de novo and ISR CTOs. © 2014 Wiley Periodicals, Inc.

Application of the “Hybrid Approach” to Chronic Total Occlusions in Patients With Previous Coronary Artery Bypass Graft Surgery (from a Contemporary Multicenter US Registry)

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been traditionally associated with lower success rates in patients with previous coronary artery bypass graft surgery (CABG). We sought to examine the success and complication rates of CTO PCI using the "hybrid" crossing algorithm among patients with a history of previous CABG. The procedural outcomes of 496 consecutive CTO PCIs performed at 5 high-volume PCI centers in the United States from January 2012 to August 2013 were assessed. The outcomes of patients with previous CABG were compared with those of patients without previous CABG. Compared with patients without previous CABG (n = 320), patients with previous CABG (n = 176, 35%) were older, had more coronary artery disease risk factors, and had less favorable baseline angiographic CTO characteristics. Technical and procedural success was slightly lower among patients with previous CABG (88.1% vs 93.4%, p = 0.044 and 87.5 vs 92.5%, p = 0.07, respectively). Patients with previous CABG more commonly underwent CTO PCI using the retrograde approach (39% vs 24%, respectively, p <0.001) and received higher air kerma radiation exposure (4.8 [interquartile range 3.0 to 6.4] vs 3.1 [1.9 to 5.3] Gray, p <0.001) and fluoroscopy time (59 [38 to 77] vs 34 [21 to 55] minutes, p <0.001). Major procedural complications were similar in the 2 groups: 2 of 176 (1.1%) patients with previous CABG versus 7 of 320 (2.1%) patients without previous CABG (p = 0.40). In conclusion, with application of the "hybrid" approach to CTO PCI, success was slightly lower, and complication rates were similar between patients with and without previous CABG.

Predictors of contrast-induced nephropathy in chronic total occlusion percutaneous coronary intervention

Contrast-induced nephropathy (CIN) is a leading cause of morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI). Limited data, however, are available on predictors of CIN in PCI for chronic total occlusion (CTO) lesions. The aim of the study was to determine the risk of developing CIN in patients undergoing CTO PCI by studying the effects of clinical variables, interventional techniques, and CTO lesion characteristics on renal function. This retrospective analysis included consecutive patients referred for CTO PCI between January 2002 and December 2009. CIN was defined as an elevated serum creatinine level ≥25% of baseline serum creatinine level at 48-72 hours after procedure. Patient characteristics, Mehran score, lesion characteristics, interventional procedure, and devices used were compared between CIN and non-CIN groups. For the 516 patients eligible for analysis, the incidence of CIN was 5.4% (28/516). Two patients needed transient haemodialysis (0.4%, 2/516). Analysis of risk using Mehran scoring found that the incidence of CIN was 0.5% (1/207) among low-risk patients, 3.4% (7/205) among moderate-risk patients, 15.9% (14/88) among high-risk patients and 37.5% (6/16) among very high-risk patients. The Mehran score high-risk group (11-15) and the very high-risk group (≥16) were definitely predictors of CIN after CTO PCI (OR: 27.022 [95% CI: 2.787-262.028, p=0.004]; OR: 32.512 [95% CI: 2.149-491.978, p=0.012]). Severe tortuosity was the only predictor of CIN after CTO PCI in angiographic and procedural findings (OR: 6.621 [95% CI: 1.090-40.227, p=0.040]). Being in the Mehran score high-risk group (11-15) or the very high-risk group (≥16) and severe tortuosity were predictors of CIN after CTO PCI.

