Usefulness of intravascular ultrasound guidance in percutaneous coronary intervention with second-generation drug-eluting stents for chronic total occlusions (from the Multicenter Korean-Chronic Total Occlusion Registry)

OPTImized coronary interventions eXplaIn the bEst cliNical outcomEs (OPTI-XIENCE) study. Rationale and study design

INTRODUCTION

Clinical events may occur after percutaneous coronary intervention (PCI), particularly in complex lesions and complex patients. The optimization of PCI result, using pressure guidewire and intracoronary imaging techniques, may reduce the risk of these events. The hypothesis of the present study is that the clinical outcome of patients with indication of PCI and coronary stent implantation that are at high risk of events can be improved with an unrestricted use of intracoronary tools that allow PCI optimization.

METHODS AND ANALYSIS

Observational prospective multicenter international study, with a follow-up of 12 months, including 1064 patients treated with a cobalt‑chromium everolimus-eluting stent. Inclusion criteria include any of the following: Lesion length > 28 mm; Reference vessel diameter < 2.5 mm or > 4.25 mm; Chronic total occlusion; Bifurcation with side branch ≥2.0 mm;Ostial lesion; Left main lesion; In-stent restenosis; >2 lesions stented in the same vessel; Treatment of >2 vessels; Acute myocardial infarction; Renal insufficiency; Left ventricular ejection fraction <30 %; Staged procedure. The control group will be comprised by a similar number of matched patients included in the "extended risk" cohort of the XIENCE V USA study. The primary endpoint will be the 1-year rate of target lesion failure (TLF) (composite of ischemia-driven TLR, myocardial infarction (MI) related to the target vessel, or cardiac death related to the target vessel). Secondary endpoints will include overall mortality, cardiovascular mortality, acute myocardial infarction, TVR, TLR, target vessel failure, and definitive or probable stent thrombosis at 1 year.

IMPLICATIONS

The ongoing OPTI-XIENCE study will contribute to the growing evidence supporting the use of intra-coronary imaging techniques for stent optimization in patients with complex coronary lesions.

Contemporary In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the MENATA (Middle East, North Africa, Turkey, and Asia) Chapter of the PROGRESS-CTO Registry

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been rapidly evolving in different parts of the world. We examined the clinical and angiographic characteristics and procedural outcomes of 1,079 consecutive CTO PCIs performed in 1,063 patients at 10 centers in the Middle East, North Africa, Turkey, and Asia regions between 2018 and 2022. The mean age was 61 ± 10 years and 82% of the patients were men. The prevalence of diabetes (49%) and previous PCI (50%) was high. The most common target vessel was the right coronary artery (51%), followed by the left anterior descending artery (33%) and the circumflex artery (15%). The mean Japanese CTO score was 2.1 ± 1.2 and mean PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) score was 1.2 ± 1.0. The technical and procedural success rates were high (91% and 90%, respectively) with a low incidence (1.6%) of in-hospital major adverse cardiac events. The incidence of perforation was 4.6% (n = 50): guidewire exit was the most common mechanism of perforation (48%) and 14 patients required pericardiocentesis (28%). Antegrade wire escalation was the most common crossing strategy used (91%), followed by retrograde approach (24%) and antegrade dissection and re-entry (12%). Median contrast volume, air kerma radiation dose, and fluoroscopy time were 300 (200 to 400) ml, 3.7 (2.0 to 6.3) Gy, and 40 (25 to 65) minutes, respectively. In conclusion, high success and acceptable complication rates are currently achieved at experienced centers in the Middle East, North Africa, Turkey, and Asia regions using a combination of crossing strategies.

The role of intravascular imaging in chronic total occlusion percutaneous coronary intervention

Chronic total occlusions (CTOs) represent the most complex subset of coronary artery disease and therefore careful planning of CTO percutaneous coronary recanalization (PCI) strategy is of paramount importance aiming to achieve procedural success, and improve patient's safety and post CTO PCI outcomes. Intravascular imaging has an essential role in facilitating CTO PCΙ. First, intravascular ultrasound (IVUS), due to its higher penetration depth compared to optical coherence tomography (OCT), and the additional capacity of real-time imaging without need for contrast injection is considered the preferred imaging modality for CTO PCI. Secondly, IVUS can be used to resolve proximal cap ambiguity, facilitate wire re-entry when dissection and re-entry strategies are applied and most importantly to guide stent deployment and optimization post implantation. The role of OCT during CTO PCI is currently limited to stent sizing and optimization, however, due to its high spatial resolution, OCT is ideal for detecting stent edge dissections and strut malapposition. In this review, we describe the use of intravascular imaging for lesion crossing, plaque characterization and wire tracking, extra- or intra-plaque, and stent sizing and optimization during CTO PCI and summarize the findings of the major studies in this field.

