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Erdogan E, Akkaya M, Bacaksiz A, Tasal A, Sönmez O, Elbey MA, Kul S, Vatankulu MA, Turfan M, Göktekin Ö. Early assessment of percutaneous coronary interventions for chronic total occlusions analyzed by novel echocardiographic techniques. Clinics (Sao Paulo) 2013; 68:1333-7. [PMID: 24212840 PMCID: PMC3798672 DOI: 10.6061/clinics/2013(10)07] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 07/27/2013] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Successful revascularization of chronic total occlusions has been associated with improved left ventricular systolic function, reduced anginal symptoms, increased exercise capacity, and increased survival. This study was conducted to determine the impact of revascularization in chronic total occlusion on left ventricular function using novel echocardiographic techniques. METHODS A total of 129 patients with chronic total occlusion who underwent revascularization between April 2011 and November 2012 were included in this study. Echocardiographic assessments with two-dimensional speckle tracking echocardiography and real-time three-dimensional echocardiography were performed before the procedure and one month after the procedure. The left ventricular ejection fraction, left ventricular volumes, and three-dimensional systolic dyssynchrony index were quantified. RESULTS An immediate procedural success was obtained in 118 patients (91.5%). There were no acute or subacute stent thromboses during follow-up. The mean left ventricular ejection fraction significantly increased (p<0.001), while the left ventricular end-diastolic and end-systolic volumes significantly decreased (p = 0.001 and p<0.001, respectively). The three-dimensional systolic dyssynchrony index also decreased significantly (p<0.001). The global longitudinal strain showed a significant increase after successful revascularization (p<0.001). An increase in the global longitudinal strain was correlated with an increase in the left ventricular ejection fraction (r = 0.27, p = 0.02). The patients with a left ventricular ejection fraction ≥50% displayed a greater improvement in the global longitudinal strain, and the patients with diabetes showed less improvement. CONCLUSIONS Using novel echocardiographic techniques, our results showed that restoring the coronary blood flow in chronic total occlusion patients reduces the left ventricular volumes and improves the left ventricular ejection fraction and the global longitudinal strain of hibernating myocardium.
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Affiliation(s)
- Ercan Erdogan
- Bezmialem Foundation University, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
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152
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Karmpaliotis D. Does prior coronary artery bypass grafting affect percutaneous chronic total occlusion revascularization? Interv Cardiol 2013. [DOI: 10.2217/ica.13.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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153
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Jiang L, Cheng XS, Yang RQ, Fan YL, Zhan R, Hu LJ. A meta-analysis of using a stent-based strategy for chronic total coronary occlusions recanalization: Effects of length of follow-up on clinical outcomes. Int J Cardiol 2013; 168:4941-5. [DOI: 10.1016/j.ijcard.2013.07.083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 07/06/2013] [Accepted: 07/08/2013] [Indexed: 11/25/2022]
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154
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Comparison of short- and long-term outcomes of percutaneous coronary intervention for chronic total occlusions between patients aged ≥75 years and those aged <75 years. Am J Cardiol 2013; 112:761-6. [PMID: 23735644 DOI: 10.1016/j.amjcard.2013.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/02/2013] [Accepted: 05/02/2013] [Indexed: 11/23/2022]
Abstract
Few reports are available on the safety and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) in older patients. In the present study, 284 patients who underwent PCI for CTOs were retrospectively evaluated by comparing the characteristics of 67 patients aged ≥75 years (the older group) and 217 patients aged <75 years (the younger group). Technical success was achieved in 77% of the patients in the older group and 79% of those in the younger group (p = 0.66). No significant differences were observed between the 2 groups in terms of the incidence of procedural complications. In the older group, a comparison between the patients with successful and failed PCI revealed significantly superior 3-year cardiac survival (97.6% vs 76.9%, p = 0.005). The 3-year cardiac survival of those with successful PCI was similar to that observed in the younger group. On multivariate analysis, successful PCI was found to be associated with a lower incidence of cardiac death in the older group (hazard ratio 0.09, 95% confidence interval 0.01 to 0.91, p = 0.042). In conclusion, this single-center, observational study suggests that PCI for CTOs can be performed with a high rate of procedural success and acceptably low mortality and morbidity in older patients, resulting in improved cardiac survival. Thus, PCI for CTO lesions should be included among the treatment strategies for older patients.
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155
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Yamamoto E, Natsuaki M, Morimoto T, Furukawa Y, Nakagawa Y, Ono K, Mitsudo K, Nobuyoshi M, Doi O, Tamura T, Tanaka M, Kimura T. Long-term outcomes after percutaneous coronary intervention for chronic total occlusion (from the CREDO-Kyoto registry cohort-2). Am J Cardiol 2013; 112:767-74. [PMID: 23735646 DOI: 10.1016/j.amjcard.2013.05.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/02/2013] [Accepted: 05/02/2013] [Indexed: 02/08/2023]
Abstract
Despite improving success rate of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions, the clinical benefit of recanalization of CTO is still a matter of debate. Of 13,087 patients who underwent PCI in the CREDO-Kyoto registry cohort-2, 1,524 patients received PCI for CTO (CTO-PCI). Clinical outcomes were compared between 1,192 patients with successful CTO-PCI and 332 patients with failed CTO-PCI. In-hospital death tended to occur less frequently in the successful CTO-PCI group than in the failed CTO-PCI group (1.4% vs 3.0%, p = 0.053). Through 3-year follow-up, the cumulative incidence of all-cause death was not significantly different between the successful and failed CTO-PCI groups (9.0% vs 13.1%, p = 0.18), whereas the cumulative incidence of cardiac death was significantly less in the successful CTO-PCI group than in the failed CTO-PCI group (4.5% vs 8.4%, p = 0.03). However, after adjusting confounders, successful CTO-PCI was associated with lesser risk for neither all-cause death (hazard ratio 0.93, 95% confidence interval 0.64 to 1.37, p = 0.69) nor cardiac death (hazard ratio 0.71, 95% confidence interval 0.44 to 1.16, p = 0.16). The cumulative incidence of coronary artery bypass grafting (CABG) was remarkably less in patients with successful PCI compared with those with failed PCI (1.8% vs 19.6%, p <0.0001). In conclusion, successful CTO-PCI compared with failed PCI was not associated with lesser risk for 3-year mortality. However, successful CTO-PCI was associated with significantly less subsequent CABG.
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156
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The effect of percutaneous coronary intervention of chronically totally occluded coronary arteries on left ventricular global and regional systolic function. Can J Cardiol 2013; 29:1436-42. [PMID: 24011798 DOI: 10.1016/j.cjca.2013.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 06/12/2013] [Accepted: 06/12/2013] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is frequently attempted to open chronic total occlusions (CTOs) and restore epicardial coronary flow. Data suggest adverse outcomes in the case of PCI failure. We hypothesized that failure to open a CTO might adversely affect regional cardiac function and promote deleterious cardiac remodelling, and success would improve global and regional cardiac function assessed using cardiac magnetic resonance and velocity vector imaging. METHODS Thirty patients referred for PCI to a CTO underwent cardiac magnetic resonance examination before and after the procedure. Left ventricular function and transmural extent of infarction was assessed in these patients. Regional cardiac function using Velocity Vector Imaging version 3.0.0 (Siemens) was assessed in 20 patients. RESULTS Successful CTO opening (thrombolysis in myocardial infarction 3 flow) occurred in 63% of patients. Left ventricular ejection fraction significantly increased after successful PCI (50 ± 13% to 54 ± 11%; P < 0.01). Global longitudinal strain (GLS) fell significantly in the failed group (Δ = -25 ± 17%; P = 0.02) in contrast with successful PCI in which GLS did not change (Δ 20 ± 32%; P = 0.17). GLS rate followed a pattern similar to GLS (failed, Δ -30 ± 17%; P < 0.01 vs success Δ 25 ± 48%; P = 0.34). In contrast, radial and circumferential strain/strain rate were not different between groups after success/failed PCI. CONCLUSIONS Regional cardiac function assessment using velocity vector imaging showed a significant decline in GLS and GLS rate in patients in whom PCI failed to open a CTO, with no change in global measures of cardiac function.