A thirty-four-year-old chronic total occlusion successfully treated by percutaneous coronary intervention

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) represents a major challenge for interventional cardiology. CTOs are identified in up to 30% of patients with significant coronary disease on angiography and represent only 10–15% of cases treated by PCI, with the majority of patients being treated medically or referred for surgery [ [1] Stone G.W. Kandzary D.E. Mehran R. et al. Percutaneous recanalization of chronically occluded coronary artery: a consensus document: part I. Circulation. 2005; 112: 2364-2372 Crossref PubMed Scopus (456) Google Scholar ]. This may be explained considering the lower procedural success achieved in these lesions in comparison with non-occluded lesions [ [2] Stone G.W. Rutherford B.D. Mc-Conahay D.R. et al. Procedure outcome of angioplasty for total coronary occlusion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol. 1990; 15: 849-856 Abstract Full Text PDF PubMed Scopus (212) Google Scholar ]. The major reason for procedural failure is represented by the inability to cross the occlusion, with a guidewire or a balloon [ 2 Stone G.W. Rutherford B.D. Mc-Conahay D.R. et al. Procedure outcome of angioplasty for total coronary occlusion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol. 1990; 15: 849-856 Abstract Full Text PDF PubMed Scopus (212) Google Scholar , 3 Stone G.W. Colombo A. Teirstein P.S. et al. Percutaneous recanalization of chronically occluded coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc Interv. 2005; 66: 217-236 Crossref PubMed Scopus (127) Google Scholar ]. A number of predictors of procedural success have been reported in the literature. It is accepted that a blunt occlusion stump, heavy calcification, proximity to a side branch, presence of bridging collaterals and longer occlusions, all impact unfavorably on the likelihood of procedural success [ [4] Kinoshita I. Katoh O. Nariyama J. et al. Coronary angioplasty of chronic total occlusions with bridging collateral vessels: immediate and follow-up outcome from a large single-center experience. J Am Coll Cardiol. 1995; 26: 409-415 Abstract Full Text PDF PubMed Scopus (154) Google Scholar ]. In addiction previous studies have reported that long occlusion duration may also be associated with procedural failure [ 5 Kereiakes D.J. Selmon M.R. McAuley D.B. et al. Angioplasty in total coronary artery occlusion: experience in 76 consecutive patients. J Am Coll Cardiol. 1985; 6: 526-533 Abstract Full Text PDF PubMed Scopus (140) Google Scholar , 6 Melchoir J.P. Meire B. Urban P. et al. Percutaneous transluminal coronary angioplasty for chronic total occlusion. Am J Cardiol. 1987; 59: 535-538 Abstract Full Text PDF PubMed Scopus (149) Google Scholar ]. It was supposed that this issue was related to the increase lesion organization with deposition of fibrous tissue and severe calcifications, which occur in the course of time. Furthermore aging of occlusion may determine a change in plaque composition with an increase of frequency and severity of plaque calcification [ [7] Suzuki T. Hosokawa H. Yokoya K. et al. Time-dependent morphologic characteristics in angiographic chronic total coronary occlusions. Am J Cardiol. 2001; 88: 167-169 Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar ]. A study of Barlis et al. underlined how indetermination of occlusion duration (IOD) could play a role in prediction of procedural failure and cardiac adverse events [ [8] Barlis P. Kaplan S. Dimopoulos K. et al. An indeterminate occlusion duration predicts procedural failure in the recanalization of coronary chronic total occlusions. Catheter Cardiovasc Interv. 2008; 71: 621-628 Crossref PubMed Scopus (23) Google Scholar ]. However Tomasello et al. have recently showed that IOD and long duration of CTO do not affect procedural and clinical outcome of patients who underwent CTO PCI [ [9] Tomasello S.D. Costanzo L. Campisano M.B. et al. J Interv Cardiol. 2011; 24: 223-231 Crossref PubMed Scopus (14) Google Scholar ].

Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularisation: insights from a multicentre US registry

ObjectiveTo investigate the impact of prior coronary artery bypass graft (CABG) surgery on the outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO).DesignObservational retrospective study.SettingThree tertiary hospitals in...