Comparison of Long-Term Outcomes Between Intravascular Ultrasound-, Optical Coherence Tomography- and Angiography-Guided Stent Implantation: A Meta-Analysis

Intravascular ultrasonography (IVUS) and optical coherence tomography (OCT) guided percutaneous coronary interventions (PCI) are alternative techniques to angiography-guided (ANG-g) PCI in patients with coronary artery disease (CAD), especially for optimal stent deployment in coronary arteries. We conducted a network meta-analysis including studies comparing those three techniques. We searched databases for studies that compared IVUS, OCT, and ANG-g PCI in patients with CAD. Overall, 52 studies with 231,137 patients were included in this meta-analysis. ANG-g PCI had higher major adverse cardiovascular events (MACEs), all-cause death, cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST) than IVUS-guided PCI. Of note, both OCT-guided and IVUS-guided PCI had similar outcomes. The frequency of MACEs, cardiac death, and MI were higher in ANG-g PCI than in OCT-guided PCI. The highest benefit was established with OCT for MACEs (P-score=.973), MI (P-score=.823), and cardiac death (P-score=.921) and with IVUS for all-cause death (P-score=.792), TLR (P -score=.865), and ST (P-score=.930). This network meta-analysis indicated that using OCT or IVUS for optimal stent implantation provides better outcomes in comparison with ANG-g in patients with CAD undergoing PCI.

Clinical and Procedural Outcomes of IVUS-Guided vs. Angiography-Guided CTO-PCI: A Systematic Review and Meta-Analysis

Chronic total occlusions (CTO) in coronary angiographies present a significant challenge nowadays. Intravascular ultrasound (IVUS) is a valuable tool during CTO-PCI, aiding in planning and achieving procedural success. However, the impact of IVUS on clinical and procedural outcomes in CTO-PCI remains uncertain. This meta-analysis aimed to compare IVUS-guided and angiography-guided approaches in CTO-PCI. The study included five studies and 2320 patients with stable coronary artery disease (CAD) and CTO. The primary outcome of major adverse cardiac events (MACE) did not significantly differ between the groups (p = 0.40). Stent thrombosis was the only secondary clinical outcome that showed a significant difference, favoring the IVUS-guided approach (p = 0.01). Procedural outcomes revealed that IVUS-guided procedures had longer stents, larger diameters, and longer procedure and fluoroscopy times (p = 0.007, p < 0.001, p = 0.03, p = 0.002, respectively). Stent number and contrast volume did not significantly differ between the approaches (p = 0.88 and p = 0.33, respectively). In summary, routine IVUS use did not significantly improve clinical outcomes, except for reducing stent thrombosis. Decisions in CTO-PCI should be individualized based on patient characteristics and supported by a multi-parametric approach.

Recanalisation of coronary chronic total occlusions

Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning. The contemporary procedural success rate is 80-90% with a reduction in complications. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. Despite this evidence, CTO recanalisation is grossly underutilised. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology.

Intravascular imaging in coronary stent restenosis: Prevention, characterization, and management

Despite the introduction of drug-eluting stents to combat the neointimal hyperplasia that occurred after BMS implantation, in-stent restenosis is still encountered in a significant number of patients, particularly as increasingly complex lesions are tackled by percutaneous coronary intervention. Many biological and mechanical factors interplay to produce restenosis, some of which are avoidable. Intravascular imaging provided unique insights into various forms of stent-related mechanical issues that contribute to this phenomenon. From a practical perspective, intravascular imaging can therefore help to optimize the stenting procedure to avert these issues. Moreover, once the problem of restenosis eventuates, imaging can guide the management by tackling the underlying identified mechanism. Finally, it can be used to evaluate the re-intervention results. Nevertheless, with the emergence of different treatment options, more evidence is needed to define patient/lesion-specific characteristics that may help to tailor treatment selection in a way that improves clinical outcomes.

Use of intravascular ultrasound for optimal vessel sizing in chronic total occlusion percutaneous coronary intervention

Aim

The aim of this study is to provide evidence on how use of standardized intravascular ultrasound (IVUS) use impacts stent size choice in the setting of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) compared to visual estimation.