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Godino C, Bassanelli G, Economou FI, Takagi K, Ancona M, Galaverna S, Mangieri A, Magni V, Latib A, Chieffo A, Carlino M, Montorfano M, Cappelletti A, Margonato A, Colombo A. Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI. Int J Cardiol 2013; 168:1402-9. [PMID: 23317549 DOI: 10.1016/j.ijcard.2012.12.044] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Revised: 06/27/2012] [Accepted: 12/11/2012] [Indexed: 10/27/2022]
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158
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Erdogan E, Akkaya M, Bacaksız A, Tasal A, Sönmez O, Asoglu E, Kul S, Sahın M, Turfan M, Vatankulu MA, Göktekin O. Short-term effect of percutaneous recanalization of chronic total occlusions on QT dispersion and heart rate variability parameters. Med Sci Monit 2013; 19:696-702. [PMID: 23969577 PMCID: PMC3762394 DOI: 10.12659/msm.889511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background QT dispersion (QTd), which is a measure of inhomogeneity of myocardial repolarization, increases following impaired myocardial perfusion. Its prolongation may provide a suitable substrate for life-threatening ventricular arrhythmias. We investigated the changes in QTd and heart rate variability (HRV) parameters after successful coronary artery revascularization in a patient with chronic total occlusions (CTO). Material/Methods This study included 139 successfully revascularized CTO patients (118 men, 21 women, mean age 58.3±9.6 years). QTd was measured from a 12-lead electrocardiogram and was defined as the difference between maximum and minimum QT interval. HRV analyses of all subjects were obtained. Frequency domain (LF: HF) and time domain (SDNN, pNN50, and rMSSD) parameters were analyzed. QT intervals were also corrected for heart rate using Bazett’s formula, and the corrected QT interval dispersion (QTcd) was then calculated. All measurements were made before and after percutaneous coronary intervention (PCI). Results Both QTd and QTcd showed significant improvement following successful revascularization of CTO (55.83±14.79 to 38.87±11.69; p<0.001 and 61.02±16.28 to 42.92±13.41; p<0.001). The revascularization of LAD (n=38), Cx (n=28) and RCA (n=73) resulted in decrease in HRV indices, including SDDN, rMSSD, and pNN50, but none of the variables reached statistical significance. Conclusions Successful revascularization of CTO may result in improvement in regional heterogeneity of myocardial repolarization, evidenced as decreased QTcd after the PCI. The revascularization in CTO lesions does not seem to have a significant impact on HRV.
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Affiliation(s)
- Ercan Erdogan
- Department of Cardiology, Faculty of Medicine, Bezmialem Foundation University, Istanbul, Turkey
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Procedural outcomes of revascularization of chronic total occlusion of native coronary arteries (from a multicenter United States registry). Am J Cardiol 2013; 112:488-92. [PMID: 23672987 DOI: 10.1016/j.amjcard.2013.04.008] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 01/06/2023]
Abstract
Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is a rapidly evolving area of interventional cardiology. We sought to examine the immediate procedural and in-hospital clinical outcomes of native coronary artery CTO PCI from a multicenter United States (US) registry. We retrospectively examined the procedural outcomes of 1,361 consecutive native coronary artery CTO PCIs performed at 3 US institutions from January 2006 to November 2011. Mean age was 65 ± 11 years, 85% of patients were men, 40% had diabetes, 37% had previous coronary artery bypass graft surgery, and 42% had previous PCI. The CTO target vessel was the right coronary artery (55%), circumflex (23%), left anterior descending artery (21%), and left main or bypass graft (1%). The retrograde approach was used in 34% of all procedures. The technical and procedural success rates were 85.5% and 84.2%, respectively. The mean procedural time, fluoroscopy time, and contrast utilization were 113 ± 61 minutes, 42 ± 29 minutes, and 294 ± 158 ml, respectively. In multivariate analysis, female gender, no previous coronary artery bypass surgery, and years since initiation of CTO PCI at each center were independent predictors of procedural success. Major complications occurred in 24 patients (1.8%). In conclusion, among selected US-based institutions with experienced operators, native coronary artery CTO PCI can be performed with high success and low major complication rates.
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160
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Moreno R, García E, Teles R, Rumoroso JR, Cyrne Carvalho H, Goicolea FJ, Moreu J, Mauri F, Sabaté M, Mainar V, Patricio L, Valdés M, Cuellas C, Almeida M, Sánchez-Recalde A, Galeote G, Jimenez-Valero S, Calvo L, Plaza I, Lopez-Sendón JL, Martín JLR. Techniques and material used in the percutaneous treatment of chronic coronary occlusions. Data from the CIBELES study. Rev Port Cardiol 2013; 32:593-9. [PMID: 23896301 DOI: 10.1016/j.repc.2012.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 11/01/2012] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION In recent years, various specific techniques and materials have been developed for the treatment of coronary chronic total occlusions (CTO). OBJECTIVE To evaluate the current situation in the treatment of CTO (techniques and material) in our setting. METHODS We evaluated data on techniques and material used in the CIBELES (ChronIc coronary occlusion treated By EveroLimus Eluting Stent) trial, a randomized comparison of sirolimus- and everolimus-eluting stents in 207 patients with CTO in 13 centers in Spain and Portugal. RESULTS A radial approach was used in 23% of patients, and retrograde techniques were used in only 5%. A high number of balloons were used (2.2±0.9 per patient). Microcatheters were used in 33% of patients, and post-dilatation balloons in only 25%. The mean number of stents implanted per patient was 2.1±1.0, with a mean total stent length of 49±24 mm. Other devices and techniques used were: Tornus penetration catheter in 4% of patients, rotational atherectomy in 2%, and cutting balloon in 1%. Intracoronary ultrasound was used in only 6% of patients. In 34% of cases, operators used guidewires that were not specifically for CTO. Considerable variability between centers was detected in the use of different techniques, the highest and lowest variability being observed in the use of intracoronary ultrasound and the use of CTO guidewires, respectively. CONCLUSIONS In the CIBELES trial, techniques and devices specifically designed for the treatment of CTO were used in a relatively low proportion of patients. Considerable variability between centers was detected.
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Affiliation(s)
- Raul Moreno
- Interventional cardiology, University Hospital La Paz, Madrid, Spain.
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161
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Recanalisation of coronary chronic total occlusions with new techniques including the retrograde approach via collaterals. Neth Heart J 2013; 19:162-7. [PMID: 22020996 DOI: 10.1007/s12471-011-0091-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Percutaneous treatment of coronary chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The strategies of recanalisation in CTO have changed drastically due the development of new techniques such as the retrograde approach via collaterals. In this single-centre experience we sought to analyse the success rates with the use of different CTO techniques, the complication rates, and we evaluated predictors of failed CTO recanalisation attempts. METHODS AND RESULTS In this single-centre observational study we analysed the prospectively entered data of 331 consecutive patients, undergoing percutaneous coronary intervention (PCI) for CTO in 338 lesions at the Heart Center Wuppertal between June 2007 and July 2010. Nineteen lesions were attempted twice and one lesion three times (=358 procedures). The lesion-related success rates were 81.1%. Single-wire usage was the predominant strategy used in 198 antegrade cases (65.6%) followed by parallel wire technique and see-saw technique in 94 cases (31.1%). In the retrograde procedures, the reverse CART technique was predominantly used (35.7%), followed by retrograde wire passage (17.9%), marker wire (17.9%) and CART (14.3%). The in-hospital complications were low and comparable with conventional PCI data. The presence of blunt stump, severe calcification, severe tortuosity and occlusion length >30 mm were independent predictors of procedural failure. CONCLUSIONS A high degree of success with low in-hospital complications comparable with conventional PCI data can be expected in the hands of experienced CTO operators. A second try with a retrograde approach after antegrade failure should be considered.