Long‐term clinical outcomes after percutaneous coronary intervention for chronic total occlusions in elderly patients (≥75 Years)

To investigate procedural success rates and long-term clinical outcome of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in elderly patients. Little is known about procedural success and long-term clinical outcome of PCI for CTO in the elderly. A total of 1,791 consecutive patients with 1,852 CTO underwent PCI at three large centers in USA, Italy, and South Korea. Outcomes included procedural success and major adverse cardiac events (MACE, composite of mortality, myocardial infarction, or coronary artery bypass graft surgery [CABG]).Time-to-event analyses were performed using Kaplan-Meier statistics, and the log-rank statistic was used to test for differences between patients aged ≥75 and patients aged <75 years. Two hundred and thirteen patients (12%) were aged ≥75 years. Procedural success rates were similar in elderly patients compared with patients <75 years (63.8% vs. 69.1%, P = 0.12). Median follow-up was 890 days (IQR: 380-1,480 days). MACE rates after successful versus failed PCI were 25.8% versus 42.3% in the elderly (P = 0.02) and 11.2 versus 20.8% in younger patients (P < 0.01). In elderly patients, this reduction in MACE after successful PCI was mainly driven by a reduction in CABG (0.0% vs. 20.4%, P < 0.01), there were no significant differences in terms of mortality (19.6% vs. 24.6%, P = 0.13) or MI (11.5% vs. 8.0%, P = 0.87). CTO PCI in patients ≥75 years has similar success as in patients <75 years. In elderly patients undergoing CTO PCI, MACE rates were relatively high but successful revascularization is associated with a reduction in MACE at 5-year follow-up in both elderly and younger patients.

307 Percutaneous Coronary Intervention To Chronic Total Occlusions Can Be Safely And Effectively Performed In Standalone PCI Centres

Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) has been shown to reduce angina symptoms, reduce the need for coronary bypass surgery and may improve survival. With the development of retrograde and contemporary anterograde approaches the success rates of CTO PCI continues to improve. There remains much debate whether CTO PCI can be performed safely and effectively in high volume stand alone PCI centres. The Royal Alexandra Hospital has been performing PCI without on site surgery over the last 30 years. We identified all patients undergoing CTO PCI between January 2010 and March 2012. Patient demographics, angiographic features, procedure details and clinical outcomes were collected from local medical records the APPROACH database. 170 patients (85.8% male; 63.15 years) underwent PCI to 172 CTO lesions. Clinical presentations of the patients were stable angina (91.78%), non ST elevation MI (7.05%) and left ventricular failure ((LVF) 1.17%). The overall PCI success rate was 74.41%.Success rates of ad hoc, elective first, and subsequent reattempts were 59.1%, 68% and 69.7% respectively. Retrograde approach was attempted in 15% of the cases. Arterial access used was radial only in 63.6%, femoral only in 21.2% and radial-femoral combination in 15.2%. Bilateral injections were used in 37.2% of cases. Mean procedure time was 75.2 minutes. Mean radiation dose was 3.4±0.2 Gy/cm2. Mean contrast volume used was 297±10 ml. Complications of coronary perforation and coronary dissection occurred in 2% and 3% respectively with no occurrence of cardiac tamponade. Periprocedural myocardial infarction occurred in 1%. There were no periprocedural deaths and no patients required emergency cardiac surgery. The mean hospital stay in patients presenting with the stable angina, NSTEMI and LVF were 1.5, 9 and 4 days respectively. At mean follow up of 285 days, target vessel revascularisation (TVR) was only 3.1%. After successful CTO PCI, patient's CCS angina class decreased significantly from 2.2 to 0.5 (p<0.0001). Successful CTO PCI significantly improves angina symptoms with overall low rates of periprocedural complications. Using contemporary anterograde and retrograde techniques, CTO PCI can be safely and effectively performed in experienced stand alone PCI centres.

Changes in myocardial ischemic burden following percutaneous coronary intervention of chronic total occlusions