Methods and results

Data of 82 consecutive patients who had successfully undergone IVUS-guided revascularization of CTO at the University Medical Center Mainz were analyzed. Angiography-based stent size prediction for the proximal and distal vessels was compared to the implanted stent diameter after IVUS assessment. Angiography-based stent size prediction for the proximal vessel was 3.09 ± 0.41, whereas IVUS use demonstrated larger vessel diameter, resulting in larger implanted stent diameter (3.24 ± 0.45, p &lt; 0.001). Proximal vessel stent size prediction was underestimated in the majority of patients by angiographic estimation. Angiography-based stent size prediction for the distal vessel was 2.79 ± 0.38, whereas IVUS use demonstrated larger vessel diameter, resulting in larger implanted stent diameter (2.92 ± 0.39, p &lt; 0.001).

Conclusion

Pre-stent IVUS assessment in CTO PCI provides important information on vessel morphology and size. Angiography-based stent size prediction for the proximal and distal vessels was frequently underestimated, IVUS use demonstrated larger vessel diameter, resulting in significantly larger implanted stent diameter.

The Clinical Effects of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion: A Meta-Analysis

Background

The clinical effects of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) lesions remain unclear.

Methods

We identified all full-text published studies that compared the effects of IVUS-guided CTO-PCI with angiography-guided CTO-PCI by searching electric databases including PubMed, Embase, Cochrane Library, and ISI Web of Science from the establishment to Nov 2021. There was no language limitation. The endpoints included the incidence of major adverse cardiac events (MACE), cardiac death, all-cause death, myocardial infarction (MI), and target vessel revascularization (TVR).

Results

Five studies involving a total of 2320 patients were included in this meta-analysis. Compared to the angiography-guided group, IVUS-guided PCI showed no significant reduction in the incidence of MACE (I² = 27.4%, P = 0.239; RR 0.929, 95% CI 0.765 to 1.128, P = 0.457), cardiac death (I² = 0.0%, P = 0.459; RR 0.574, 95% CI 0.299 to 1.103, P = 0.096), all-cause death (I² = 0.0%, P = 0.964; RR 0.677, 95% CI 0.395 to 1.163, P = 0.158), MI (I² = 46.7%, P = 0.131; RR0.836, 95% CI 0.508 to 1.377, P = 0.482), and TVR (I² = 21.2%, P = 0.279; RR 0.929, 95% CI 0.679 to 1.272, P = 0.648).

Conclusions

IVUS-guided PCI demonstrated no significant benefit on MACE, cardiac death, all-cause death, MI, and TVR in patients with CTO lesions. However, given the study's limitations, additional high-quality RCTs are needed.

Short- and Long-Term Prognosis of Intravascular Ultrasound-Versus Angiography-Guided Percutaneous Coronary Intervention: A Meta-Analysis Involving 24,783 Patients

Background

Intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) has potential benefits. This meta-analysis aimed to explore whether IVUS-guided PCI had better short- and long-term prognoses than angiography-guided PCI.

Methods

We retrieved studies from PubMed, Embase, and Cochrane Library. Clinical trials including retrospective and randomized controlled trials (RCTs) that compared IVUS-guided PCI with angiography-guided PCI were included. The patients were followed up after operation at 30 days, 1 year, 2 years, and 3 years. The clinical outcomes were target lesion revascularization (TLR), target vessel revascularization (TVR), and MACEs, including stent thrombosis (ST), myocardial infarction (MI), cardiac death, and all-cause death. The study population included patients with MI, coronary bifurcation lesions, short or long lesions, and unprotected left main coronary artery stenosis (ULMCA). The quality of retrospective trials was evaluated using the Newcastle-Ottawa Scale, and the quality of randomized controlled trials was evaluated using the Jadad score. A total of 20 clinical trials met the criteria. Three trials were randomized controlled trials, while 17 were retrospective trials.

Results

A total of 24,783 patients were included. In observational trials, the OR of MACEs was 0.49 (95% CI: 0.38-0.62) in 30 days, 0.65 (95% CI: 0.58-0.73) in one year, 0.51 (95% CI: 0.36-0.71) in two years, and 0.45 (95% CI: 0.31-0.65) in three years. In patients with long coronary lesions, the OR of MACEs in 1 year was 0.64 (95% CI: 0.28-1.50). In patients with left main artery disease, the OR of MACEs in 3 years was 0.42 (95% CI: 0.26-0.67). Compared with angiography-guided PCI, IVUS-guided PCI was associated with a lower incidence of MACEs during the same following period.

Conclusion

Compared with angiography-guided PCI, IVUS-guided PCI has better performance in reducing the occurrence of MACEs.

Procedural Results and Long-Term Outcomes of Percutaneous Coronary Intervention for in-Stent Restenosis Chronic Total Occlusion Compared with de novo Chronic Total Occlusion

Background

In-stent restenosis (ISR) chronic total occlusion (CTO) represents a challenging subgroup for revascularization of CTO by percutaneous coronary intervention (PCI). There are limited data on the treatment and outcomes of PCI for ISR CTO.