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162
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Moreno R, García E, Teles R, Rumoroso JR, Cyrne Carvalho H, Goicolea FJ, Moreu J, Mauri F, Sabaté M, Mainar V, Patricio L, Valdés M, Cuellas C, Almeida M, Sánchez-Recalde A, Galeote G, Jimenez-Valero S, Calvo L, Plaza I, Lopez-Sendón JL, Martín JLR. Techniques and material used in the percutaneous treatment of chronic coronary occlusions. Data from the CIBELES study. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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163
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Rolf A, Werner GS, Schuhbäck A, Rixe J, Möllmann H, Nef HM, Gundermann C, Liebetrau C, Krombach GA, Hamm CW, Achenbach S. Preprocedural coronary CT angiography significantly improves success rates of PCI for chronic total occlusion. Int J Cardiovasc Imaging 2013; 29:1819-27. [DOI: 10.1007/s10554-013-0258-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/14/2013] [Indexed: 11/25/2022]
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164
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Michael TT, Karmpaliotis D, Brilakis ES, Abdullah SM, Kirkland BL, Mishoe KL, Lembo N, Kalynych A, Carlson H, Banerjee S, Lombardi W, Kandzari DE. Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularisation: insights from a multicentre US registry. Heart 2013; 99:1515-8. [PMID: 23598543 DOI: 10.1136/heartjnl-2013-303763] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Tesfaldet T Michael
- Department of Internal Medicine/Cardiology, VA North Texas Healthcare System, , Dallas, Texas, USA
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165
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Karrowni W, El Accaoui RN, Chatterjee K. Coronary collateral circulation: Its relevance. Catheter Cardiovasc Interv 2013; 82:915-28. [DOI: 10.1002/ccd.24910] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 02/12/2013] [Accepted: 02/26/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Wassef Karrowni
- Division of Cardiovascular Diseases; University of Iowa Hospitals and Clinics; Iowa City Iowa
| | - Ramzi N. El Accaoui
- Division of Cardiovascular Diseases; University of Iowa Hospitals and Clinics; Iowa City Iowa
| | - Kanu Chatterjee
- Division of Cardiovascular Diseases; University of Iowa Hospitals and Clinics; Iowa City Iowa
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166
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Sohrabi B, Ghaffari S, Habibzadeh A, Chaichi P, Kamalifar A. Outcome of Successful Versus Unsuccessful Percutaneous Coronary Intervention in Chronic Total Occlusions in One Year Follow-Up. Cardiol Res 2013; 4:68-73. [PMID: 28352423 PMCID: PMC5358216 DOI: 10.4021/cr258w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2013] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Chronic total occlusions (CTO) comprises already one-third of percutaneous coronary interventions (PCIs). There is controversy in PCI results considering short-term and long-term outcomes. We aim to compare efficacy and outcome of successful versus unsuccessful PCI in CTO in 1 year follow-up. METHODS In this retrospective study we choose 330 consecutive patients undergone PCI on a CTO of a native coronary artery (163 successful and 167 unsuccessful) in Madani Heart Hospital, Tabriz, Iran. Patients were followed for a mean period of about 15 ± 3 months. Major adverse cardiac events (MACE) in hospital and in follow-up were recorded comprising death, acute myocardial infarction, and need for repeat revascularization. RESULTS Patients with unsuccessful PCI compared to successful PCI were mainly male (87.4% vs. 77.3%; P < 0.02), had a higher incidence of diabetes mellitus (31.1% vs. 20.9%; P < 0.04) and hypertension (53.3% vs. 42.3%; P < 0.04). Most patients in successful group had single vessel disease (63.4% vs. 46.7%; P < 0.001) and less three-vessel disease (11.8% vs. 22.8%) compared to unsuccessful group. In-hospital MACE was insignificantly higher in unsuccessful PCI (17.4% vs. 11%). Unsuccessful PCI was significantly associated with higher rate of 12 months MACE (43.7% vs. 30.1%, P = 0.01), especially revascularization (41.3% vs. 25.2%, P = 0.02). CONCLUSION Although in hospital outcome was the same between groups, patients with successful PCI of CTO had a better one year follow-up outcome than unsuccessful PCI. However mortality rate was the same and main complications were due to revascularization.
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Affiliation(s)
- Bahram Sohrabi
- Dept. of Cardiology, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ghaffari
- Dept. of Cardiology, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afshin Habibzadeh
- Dept. of Cardiology, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parastoo Chaichi
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Kamalifar
- Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
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167
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Khan MF, Wendel CS, Thai HM, Movahed MR. Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: a meta-analysis comparing successful versus failed percutaneous intervention for chronic total occlusion. Catheter Cardiovasc Interv 2013; 82:95-107. [PMID: 23413111 DOI: 10.1002/ccd.24863] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 01/28/2013] [Accepted: 02/09/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Muhammad F Khan
- Southern Arizona VA Health Care System, Tucson, Arizona, USA.
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168
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Nassar Y, Boudou N, Carrie D. Radial approach and single wiring as first intentional strategies in chronic total occlusions of the left anterior descending coronary artery. J Saudi Heart Assoc 2013; 25:67-73. [PMID: 24174849 DOI: 10.1016/j.jsha.2013.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 02/11/2013] [Accepted: 02/24/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of the left anterior descending coronary artery (LAD) specifically is associated with improved long-term 5 years survival as compared to PCI failure. Simpler PCI techniques may be successful and safer than complex techniques which are perceived to have high failure rates and technical complexity. We aimed to describe the safety and effectiveness of first intentional single wiring and radial approach in the treatment of patients with a CTO of the native LAD coronary artery at Toulouse Rangueil university hospitals. PATIENTS AND METHODS The study was a single center prospective registry. All patients showed evidence of myocardial viability in LAD territory. The operators' initial strategy was to start by a radial access as a first choice whenever feasible; if not, a femoral access was chosen. The initial strategy for lesion crossing in either antegrade or retrograde approaches was single wiring by lesion crossing using one guidewire (GW) as a simple technique. RESULTS A total of 30 patients with 30 LAD CTO lesions (100%) were recorded. Mean age was 71.6 + 15 years, 77% were males and 23% were females. The access route was radial 66% of the time and femoral 54% of the time and with double access for contralateral injection in 40% of the patients. Sheaths and catheters sizes 6F were used in 53% of the patients, and 7F in 73% of the patients. Overall lesion success rate was 83% of lesions. Single wiring was the prevailing technique used in 97% of successful lesions (83% of total cases), while only 3% were by multiple wiring techniques. Successful single antegrade wiring represented 63% of our total study cases with a GW success rate of 92% of cases. Successful single retrograde wiring represented 13% of our cases with a GW success rate of 67%. Q-wave myocardial infarction (MI), stent thrombosis, stroke, emergency coronary artery bypass graft (CABG), major bleeding, radiation dermatitis, cardiac tamponade or clinical perforation requiring any hemostatic maneuvers did not occur. There was a post-procedural Troponin rise of 3x normal levels in 30% of patients, and contrast induced nephropathy in 7%. Intra-aortic balloon counterpulsation (IABCP) was used in 3% of patients and cardiac death occurred in 3% of patients. CONCLUSION Single wiring and radial access as initial strategies in PCI for LAD-CTO lesions in either approaches antegrade or retrograde are associated with a high procedural success rate and an acceptable incidences of adverse events.