We assessed the potential for percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) to decrease myocardial ischemia and established objective criteria to predict post-procedure improvement. Optimal treatment for CTO of coronary arteries is controversial, and selection criteria for PCI of CTO are subjective. All patients undergoing CTO PCI at a single center between 2002 and 2007 were included if myocardial perfusion imaging (MPI) was performed within 12 ± 3 months before and a follow-up study within 12 ± 3 months after PCI. Average summed difference scores were calculated and converted to percent ischemic myocardium to classify patients as having normal/minimal, mild, moderate, or severe ischemia. A significant improvement in ischemia following PCI was classified as an absolute ≥5% decrease in ischemic myocardium. Receiver operating characteristic (ROC) curves were used to identify ischemic thresholds predictive of decreased and increased ischemic burden on follow-up MPI. In 301 patients, average baseline ischemic burden was 13.1% ± 11.9% and decreased to 6.9% ± 6.5% (P < 0.001) during follow-up. Overall, 53.5% of patients met criteria for improvement following PCI. These patients were more likely to be male, without diabetes, with CTO in the left anterior descending artery, and classified as having high ischemic burden at baseline. ROC analysis identified a baseline 12.5% ischemic burden as optimal in identifying those most likely to have a significantly decreased ischemic burden post-PCI. Those with a baseline ischemic burden less than 6.25% were more likely to have an increased ischemic burden post-PCI. Ischemic burden is reduced following CTO PCI, and the decrease is greater at high ischemic burden. A threshold of 12.5% ischemic burden is suggested as a criterion for performing PCI in the setting of CTO.

Does Occlusion Duration Influence Procedural and Clinical Outcome of Patients Who Underwent Percutaneous Coronary Intervention for Chronic Total Occlusion?

Previous studies have reported that the indeterminable aging and long-duration occlusion are associated with procedural failure and adverse long-term outcome. We aimed to investigate the clinical impact of occlusion duration in a consecutive series of patients who underwent percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. From October 2005 to June 2009, a total of 303 patients with 328 CTO lesions were consecutively treated achieving a success rate of 86.3%. The average of occlusion duration estimated in 62.5% of cases (known occlusion duration [KOD] patients, n = 188) was 29.8 ± 41.3 months. In the remaining 37.5% of cases, the occlusion duration was indeterminate (indetermination of occlusion duration [IOD] patients, n = 115). No influence of duration in procedural outcome was observed. Moreover, no differences of 1-year major adverse cardiac events (MACE) were observed between KOD and IOD patients. The multivariate COX regression analysis identified diabetes mellitus and multivessel coronary disease as independent predictors of 12-month MACE (HR 5.023; 95% CI 0.164-9.653; P = 0.025 and HR 0.801; 95% CI 0.109-0.909, P = 0.033). The analysis did not show any influence of IOD and long occlusion duration in the occurrence of MACE. Predictors of angiographic failure recognized with multivariate binary logistic were vessel diameter <2.5 mm (OR 5.3; 95% CI 1.19-8.91; P = 0.02), CTO length >20 mm (OR 6.3; 95% CI 1.22-9.54; P = 0.02), and severe calcification (OR 3.2; 95% CI 1.62-5.51; P = 0.03). IOD and long duration of CTO do not affect procedural and clinical outcome of patients who underwent CTO PCI. This marks the importance of considering PCI treatment, a reliable strategy in cases of IOD or long occlusion duration.

A comparison of the transradial and the transfemoral approach in chronic total occlusion percutaneous coronary intervention

Transradial coronary intervention is a safe and effective method of percutaneous revascularization. Furthermore, the indications for transradial percutaneous coronary intervention (PCI) are expanding. However, there is limited data on the efficacy and the safety of the transradial approach for chronic total occlusion (CTO) PCI. We examined 468 patients who underwent CTO PCI between January 2003 and December 2005, and compared the radial (318 patients) and the femoral (150 patients) approach. Baseline demographics, lesion location, and the vessel treated were similar in both groups. Angiographic success was 82% in radial versus 86% in femoral group, P = 0.28, similar in both groups. Total fluoroscopy time (24.49 +/- 13.18 vs. 24.07 +/- 14.12 min, P = 0.36), total procedure time (54.22 +/- 25.35 vs. 60.23 +/- 28.15 min, P = 0.23), and the use of total contrast volume (395.54 +/- 180.25 vs. 406.15 +/- 173.98 ml, P = 0.27) were similar in radial and femoral group, respectively. In hospital MACE [radial: 12 MI (3.8%) vs. femoral: 1 death (0.7%) and 5 MI (3.5%), P = 0.26] were similar in both groups. Access site vascular complications [radial: 11 (3.5%) vs. femoral: 17 (11.3%), P <or= 0.001] were significantly less in radial group. The radial approach in CTO PCI is as fast and successful as the femoral approach with comparable in hospital MACE. However, there are far less access site complications with radial approach.