Objective

We aimed to evaluate the procedural results and 2-year outcomes of PCI for ISR CTO compared with de novo CTO.

Methods

Patients undergoing attempted CTO PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 2-year major adverse cardiac events (MACE) in patients undergoing ISR CTO and those undergoing de novo CTO PCI.

Results

A total of 426 patients undergoing 484 consecutive CTO PCI (ISR CTO PCI, n=84; de novo CTO, n=400) were enrolled during the study period. Patients undergoing de novo CTO PCI had a significantly greater syntax score than those undergoing ISR CTO PCI [23.0 (17.5, 30.5) vs 21.5 (14.5, 27.0), p=0.039]. Technical (73.8% vs 79.0%, p=0.296) and procedural (73.8% vs 78.0, p=0.405) success rates, as well as the incidence of major procedural complications (1.2% vs 2.3%, p=0.842), were comparable between the two groups. After a median follow-up of 20 months, patients who underwent ISR CTO PCI had a significantly higher incidence of MACE (33.3% vs 10.3%, p<0.001), mainly attributed to the higher TVR rates (24.7% vs 7.6%, p<0.001). ISR CTO was the only independent predictor of MACE (hazard ratio, 4.124; 95% confidence interval, 1.951–8.717; p<0.001) during follow-up in patients who underwent CTO PCI.

Conclusion

ISR CTO PCI shows comparable technical and procedural success, as well as major procedural complications compared with de novo CTO PCI. However, patients who underwent ISR CTO PCI had a significantly worse prognosis than those who underwent de novo CTO PCI, in terms of MACE, driven by TVR. ISR CTO was the only independent predictor of MACE during the follow-up.

Factors Influencing Stent Failure in Chronic Total Occlusion Coronary Intervention

Stent failure remains one of the greatest challenges for interventional cardiologists. Despite the evolution to superior second- and third-generation drug-eluting stent designs, increasing use of intracoronary imaging and the adoption of more potent antiplatelet regimens, registries continue to demonstrate a prevalence of stent failure or target lesion revascularisation of 15-20%. Predisposition to stent failure is consistent across both chronic total occlusion (CTO) and non-CTO populations and includes patient-, lesion- and procedure-related factors. However, histological and pathophysiological properties specific to CTOs, alongside complex strategies to treat these lesions, may potentially render percutaneous coronary interventions in this cohort more vulnerable to failure. Prevention requires recognition and mitigation of the precipitants of stent failure, optimisation of interventional techniques, including image-guided precision percutaneous coronary intervention, and aggressive modification of a patient's cardiovascular risk factors. Management of stent failure in the CTO population is technically challenging and itself begets recurrence. We aim to provide a comprehensive review of factors influencing stent failure in the CTO population and strategies to attenuate these.

Impact of intravascular ultrasound on chronic total occlusion percutaneous revascularization

AIM

We sought to investigate the impact of IVUS use on chronic total occlusion (CTO) PCI using data from a contemporary registry of consecutive patients and applying a propensity score matching analysis.

METHODS AND RESULTS

We evaluated 514 successful CTO-PCIs, median age: 67 years (IQR: 58-73), 83.5% males. IVUS-guided PCI was performed in 184 (35.8%) of cases. After using 1:1 propensity matching score analysis, two groups of 182 patients each (IVUS-guided vs. angiography-guided CTO-PCI group) were produced to form the study population. In the IVUS-guided group the median maximum stent diameter was larger and the median total stented segment was longer compared to the angiography-guided group [(3.5 mm, IQR: 3.0-4.0 vs. 3.2 mm, IQR: 3.0-3.5, p < 0.001) and (60.0 mm, IQR: 38.0-91.3 vs. 38.0 mm, IQR: 32.0-70.5, p < 0.001), respectively]. In the IVUS-guided group, retrograde recanalization was more frequently encountered compared to the angiography-guided PCI group (30.2% vs. 20.9%, p = 0.04). Procedural time was significantly longer in the IVUS-guided group, without any difference in fluoroscopy time, radiation dose and contrast volume. Multivariate linear regression analysis showed that IVUS use was the strongest independent factor associated with larger maximum diameter stents (p < 0.001) and a strong independent predictor for total stented segment length during CTO-PCI (p < 0.001). Up to 8 years follow-up, there was no difference in the incidence of the composite endpoint of all-cause death, cardiac death, myocardial infarction and target vessel revascularization between the IVUS-guided PCI and the angiography-guided PCI groups (hazard ratio: 13.7% vs. 15.9%, respectively, log-rank: p = 0.67, median follow-up time: 49.0 months, IQR: 33.0-67.0).