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169
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Hoebers LP, Claessen BE, Dangas GD, Park SJ, Colombo A, Moses JW, Henriques JPS, Stone GW, Leon MB, Mehran R. Long-term clinical outcomes after percutaneous coronary intervention for chronic total occlusions in elderly patients (≥75 years): five-year outcomes from a 1,791 patient multi-national registry. Catheter Cardiovasc Interv 2013; 82:85-92. [PMID: 23436690 DOI: 10.1002/ccd.24731] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 09/20/2012] [Accepted: 10/15/2012] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To investigate procedural success rates and long-term clinical outcome of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in elderly patients. BACKGROUND Little is known about procedural success and long-term clinical outcome of PCI for CTO in the elderly. METHODS 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. RESULTS 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). CONCLUSION 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.
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Affiliation(s)
- Loes P Hoebers
- Academic Medical Center, University of Amsterdam, The Netherlands
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170
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Li M, Zhang J, Pan J, Lu Z. Obstructive Coronary Artery Disease: Reverse Attenuation Gradient Sign at CT Indicates Distal Retrograde Flow—A Useful Sign for Differentiating Chronic Total Occlusion from Subtotal Occlusion. Radiology 2013; 266:766-72. [DOI: 10.1148/radiol.12121294] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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171
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Pancholy SB, Boruah P, Ahmed I, Kwan T, Patel TM, Saito S. Meta-analysis of effect on mortality of percutaneous recanalization of coronary chronic total occlusions using a stent-based strategy. Am J Cardiol 2013; 111:521-5. [PMID: 23375252 DOI: 10.1016/j.amjcard.2012.10.034] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/22/2012] [Accepted: 10/22/2012] [Indexed: 11/18/2022]
Abstract
We performed a systematic review and meta-analysis comparing the all-cause mortality outcomes of successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) with unsuccessful CTO-PCI, using a stent-based strategy. Multiple studies comparing successful CTO-PCI with unsuccessful CTO-PCI have reported variable outcomes. No systematic review or meta-analysis has been performed after stenting became the default strategy for CTO-PCI. Searching major electronic databases, 64 studies were identified using the keywords "CTO," "PCI," and "mortality." Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method, 13 studies met the criteria for inclusion in the present meta-analysis. The short-term (≤30 days) and long-term (≥1 year) mortality outcomes were analyzed comparing successful CTO-PCI and unsuccessful CTO-PCI. Coronary perforation and its association with CTO-PCI success was analyzed. A significant reduction in short-term mortality was noted with successful CTO-PCI compared to unsuccessful CTO-PCI (odds ratio 0.218, 95% confidence interval 0.095 to 0.498, Z = -3.61, p <0.001). A similar, significant reduction in long-term mortality was noted with successful CTO-PCI compared to unsuccessful CTO-PCI (odds ratio 0.391, 95% confidence interval 0.311 to 0.493, Z = -7.957, p <0.001). A significant association was present between coronary perforation and unsuccessful CTO-PCI (odds ratio 0.168, 95% confidence interval 0.104 to 0.271, Z = -7.333, p <0.001). In conclusion, successful CTO-PCI using a predominantly stent-based strategy is associated with a significant reduction in short- and long-term mortality compared to unsuccessful CTO-PCI. Coronary perforation was associated with CTO-PCI failure.
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Affiliation(s)
- Samir B Pancholy
- Cardiovascular Diseases, The Wright Center for Graduate Medical Education and Medicine, The Commonwealth Medical College, Scranton, Pennsylvania, USA.
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Choi JH, Chang SA, Choi JO, Song YB, Hahn JY, Choi SH, Lee SC, Lee SH, Oh JK, Choe Y, Gwon HC. Frequency of Myocardial Infarction and Its Relationship to Angiographic Collateral Flow in Territories Supplied by Chronically Occluded Coronary Arteries. Circulation 2013; 127:703-9. [DOI: 10.1161/circulationaha.112.092353] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Despite complete interruption of antegrade coronary artery flow in the setting of a chronic total occlusion (CTO), clinical recognition of myocardial infarction is often challenging. Using cardiac MRI, we investigated the frequency and extent of myocardial infarction in patients with CTO, and assessed their relationship with regional systolic function and the extent of angiographic collateral flow.
Methods and Results—
We included 170 consecutive patients (median age, 62 years) with angiographically documented CTO. Regional late gadolinium enhancement and wall motion score index were assessed by cardiac MRI with the use of a 17-segment model. Angiographic collateral flow was assessed by the collateral connection grade and the Rentrop score. Evidence of previous myocardial infarction was found in 25% of patients by ECG Q waves, in 69% by regional wall motion abnormality, and in 86% of patients by late gadolinium enhancement. Increased angiographic collateral flow was associated with a lower frequency of Q waves on ECG, and a lower regional wall motion score index, late gadolinium enhancement volume (%), and degree of late gadolinium enhancement transmurality (all
P
<0.001), as well.
Conclusions—
The frequency of myocardial infarction in territories subtended by CTO is significantly higher than previously recognized. The degree of myocardial injury downstream epicardial CTO is inversely correlated with the degree of angiographic collaterals.
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Affiliation(s)
- Jin-Ho Choi
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Sung-A Chang
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Jin-Oh Choi
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Young Bin Song
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Joo-Yong Hahn
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Seung Hyuk Choi
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Sang-Chol Lee
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Sang-Hoon Lee
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Jae K. Oh
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - YeonHyeon Choe
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
| | - Hyeon-Cheol Gwon
- From Department of Medicine (J.-H.C., S.-A.C., J.-.O.C., Y.B.S., J.-Y.H., S.H.C., S.-C.L., S.-H.L., J.K.O., Y.H.C., H.C.G.); Department of Emergency Medicine (J.-H.C); Department of Radiology (Y.-H.C.), Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN (J.K.O.)
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Moreno R, García E, Teles R, Rumoroso JR, Cyrne Carvalho H, Goicolea FJ, Moreu J, Mauri J, Sabaté M, Mainar V, Patricio L, Valdés M, Fernández Vázquez F, Sánchez-Recalde A, Galeote G, Jimenez-Valero S, Almeida M, Lopez de Sa E, Calvo L, Plaza I, Lopez-Sendón JL, Martín JLR. Randomized comparison of sirolimus-eluting and everolimus-eluting coronary stents in the treatment of total coronary occlusions: results from the chronic coronary occlusion treated by everolimus-eluting stent randomized trial. Circ Cardiovasc Interv 2013; 6:21-8. [PMID: 23403384 DOI: 10.1161/circinterventions.112.000076] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Patients with coronary total occlusions are at especially high risk for restenosis and new revascularizations. Sirolimus-eluting stents dramatically improved the clinical outcome of this subset of patients in randomized trials, but other drug-eluting stents, mainly the everolimus-eluting stent (currently the most frequently used stent), have not yet been evaluated in patients with coronary total occlusions. The objective was to compare the second-generation everolimus-eluting stent with the first-generation sirolimus-eluting stent in patients with coronary total occlusions. METHODS AND RESULTS A total of 207 patients with coronary total occlusions and estimated time since occlusion >2 weeks were randomized to everolimus- or sirolimus-eluting stent. The primary end point was in-stent late loss at 9-month angiographic follow-up (noninferiority trial). Clinical follow-up was performed at 1 and 12 months. In-stent late loss at 9 months was 0.29±0.60 versus 0.13±0.69 mm in patients allocated to sirolimus- and everolimus-eluting stent, respectively. The observed difference in in-stent late loss between both groups was -0.16 mm (95% confidence interval, 0.04 to -0.36 mm; P for noninferiority <0.01). The rate of binary angiographic restenosis was 10.8% and 9.1% in patients allocated to sirolimus- and everolimus-eluting stent, respectively (P=0.709), whereas the rate of vessel reocclusion was 3.2% and 1.1%, respectively (P=0.339). At 12 months, the rate of major adverse events was 15.9% versus 11.1% with sirolimus- and everolimus-eluting stent, respectively (P=0.335), and probable or definitive stent thrombosis occurred in 3.0% and 0.0% of patients, respectively (P=0.075). CONCLUSIONS In patients with coronary total occlusions, everolimus-eluting stent is as effective as sirolimus-eluting stent. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00793221.