CONCLUSIONS

Use of IVUS in CTO-PCI was associated with larger stent diameter and longer stented segments. Despite more frequent use of IVUS in retrograde CTO-PCI, there was no difference in long-term adverse events between IVUS and angiography CTO-PCI groups; nevertheless, the study was not powered to assess clinical outcomes.

When to use intravascular ultrasound or optical coherence tomography during percutaneous coronary intervention?

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are intravascular imaging technologies widely used in the cardiac catheterization laboratory. The impact of these modalities for optimizing the acute and longer-term clinical impact following percutaneous coronary intervention (PCI) is supported by a wealth of clinical evidence. Intravascular imaging provides unique information for enhanced lesion preparation, optimal stent sizing, recognizing post PCI complications, and the etiology of stent failure. This review compares and contrasts the key aspects of these imaging modalities during PCI.

Intravascular Ultrasound Imaging-Guided Versus Coronary Angiography-Guided Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

Background

Intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) offers tomographic images of the coronary vessels, allowing optimization of stent implantation at the time of PCI. However, the long‐term beneficial effect of IVUS over PCI guided by coronary angiography (CA) alone remains under question. We sought to investigate the outcomes of IVUS‐guided compared with CA‐guided PCI.

Methods and Results

We performed a comprehensive search of PubMed, Medline, and Cochrane Central Register, looking for randomized controlled trials and observational studies that compared PCI outcomes of IVUS with CA. Data were aggregated for the primary outcome measure using the random‐effects model as pooled risk ratio (RR). The primary outcomes were the rate of cardiovascular death, need for target lesion revascularization, occurrence of myocardial infarction, and rate of stent thrombosis. A total of 19 studies met the inclusion criteria, comprising 27 610 patients divided into IVUS (n=11 513) and CA (n=16 097). Compared with standard CA‐guided PCI, we found that the risks of cardiovascular death (RR, 0.63; 95% CI, 0.54–0.73), myocardial infarction (RR, 0.71; 95% CI, 0.58–0.86), target lesion revascularization (RR, 0.81; 95% CI, 0.70–0.94), and stent thrombosis (RR, 0.57; 95% CI, 0.41–0.79) were all significantly lower using IVUS guidance.

Conclusions

Compared with standard CA‐guided PCI, the use of IVUS imaging guidance to optimize stent implantation is associated with a reduced risk of cardiovascular death and major adverse events, such as myocardial infarction, target lesion revascularization, and stent thrombosis.

Impact of Elevated Serum Uric Acid Level on Target Lesion Revascularization After Percutaneous Coronary Intervention for Chronic Total Occlusion

Elevated serum uric acid (SUA) level is reportedly associated with subsequent cardiovascular events including revascularization in patients with coronary artery disease. However, the impact of SUA level on revascularization in patients with chronic total occlusion (CTO), one of the highest risk subsets in coronary artery disease, is unclear. The aim of this study was to evaluate the impact of SUA level on target lesion revascularization (TLR) in contemporary percutaneous coronary intervention (PCI) for CTO. A total of 165 patients who underwent successful PCI with new-generation drug-eluting stent for CTO under intravascular ultrasound guidance were included. Patients were classified into 3 groups according to the tertiles of SUA level at baseline. Coronary angiography was qualitatively and quantitatively assessed, and gray-scale intravascular ultrasound was also analyzed. The primary end point was TLR. The tertiles of SUA level were as follows: low tertile, ≤5.2 mg/dl; intermediate tertile, 5.3 to 6.4 mg/dl; and high tertile, ≥6.5 mg/dl. During a median follow-up of 34 months, TLR was observed in 5 patients (8.8%) in the low tertile, in 5 (9.4%) in the intermediate tertile, and in 14 (25.5%) in the high tertile (p = 0.02). Kaplan-Meier analysis demonstrated a significantly higher incidence of TLR in patients with high tertile than the low and intermediate groups. Multivariable analysis showed SUA ≥6.5 mg/dl, diabetes mellitus, and longer CTO length as independent predictors of TLR. In conclusion, in patients who underwent PCI with drug-eluting stent, elevated SUA level was associated with TLR after successful recanalization of CTO.

A novel real-time intravascular ultrasound double-lumen microcatheter for recanalization of chronic total occlusion: a case report

Background

Chronic total occlusion revascularization remains a challenging problem because of its complexity. We present a case of a patient with chronic total occlusion who was successfully revascularized with the use of a new device called a real-time intravascular ultrasound double-lumen microcatheter.

Case presentation

A 58-year-old East Asians woman presented to our hospital with a complaint of recurrent chest pain of 5 months’ duration. Angiography revealed chronic total occlusion of the right coronary artery from the right coronary artery ostium to the ostia of the posterolateral and posterior descending branches. A guidewire was passed to the distal right coronary artery but went into the false lumens at the posterior descending and posterolateral ostia after use of the antegrade and retrograde approaches. Hence, we used the new device to pass through the subintimal right coronary artery space with reentry into the true lumen before the posterior descending and posterolateral ostia. A stent was successfully deployed at the posterior descending and posterolateral ostia, and the final result was excellent.

Conclusions

This device was useful for finding the entry point and for reentry into the true lumen of a chronic total occlusion. It may be a valuable tool for recanalization of complex chronic total occlusion lesions.

Chronic total occlusion intervention of the non-infarct-related artery in acute myocardial infarction patients: the Korean multicenter chronic total occlusion registry

BACKGROUND

The Korean chronic total occlusion (CTO) registry was collected prospectively from 26 cardiovascular centers since May 2007. The aim of this study is to investigate the impact of a successful staged percutaneous coronary intervention (PCI) of CTO lesions in acute myocardial infarction (AMI) patients on clinical outcomes.

PATIENTS AND METHODS

Among 2813 patients who underwent a staged PCI because of CTO lesions, 422 (15%) patients underwent primary PCI because of AMI. Among 422 patients, successful staged CTO-PCI was performed in 76%. The clinical outcomes were compared between the successful CTO-PCI group (n=321) and the failed CTO-PCI group (n=101). To adjust for potential confounders, a propensity score matching (PSM) analysis was carried out using the logistic regression model.

RESULTS

After the PSM analysis, two propensity-matched groups (85 pairs, n=170) were generated and the baseline characteristics were balanced. The incidence of total death (P=0.029) and non-ST-segment elevation myocardial infarction (NSTEMI, P=0.043) at 1 year was higher in the failed CTO-PCI group. Multivariate regression showed that successful CTO-PCI was an independent predictor of preventing mortality (hazard ratio, 0.21, P=0.048). In the subgroup analysis, the Kaplan-Meier curve showed that successful CTO-PCI had a lower incidence of total death (log-rank=0.004) and cardiac death (log-rank=0.005) up to 1 year in NSTEMI patients. Cox-proportional analysis showed that successful CTO-PCI was beneficial in patients with NSTEMI, hypertension, and non-left-anterior descending artery lesion for preventing mortality.

CONCLUSION

In this study, a staged successful CTO-PCI in AMI patients was associated with improved 1-year survival in the Korean population.

Intravascular ultrasound guidance improves patient survival (mortality) after drug-eluting stent implantation: review and updated bibliography

Individual studies IVUS vs angiography-guided DES implantation studies, whether randomized clinical trials or registries are underpowered, to show a reduction in mortality, especially at 1 year of follow-up. However, either meta-analyses or the few studies with long-term (> 5 year) follow-up showed that IVUS guidance reduced mortality and improved patient survival, even with second-generation DES.

Intravascular Ultrasound and Angioscopy Assessment of Coronary Plaque Components in Chronic Totally Occluded Lesions

BACKGROUND

The in vivo lesion morphologies and plaque components of coronary chronic total occlusion (CTO) lesions remain unclear.Methods and Results:We investigated 57 consecutive CTO lesions in 57 patients with stable angina pectoris undergoing elective percutaneous coronary intervention with intravascular ultrasound (IVUS) and coronary angioscopy (CAS) examination. All CTO lesions were classified according to the proximal angiographic lumen pattern; tapered-type (T-CTO) and abrupt-type (A-CTO). The differences in the intracoronary images of these lesion types were evaluated according to the location within the CTO segment. A total of 35 lesions (61.4%) were T-CTO. T-CTO lesions had higher frequencies of red thrombi (proximal 71.4%; middle 74.3%; distal 31.4%; P<0.001) and bright-yellow plaques (yellow-grade 2-3) (48.6%; 74.3%; 2.9%; P<0.001) at the proximal or middle than at the distal subsegment; A-CTO lesions showed no significant differences among the 3 sub-segments. At the middle subsegment, T-CTO lesions showed higher frequencies of positive remodeling (51.4% vs. 18.2%, P=0.01) and bright-yellow plaques (74.3% vs. 13.6%, P<0.001) compared with A-CTO lesions. Multivariate analysis identified bright-yellow plaque as an independent predictor (odds ratio, 7.25; 95% confidence interval, 1.25-42.04; P=0.03) of the occurrence of periprocedural myocardial necrosis.

CONCLUSIONS

The combination of IVUS and CAS analysis may be useful for identifying lesion morphology and plaque components, which may help clarify the pathogenetic mechanism of CTO lesions.