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Affiliation(s)
- Raul Moreno
- Hospital Universitario La Paz, 28046 Madrid, Spain.
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Percutaneous recanalization of chronic total occlusions: wherein lies the body of proof? Am Heart J 2013; 165:133-42. [PMID: 23351815 DOI: 10.1016/j.ahj.2012.10.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/05/2012] [Indexed: 01/28/2023]
Abstract
Although interventional technology and skills have markedly advanced, percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) lesions remains challenging. Indeed, CTO PCI is technically complex, carries the potential for a relatively high likelihood of failure and acute complications, and requires specifically skilled operators and a demanding use of resources. In addition, controversy persists surrounding appropriate indications for attempting CTO revascularization. Finally, there is a wide uncertainty on the actual benefits achieved with successful CTO recanalization. A growing number of studies have reported procedural results and/or assessed functional effects and long-term clinical outcomes of CTO PCI. We therefore sought to review and critically appraise the evidence base for procedural outcomes and potential clinical benefits of CTO PCI.
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175
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Ide S, Sumitsuji S, Kaneda H, Kassaian SE, Ostovan MA, Nanto S. A case of successful percutaneous coronary intervention for chronic total occlusion using the reversed guidewire technique. Cardiovasc Interv Ther 2013; 28:282-6. [PMID: 23315194 DOI: 10.1007/s12928-012-0156-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 12/26/2012] [Indexed: 11/29/2022]
Abstract
Percutaneous coronary intervention for chronic total occlusion remains a challenging field for interventional cardiologists because of inability to advance a wire beyond the occlusion. In case that the wire is not crossed to the distal main vessel but a side branch originated from distal end of the occlusion, we applied "reversed guidewire technique" which was initially proposed as a technique for extremely angulated bifurcations with utilizing hairpin shaped wire. In this case report, we describe application of this technique for chronic total occlusion in detail with potential limitations.
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Affiliation(s)
- Seiko Ide
- Department of Advanced Cardiovascular Therapeutics, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita-city, Osaka, 565-0871, Japan.
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Zhang S, Gai L, Jin Q, Gai J, He B, Chen Y. Comparison of coronary angiography-assisted and computed coronary tomography angiography-assisted recanalisation of coronary chronic total occlusion. HEART ASIA 2013; 5:148-53. [PMID: 27326112 DOI: 10.1136/heartasia-2013-010302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 05/21/2013] [Accepted: 06/30/2013] [Indexed: 11/04/2022]
Abstract
BACKGROUND Computed coronary tomography angiography (CCTA) provides an alternative to coronary angiography (CAG) and a complementary way of imaging. OBJECTIVE To determine whether CT assistance might help increase the recanalisation rate of coronary chronic total occlusion (CTO). METHOD Two experienced physicians took part in the study-one specialised in both CCTA and percutaneous coronary intervention (PCI), and the other had PCI experience only and no knowledge of CCTA. Consecutive patients were enrolled if CTO was diagnosed by CAG or by CCTA. The images were analysed on a dedicated work station which examined the length and characteristics of the occlusion, the calibre of the artery, the best projection for precision guidewire penetration, the use of a side branch and calcification for landmarking and selection of most suitable guidewires. Patients underwent CAG-guided PCI or CCTA-assisted PCI. The main end point was the recanalisation rate. Secondary end points included the time for successful passage of the guidewire, fluoroscopy time, and contrast, guidewire and stent consumption. RESULTS Thirty-six patients underwent CAG and 44 CCTA. The clinical characteristics and laboratory data of the two groups were similar (p>0.05). The patients in the CCTA group had more complex disease than those in the CAG group as shown by the J-CTO score (Multicenter CTO Registry of Japan) (p<0.05). Recanalisation was possible in 75.8% of the CAG group and 72.1% of the CCTA group. However, no statistical significance was found, p>0.05. In five of seven patients who had undergone unsuccessful PCI previously the procedure was successful at the second attempt when CCTA-assisted PCI was used. The patients were divided into those for whom the procedure was a failure or a success. The J-CTO score was an independent predictor of failure (OR=0.290, 95% CI 0.158 to 0.533). CONCLUSION CTO with favourable characteristics does not need CCTA guidance, but CCTA can be used to recanalise CTO with unfavourable characteristics when the procedure has previously failed. ACTRN12611000368932.
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Affiliation(s)
- Shuoyang Zhang
- Department of Cardiology , Chinese PLA General Hospital , Beijing , China
| | - Luyue Gai
- Department of Cardiology , Chinese PLA General Hospital , Beijing , China
| | - Qinhua Jin
- Department of Cardiology , Chinese PLA General Hospital , Beijing , China
| | - Jingjing Gai
- Department of Cardiology , Chinese PLA General Hospital , Beijing , China
| | - Bin He
- Department of Cardiology , Chinese PLA General Hospital , Beijing , China
| | - Yundai Chen
- Department of Cardiology , Chinese PLA General Hospital , Beijing , China
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177
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Li M, Zhang J, Pan J, Lu Z. Coronary total occlusion lesions: linear intrathrombus enhancement at CT predicts better outcome of percutaneous coronary intervention. Radiology 2012. [PMID: 23204539 DOI: 10.1148/radiol.12120961] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the presence of linear intrathrombus enhancement in coronary total occlusion (CTO) lesions observed at coronary computed tomographic (CT) angiography and its correlation with the outcome of percutaneous coronary intervention (PCI). MATERIALS AND METHODS All patients gave written informed consent, and the study protocol was approved by the hospital ethics committee. Consecutive patients with CTO confirmed at initial conventional coronary angiography were prospectively chosen to undergo a coronary CT angiography examination prior to their staged PCI. Linear intrathrombus enhancement was defined as a linear area of enhanced opacity traversing the nonopacified occluded segment with attenuation higher than 120 HU. Angiographic features, including lesion length, linear intrathrombus enhancement length, and calcification score, were measured at coronary CT angiography. Univariate and multivariate statistical tests were performed to identify variables associated with successful PCI. RESULTS Eighty patients with 88 CTO lesions were included in this study. Fifty-one lesions were successfully recanalized at PCI. Lesion length was longer in the PCI failure group (P = .043). Linear intrathrombus enhancement was observed in 30 (59%) of the 51 lesions successfully treated with PCI. However, linear enhancement was found in seven (19%) of 37 patients with failed PCI (P < .001 as compared with patients with successful PCI). Tortuous course was revealed to be the only angiographic parameter associated with unfavorable PCI outcome (P = .008). The presence of linear intrathrombus enhancement proved at multivariate analysis to be the only independent predictor of PCI success (odds ratio: 4.926; 95% confidence interval: 1.646, 14.74; P = .004). CONCLUSION The presence of coronary CT angiography-visible linear intrathrombus enhancement within the occluded segment predicts better outcome of PCI in CTOs.