Performance of J-CTO and PROGRESS CTO Scores in Predicting Angiographic Success and Long-term Outcomes of Percutaneous Coronary Interventions for Chronic Total Occlusions

Patient selection for and predicting clinical outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remain challenging. We hypothesized that both J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores will predict not only angiographic success but also long-term clinical outcomes of the patients who underwent PCI of CTO. Of 325 CTO PCIs performed at 2 Emory University hospitals from January 2012 to August 2015, 249 patients with complete baseline clinical, angiographic and follow-up data, were included in this analysis. Major adverse cardiovascular events (MACEs) consisted of a composite of death, myocardial infarction, and target vessel revascularization. Mean age was 63 ± 11 years old and mean follow-up was 19.8 ± 13.1 months. Angiographic success rates increased from 74.5% in 2012 to 85.7% in 2015. Greater J-CTO and PROGRESS CTO scores were not only associated with lower likelihood of angiographic success but also higher rates of long-term MACE. Compared with the scores of 0 to 2, J-CTO and PROGRESS CTO scores of ≥3 were associated with higher MACE. Multivariable analysis demonstrated that PROGRESS CTO scores of ≥3, male sex, and peripheral vascular disease were independent predictors of MACE. In conclusion, J-CTO and PROGRESS CTO scores are useful in predicting procedural success. In addition, the PROGRESS CTO score, and to a lesser degree J-CTO score, have predictive value for long-term outcomes in patients who underwent CTO PCI.

Incidence, predicting factors, and clinical outcomes of periprocedural myocardial infarction after percutaneous coronary intervention for chronic total occlusion in the era of new-generation drug-eluting stents

OBJECTIVE

This study aimed to examine predictors and clinical outcomes of periprocedural myocardial infarction (PMI) after chronic total occlusion (CTO) intervention.

BACKGROUND

There are limited data on the clinical implications of PMI after CTO intervention in the new-generation drug-eluting stent (DES) era.

METHODS

We enrolled 337 patients who underwent CTO intervention and met the study criteria. We evaluated the incidence and predictors of PMI, defined as an increase in creatine kinase-MB ≥3× the upper limit of normal (ULN) after intervention and compared the occurrence rates of major adverse cardiac and cerebrovascular events (MACCE, defined as the composite of cardiac death, myocardial infarction, stent thrombosis, target-vessel revascularization, or cerebrovascular accidents) between the PMI and non-PMI groups.

RESULTS

PMI occurred in 23 (6.8%) patients after CTO intervention. Significant independent predictors were previous bypass surgery [odds ratio (OR) = 5.52, 95% confidence interval (CI) = 1.17-25.92; P = 0.03], Japan-CTO score ≥3 (OR = 7.06, 95%CI = 2.57-19.39; P < 0.001), side branch occlusion (OR = 4.21, 95%CI = 1.13-15.66; P = 0.03), and longer procedure time (OR = 4.18, 95%CI = 1.35-12.99; P = 0.01). During a median follow-up of 29.6 months, the PMI group had a significantly higher MACCE rate than the non-PMI group (23.7 vs. 5.6%, P = 0.008 by log-rank test). PMI was an independent predictor of MACCE (HR = 4.26, 95%CI = 1.35-13.43; P = 0.01). The MACCE rate gradually increased in a CK-MB-dependent fashion and was highest in patients with ≥10× ULN (P = 0.005).

CONCLUSION

Previous bypass surgery, high Japan-CTO score, side branch occlusion, and longer procedure time were strongly related to PMI occurrence after CTO intervention. PMI was significantly associated with worse clinical outcomes in the new-generation DES era.

Utility of Intravascular Ultrasound in Percutaneous Revascularization of Chronic Total Occlusions: An Overview

Intravascular ultrasound has been used for >20 years to guide percutaneous coronary intervention in different subsets of coronary lesions. During the last decade, the interest in percutaneous coronary intervention for chronic total occlusion (CTO) has increased dramatically, leading to high success rates. Failure of guidewire crossing is the most common reason for failed CTO attempts. Certain angiographic features, such as blunt proximal CTO cap, tortuosity, heavy calcification, and lack of visibility of path in the distal vessel, increase procedural difficulty. A better understanding of the behavior of the guidewire within the CTO segment may represent a key issue to achieve successful outcome. In this respect, intravascular ultrasound imaging might have potential roles in the recanalization of CTOs. In this paper, we focused on the usefulness and the applications of intravascular ultrasound imaging in percutaneous CTO recanalization, underlying its impact on clinical outcome.