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Affiliation(s)
- Minghua Li
- Department of Radiology, Shanghai No. 6 People's Hospital, School of Medicine, Shanghai Jiaotong University, 600 Yishan Rd, Shanghai, China 200233
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Geraci S, La Manna A, Tamburino C. How should I treat a massive thrombus embolisation in the left coronary artery during chronic total occlusion revascularisation? EUROINTERVENTION 2012; 8:866-75. [PMID: 23171806 DOI: 10.4244/eijv8i7a130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND A 53-year-old man symptomatic for unstable angina, underwent PCI for a severe stenosis of the first obtuse marginal and a CTO of the left circumflex arteries. INVESTIGATIONS Physical examination, myocardial necrosis markers, ECG, transthoracic echocardiography, exercise ECG test, bilateral coronary angiography, cardiac magnetic resonance. DIAGNOSIS During PCI, antegrade contrast injection displaced a large clot from the guiding catheter into the left coronary artery causing massive thrombosis. The patient became haemodynamically unstable. The pressure wave from the guiding catheter was damped. MANAGEMENT Intravenous UFH and abciximab followed by aspiration from the guiding catheter, and then through an aspiration catheter, until clear blood came out and pressure wave was normalised. Subsequent left coronary angiography showed no residual thrombi with TIMI-3 flow. Afterwards, a CMR scan showed no myocardial damage.
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Affiliation(s)
- Salvatore Geraci
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
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Muramatsu T, Tsukahara R, Ito Y, Ishimori H, Park SJ, de Winter R, Shokry K, Wang L, Chen J, Wang H. Changing strategies of the retrograde approach for chronic total occlusion during the past 7 years. Catheter Cardiovasc Interv 2012; 81:E178-85. [PMID: 22517670 PMCID: PMC3600528 DOI: 10.1002/ccd.24447] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 03/13/2012] [Accepted: 04/12/2012] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We reviewed the technical changes and results achieved with the retrograde approach since we introduced it 7 years ago. SUBJECTS AND METHODS The subjects were 1,268 patients who were treated for CTO between January 2004 and December 2010. They were investigated with respect to the success rate, the frequency of employing the retrograde approach and its outcome, and other factors. RESULTS The retrograde approach was employed in ∼30% of chronic total occlusion (CTO) patients (n = 281) and the retrograde guidewire success rate was 81.1%. The kissing wire technique was substituted for the retrograde approach in 126 of the 281 patients, with antegrade crossing of a guidewire being successful in 88 of them (70%). The retrograde approach was combined with the CART and reverse controlled antegrade retrograde tracking (CART) techniques in 22 and 21 patients, respectively. Among 83 patients treated with Corsair catheters, crossing of the CTO was achieved in 63. The overall procedural success rate was 79.7% (224 patients). Complications of the retrograde approach included collateral channel dissection (2.1%), channel perforation (1.7%), CTO perforation (1.7%), and donor artery occlusion (1.1%). CONCLUSION The success rate and safety of the retrograde approach are both satisfactory if the appropriate devices and techniques are selected.
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Affiliation(s)
- Toshiya Muramatsu
- Division of Cardiology, Saiseikai Yokohama-City Eastern Hospital, 3-6-1 Shimosueyoshi, Tsurumu-ku, Yokohama-Shi, Kanagawa-Pref., Japan.
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180
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Improved cardiac survival, freedom from mace and angina-related quality of life after successful percutaneous recanalization of coronary artery chronic total occlusions. Int J Cardiol 2012; 161:31-8. [DOI: 10.1016/j.ijcard.2011.04.023] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 04/10/2011] [Accepted: 04/24/2011] [Indexed: 12/11/2022]
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181
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Galiuto L, Barchetta S, Fedele E, De Caterina AR, Locorotondo G, Leone AM, Burzotta F, Niccoli G, Rebuzzi AG, Crea F. Effects of late REopening of Coronary total Occlusion on micRovascular perfusion and myocarDial function: the RECORD study. Eur Heart J Cardiovasc Imaging 2012; 14:487-94. [DOI: 10.1093/ehjci/jes188] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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182
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Niccoli G, De Felice F, Belloni F, Fiorilli R, Cosentino N, Fracassi F, Cataneo L, Burzotta F, Trani C, Porto I, Leone AM, Musto C, Violini R, Crea F. Late (3 years) follow-up of successful versus unsuccessful revascularization in chronic total coronary occlusions treated by drug eluting stent. Am J Cardiol 2012; 110:948-53. [PMID: 22721573 DOI: 10.1016/j.amjcard.2012.05.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 05/23/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
Abstract
The success rate of recanalization of coronary chronic total occlusion (CTO) has improved in recent years, but the clinical benefit associated with successful CTO recanalization in the drug-eluting stent (DES) era is not well known. A cohort of 317 consecutive patients (mean age 65 ± 10, 84% men) with CTOs (defined as Thrombolysis In Myocardial Infarction [TIMI] flow grade 0 and duration >3 months) of native coronary vessels in which percutaneous coronary intervention was attempted was enrolled from June 2005 to March 2009. All successful procedures (196 patients) were performed by DES implantation. The incidence of major adverse cardiac events (MACEs; a composite of cardiac death, myocardial infarction, and repeat revascularization) was assessed during a mean follow-up period of 3 years. MACE predictors were assessed in clinical, angiographic, and procedural data, including procedural success. Patients with successful percutaneous coronary intervention experienced a significantly lower MACE rate compared to those with failed procedures (17 [9%] vs 32 [26%], p = 0.008). Patients with multivessel disease experienced MACEs more frequently than those with single-vessel disease (45 [22%] vs 4 [4%], p = 0.002). On multiple Cox regression analysis, the presence of multivessel disease and CTO opening failure were independent predictors of MACEs (hazard ratio 2.31, 95% confidence interval 1.17 to 4.96, p = 0.01, and hazard ratio 1.81, 95% confidence interval 1.33 to 4.12, p = 0.02, respectively). The worst prognosis was confined to patients with multivessel disease and failed procedures (hazard ratio 2.73, 95% confidence interval 1.21 to 3.92, p = 0.03). In conclusion, successful recanalization of CTOs with DES translates into a reduction of the 3-year MACE rate compared to failed procedures, and the worst prognosis is observed in patients with failed procedures and multivessel disease, a notion that might be taken into account in the management of patients with coronary CTOs.
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183
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Kim YH, Hwang SH, Lim CH, An HM, Kim HJ, Moon SG, Kang WY, Hwang SH, Kim W, Kim W. Reverse controlled antegrade and retrograde subintimal tracking in chronic total occlusion of right coronary artery. Korean Circ J 2012; 42:625-8. [PMID: 23091508 PMCID: PMC3467447 DOI: 10.4070/kcj.2012.42.9.625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 02/10/2012] [Accepted: 02/13/2012] [Indexed: 11/30/2022] Open
Abstract
Passage failure of guidewire is still remained most common reason for percutaneous coronary intervention (PCI) failure in chronic total occlusion (CTO). Intravascular ultrasound study (IVUS) and cardiac CT angiography can help identify features that most influence current success rates of PCI. We report our experience using the reverse controlled antegrade and retrograde subintimal tracking technique under the aid of IVUS, cardiac CT angiography for an ambiguous CTO of proximal right coronary artery.
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Affiliation(s)
- Yeon-Hwa Kim
- Division of Cardiology, Department of Internal Medicine, Gwangju Veterans Hospital, Gwangju, Korea
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184
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Ino Y, Toyoda Y, Ishii S, Mizukoshi M, Kusuyama Y, Kubo T, Imanishi T, Akasaka T. Occlusion of left main coronary artery during percutaneous coronary intervention for chronic total occlusion of left circumflex artery with retrograde approach. Cardiovasc Interv Ther 2012; 28:81-6. [PMID: 22930371 DOI: 10.1007/s12928-012-0116-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 06/14/2012] [Indexed: 11/27/2022]
Abstract
The retrograde approach, a new technique of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO), allows coronary interventionalists to improve the success rate. However, this technique occasionally has serious complications. We report a case with the occlusion of left main coronary artery (LMCA) during PCI for CTO in the proximal LCX with retrograde approach because of backward spiral dissection formed by retrograde wire. We could perform bail-out stenting for LMCA. In PCI for CTO in the proximal site of left coronary artery with retrograde approach, we should keep in mind a backward dissection to LMCA formed by retrograde wire.
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Affiliation(s)
- Yasushi Ino
- Division of Cardiology, Wakayama National Hospital, 1138 Wada, Mihama-cho, Hidaka-gun, Wakayama, Japan.
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185
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STOJKOVIC SINISA, SIANOS GEORGE, KATOH OSAMU, GALASSI ALFREDOR, BELESLIN BRANKO, VUKCEVIC VLADAN, NEDELJKOVIC MILAN, STANKOVIC GORAN, ORLIC DEJAN, DOBRIC MILAN, TOMASEVIC MILOJE, OSTOJIC MIODRAG. Efficiency, Safety, and Long-Term Follow-up of Retrograde Approach for CTO Recanalization: Initial (Belgrade) Experience with International Proctorship. J Interv Cardiol 2012; 25:540-8. [DOI: 10.1111/j.1540-8183.2012.00754.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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186
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Sun D, Wang J, Tian Y, Narsinh K, Wang H, Li C, Ma X, Wang Y, Wang D, Li C, Wu JC, Tian J, Cao F. Multimodality imaging evaluation of functional and clinical benefits of percutaneous coronary intervention in patients with chronic total occlusion lesion. Am J Cancer Res 2012; 2:788-800. [PMID: 22916078 PMCID: PMC3425125 DOI: 10.7150/thno.4717] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 07/13/2012] [Indexed: 12/21/2022] Open
Abstract
AIMS To determine the effects of percutaneous coronary intervention (PCI) on cardiac perfusion, cardiac function, and quality of life in patients with chronic total occlusion (CTO) lesion in left anterior descending (LAD) coronary artery. METHODS AND RESULTS Patients (n=99) with CTO lesion in the LAD coronary artery who had successfully undergone PCI were divided into three groups based on the SPECT/CTCA fusion imaging: (a) no severe cardiac perfusion defects (n=9); (b) reversible cardiac perfusion defects (n=40); or (c) fixed cardiac perfusion defects (n=50). No statistical difference of perfusion abnormality was observed at 6 months and 1 year after PCI in group (a). In group (b), SPECT/CTCA fusion imaging demonstrated that cardiac perfusion abnormality was significantly decreased 6 month and 1 year after PCI. Left ventricular ejection fraction (LVEF) increased significantly at 6 months and 1 year follow up. Quality of life improved at 6 months and 1 year after PCI procedure. Moreover, patients in group (c) also benefited from PCI therapy: a decrease in cardiac perfusion abnormality, an increase in LVEF, and an improvement in quality of life. PCI of coronary arteries in addition to LAD did not significantly affect cardiac function and quality of life improvement in each group. CONCLUSIONS PCI exerts functional and clinical benefits in patients with CTO lesion in LAD coronary artery, particularly in patients with reversible cardiac perfusion defects. SPECT/CTCA fusion imaging may serve as a useful tool to evaluate the outcomes of patients with CTO lesion in LAD coronary artery.
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187
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Waram KC, Willis NP, Girotra S, Shaker RL, Pershad A. Rationale for Percutaneous Intervention of CTO. Interv Cardiol Clin 2012; 1:265-279. [PMID: 28582012 DOI: 10.1016/j.iccl.2012.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Chronic total occlusion accounts for 15% of cases during diagnostic angiography with higher referral rate to surgical revascularization. With contemporary strategies and techniques, the success rate with experienced operators can exceed 90%. Currently available observational studies in carefully selected patient populations show evidence of a trend toward symptom relief; improvement in quality of life, left ventricular function, and mortality; and improved tolerance toward future ischemic events. Lack of randomized controlled trials comparing current optimal medical management with percutaneous coronary intervention for chronic total occlusion is a major barrier to widespread adaptation of this advanced complex interventional technique.
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Affiliation(s)
- Kethes C Waram
- Department of Interventional Cardiology, Banner Good Samaritan Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Nicholas P Willis
- Department of Interventional Cardiology, Banner Good Samaritan Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Sudhakar Girotra
- Department of Interventional Cardiology, Banner Good Samaritan Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Rimon L Shaker
- Department of Interventional Cardiology, Banner Good Samaritan Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Ashish Pershad
- Department of Interventional Cardiology, Banner Good Samaritan Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006, USA.
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188
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Lau E, Whitlow P. Informed Consent of the Chronic Total Occlusion Patient. Interv Cardiol Clin 2012; 1:365-372. [PMID: 28582022 DOI: 10.1016/j.iccl.2012.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This article focuses on the general principles of informed consent, then highlights the particular risks associated with chronic total occlusion interventions. The goal is to provide a basic framework for the interventional cardiologist to use when having consent discussions with his or her patients.
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Affiliation(s)
- Evan Lau
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44118, USA
| | - Patrick Whitlow
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44118, USA.
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189
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Murarka S, Heuser RR. Chronic total occlusions: successful recanalization of very old lesions. Catheter Cardiovasc Interv 2012; 81:802-9. [PMID: 22745054 DOI: 10.1002/ccd.24539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 06/24/2012] [Indexed: 11/06/2022]
Abstract
PURPOSE The treatment of chronic total occlusion is thought to be the final frontier in treating coronary artery disease nonsurgically. In the past, an old occlusion was not likely to be treated successfully percutaneous. We have had success in revascularizing some very old 20 plus year old occlusions percutaneously. METHODS Six patients were treated who had >20-year-old occlusions. Five patients were male; mean age of patients was 72.2 years (range 63-86). Mean age of the occlusion was 24.8 years. All patients had ischemia in the corresponding territory. Four of the patients had right coronary artery occlusions; one had a left circumflex occlusion and one had left anterior descending artery occlusion. RESULTS Using a combination of radial and/or femoral approach, we successfully recanalized all of these old occlusions. No patients had major adverse cardiac events. Two patients developed restenosis at follow-up that was subsequently treated uneventfully. All the patients had a complete relief of angina. CONCLUSION In a small single center experience, even very old occlusions >20-year old can be effectively treated with dedicated systems, excellent guiding catheter support and experienced physicians.
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Affiliation(s)
- Shishir Murarka
- Division of Internal Medicine, Banner Estrella Medical Center, Phoenix, Arizona, USA
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190
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Karmpaliotis D, Lembo NJ, Brilakis ES, Kandzari DE. Percutaneous Chronic Total Occlusion Revascularization: Program Development, Resource Utilization, and Economic Outcomes. Interv Cardiol Clin 2012; 1:391-395. [PMID: 28582024 DOI: 10.1016/j.iccl.2012.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Against the background of current data supporting indications for chronic total occlusion (CTO) revascularization and strategies that promote incrementally higher procedural success rates, this article introduces a multidisciplinary approach to CTO program development, establishes guidelines for the performance of safe and efficient CTO percutaneous coronary intervention, and reviews considerations related to resource utilization and economic outcomes with complex percutaneous coronary revascularization.
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Affiliation(s)
- Dimitri Karmpaliotis
- Piedmont Heart Institute, 275 Collier Road North West, Suite 300, Atlanta, GA 30309, USA.
| | - Nicholas J Lembo
- Piedmont Heart Institute, 275 Collier Road North West, Suite 300, Atlanta, GA 30309, USA
| | - Emmanouil S Brilakis
- Division of Cardiology, VA North Texas Health Care System, The University of Texas Southwestern Medical Center at Dallas, 4500 South Lancaster Road, Dallas, TX 75216, USA
| | - David E Kandzari
- Piedmont Heart Institute, 275 Collier Road North West, Suite 300, Atlanta, GA 30309, USA
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191
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2012; 79:453-95. [PMID: 22328235 DOI: 10.1002/ccd.23438] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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192
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Jaguszewski M, Targonski R, Fijalkowski M, Masiewicz E, Dubaniewicz W, Templin C, Koprowski A, Ciecwierz D, Nallamothu BK, Rynkiewicz A. Recanalization of isolated chronic total occlusions in patients with stable angina. Int J Cardiol 2012; 167:1542-6. [PMID: 22578737 DOI: 10.1016/j.ijcard.2012.04.097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 04/02/2012] [Accepted: 04/14/2012] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite procedural advances, recanalization of chronic total occlusions (CTOs) with percutaneous coronary intervention (PCI) remains controversial, particularly given that its long-term benefits are unclear. We assessed the association between successful PCI and symptom improvement as well as outcomes in patients with CTO and stable angina. METHODS We performed a retrospective study of 386 consecutive patients undergoing attempted PCI of an isolated CTO (i.e., no other angiographically-significant disease was present). We analyzed prospectively the change in Canadian Cardiovascular Society (CCS) classification system and occurrence of major adverse cardiovascular events (death, myocardial infarction or target vessel revascularization), after stratifying patients by procedural success. To understand which patients might benefit most from attempted PCI, multivariable models were constructed to predict: likelihood of successful PCI and symptom improvement, defined as resolution of angina or improvement of ≥ 2 CCS classes. RESULTS A total of 247 (64%) patients had successful PCI. Greater symptom improvement was noted after successful PCI at both 6 months (79.8% versus 34.5% with resolution of angina or improvement of ≥ 2 CCS classes, p<0.01) and 24 months (71.7% and 20.9%, respectively, p<0.01). No differences were noted in MACE (11.3% vs. 10.0% at 6 months, p=0.70; and 18.6% vs. 19.4% at 24 months, p=0.84). Multivariable analysis identified several factors associated with successful PCI, but not predictive of symptom improvement. In conclusion, successful PCI of an isolated CTO improves symptom burden, but is not associated with MACE at 6 or 24 months. CONCLUSIONS Several factors are associated with successful PCI, but identifying those most likely to have symptom improvement remains challenging.
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Affiliation(s)
- Milosz Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland.
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193
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Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Osherov AB, Yalonetsky S, Gannot S, Samuel M, Weisbrod M, Bierstone D, Sparkes JD, Wright GA, Strauss BH. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol 2012; 59:991-7. [PMID: 22402070 DOI: 10.1016/j.jacc.2011.12.007] [Citation(s) in RCA: 540] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 12/01/2011] [Accepted: 12/02/2011] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the prevalence, clinical characteristics, and management of coronary chronic total occlusions (CTOs) in current practice. BACKGROUND There is little evidence in contemporary literature concerning the prevalence, clinical characteristics, and treatment decisions regarding patients who have coronary CTOs identified during coronary angiography. METHODS Consecutive patients undergoing nonurgent coronary angiography with CTO were prospectively identified at 3 Canadian sites from April 2008 to July 2009. Patients with previous coronary artery bypass graft surgery or presenting with acute ST-segment elevation myocardial infarction were excluded. Detailed baseline clinical, angiographic, electrocardiographic, and revascularization data were collected. RESULTS Chronic total occlusions were identified in 1,697 (18.4%) patients with significant coronary artery disease (>50% stenosis in ≥1 coronary artery) who were undergoing nonemergent angiography. Previous history of myocardial infarction was documented in 40% of study patients, with electrocardiographic evidence of Q waves corresponding to the CTO artery territory in only 26% of cases. Left ventricular function was normal in >50% of patients with CTO. Half the CTOs were located in the right coronary artery. Almost half the patients with CTO were treated medically, and 25% underwent coronary artery bypass graft surgery (CTO bypassed in 88%). Percutaneous coronary intervention was done in 30% of patients, although CTO lesions were attempted in only 10% (with 70% success rate). CONCLUSIONS Chronic total occlusions are common in contemporary catheterization laboratory practice. Prospective studies are needed to ascertain the benefits of treatment strategies of these complex patients.
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Affiliation(s)
- Paul Fefer
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Toronto, Ontario, Canada
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194
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Whitlow PL, Burke MN, Lombardi WL, Wyman RM, Moses JW, Brilakis ES, Heuser RR, Rihal CS, Lansky AJ, Thompson CA. Use of a Novel Crossing and Re-Entry System in Coronary Chronic Total Occlusions That Have Failed Standard Crossing Techniques. JACC Cardiovasc Interv 2012; 5:393-401. [DOI: 10.1016/j.jcin.2012.01.014] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 01/21/2012] [Indexed: 10/28/2022]
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195
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Martín-Yuste V, Barros A, Leta R, Ferreira I, Brugaletta S, Pujadas S, Carreras F, Pons G, Cinca J, Sabate M. Determinantes del éxito de la revascularización de las oclusiones coronarias crónicas: estudio mediante tomografía computarizada con multidetectores. Rev Esp Cardiol 2012; 65:334-40. [DOI: 10.1016/j.recesp.2011.11.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 11/02/2011] [Indexed: 11/26/2022]
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196
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Martín-Yuste V, Barros A, Leta R, Ferreira I, Brugaletta S, Pujadas S, Carreras F, Pons G, Cinca J, Sabate M. Factors Determining Success in Percutaneous Revascularization of Chronic Total Coronary Occlusion: Multidetector Computed Tomography Analysis. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.rec.2011.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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197
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Jones DA, Weerackody R, Rathod K, Behar J, Gallagher S, Knight CJ, Kapur A, Jain AK, Rothman MT, Thompson CA, Mathur A, Wragg A, Smith EJ. Successful Recanalization of Chronic Total Occlusions Is Associated With Improved Long-Term Survival. JACC Cardiovasc Interv 2012; 5:380-8. [PMID: 22516393 DOI: 10.1016/j.jcin.2012.01.012] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Revised: 12/23/2011] [Accepted: 01/05/2012] [Indexed: 02/03/2023]
Affiliation(s)
- Daniel A Jones
- Department of Cardiology, Barts and the London NHS Trust, London, United Kingdom
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198
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Moses JW, Karmpaliotis D. Percutaneous Revascularization of Chronic Total Coronary Occlusions. JACC Cardiovasc Interv 2012; 5:389-92. [DOI: 10.1016/j.jcin.2012.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 03/08/2012] [Accepted: 03/08/2012] [Indexed: 10/28/2022]
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199
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Brayton K, Mohammad A, Brilakis ES, Banerjee S. An update on coronary artery chronic total occlusions. Hosp Pract (1995) 2012; 40:232-5. [PMID: 22406899 DOI: 10.3810/hp.2012.02.964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A coronary artery chronic total occlusion (CTO) represents a coronary artery that has been occluded for a long period of time, typically months. Coronary artery CTOs are common and occur in approximately one-third of patients referred for coronary angiography. Revascularization of CTO is technically challenging and has historically been associated with lower procedural success rates and higher complication rates. Technical success of CTO revascularization has significantly improved given remarkable advances in interventional cardiology over the past 3 decades. However, the decision to perform CTO revascularization remains a dilemma, given the lack of robust clinical evidence to support its use.
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Affiliation(s)
- Kimberly Brayton
- University of Texas Southwestern Medical Center, Dallas, TX 75216, USA
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200
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Godino C, Latib A, Economou FI, Al-Lamee R, Ielasi A, Bassanelli G, Figini F, Chieffo A, Montorfano M, Colombo A, Carlino M. Coronary chronic total occlusions. Catheter Cardiovasc Interv 2012; 79:20-7. [DOI: 10.1002/ccd.23058] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 02/13/2011] [Indexed: 11/06/2022]
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