Predictors of poor clinical outcomes after successful chronic total occlusion intervention with drug-eluting stents

BACKGROUND

The aim of this study was to identify the prognostic predictors for the worse clinical outcomes after a successful chronic total occlusion (CTO) intervention with drug-eluting stents.

PATIENTS AND RESULTS

A total of 2334 patients in the multicenter Korean CTO registry who underwent a successful CTO intervention with drug-eluting stents (first generation, 1367, new generation, 967) were enrolled. The primary endpoint was the composite of cardiac death, myocardial infarction, and stent thrombosis.The cumulative incidence of the primary endpoint was 2.5% (median follow-up duration: 22 months). In multivariate analysis, age above 65 years [hazard ratio (HR)=1.769, 95% confidence interval (CI)=1.025-3.052, P=0.041], heart failure (HR=4.242, 95% CI=2.335-7.705, P<0.001), and diabetes (HR=1.773, 95% CI=1.043-3.012, P=0.034) were the significant predictors. The cumulative incidence of the primary endpoint was significantly higher in patients with three risk factors (19.1%) than in those with one (2.2%) or two (3.0%) risk factors (P=0.001). The cumulative target-vessel revascularization rate was 8.4%, with the significant predictors being a diffuse long lesion (HR=1.626, 95% CI=1.129-2.340, P=0.009) and at least three implanted stents (HR=1.964, 95% CI=1.301-2.965, P=0.001).

CONCLUSION

Clinical parameters such as age, diabetes, and heart failure were independent predictors of the composite of cardiac death, myocardial infarction, and stent thrombosis, whereas angiographic or procedural parameters such as lesion length and number of implanted stents were predictors of target-vessel revascularization. Clinical outcomes after CTO intervention were worse in patients with multiple risk factors.

The outcomes of intravascular ultrasound-guided drug-eluting stent implantation among patients with complex coronary lesions: a comprehensive meta-analysis of 15 clinical trials and 8,084 patients

Objective:

The effects of intravascular ultrasound (IVUS)-guided drug-eluting stent (DES) implantation in patients with complex coronary artery lesions remains to be controversial. This study sought to evaluate the outcomes of IVUS guidance in these patients.

Methods:

The EMBASE, Medline, and other internet sources were searched for relevant articles. The primary endpoint was major adverse cardiac events (MACE), including all-cause mortality, myocardial infarction (MI), and target-vessel revascularization (TVR). The incidence of definite/probable stent thrombosis (ST) was analyzed as the safety endpoint.

Results:

Fifteen clinical trials involving 8.084 patients were analyzed. MACE risk was significantly decreased following IVUS-guided DES implantation compared with coronary angiography (CAG) guidance (odds ratio [OR] 0.63, 95% confidence intervals [CI]: 0.53–0.73, p<0.001), which might mainly result from the lower all-cause mortality risk (OR 0.52, 95% CI: 0.40–0.67, p<0.001), MI (OR 0.70, 95% CI: 0.56–0.86, p=0.001), and TVR (OR 0.53, 95% CI: 0.40–0.70, p<0.001). The subgroup analyses indicated better outcomes of IVUS guidance in DES implantation for these patients with left main disease or bifurcation lesions.

Conclusion:

IVUS guidance in DES implantation is associated with a significant reduction in MACE risk in patients with complex lesions, particularly those with left main disease or bifurcation lesions. More large and powerful randomized trials are still warranted to guide stenting decision making. (Anatol J Cardiol 2017; 17: 258-68)

Utility of adjunctive modalities in Coronary chronic total occlusion intervention

Coronary chronic total occlusion (CTO) intervention remains one of the most challenging domains in interventional cardiology. Due to the technical challenges involved and potential procedural complications, CTO percutaneous coronary intervention (PCI) attempt and success rates remain less than standard PCI. However, the use of several adjunctive tools such as intravascular ultrasound, optical coherence tomography, rotational atherectomy, orbital atherectomy, excimer laser coronary atherectomy and percutaneous left ventricular assist device may contribute to improved CTO PCI success rates or provide better hemodynamic assessment of CTO lesion (i.e., using fractional flow reserve). In this review we present the current literature describing the utility and efficacy of these adjunctive modalities in CTO intervention.

Use of Intravascular Imaging During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry

BACKGROUND

Intravascular imaging can facilitate chronic total occlusion (CTO) percutaneous coronary intervention.

METHODS AND RESULTS

We examined the frequency of use and outcomes of intravascular imaging among 619 CTO percutaneous coronary interventions performed between 2012 and 2015 at 7 US centers. Mean age was 65.4±10 years and 85% of the patients were men. Intravascular imaging was used in 38%: intravascular ultrasound in 36%, optical coherence tomography in 3%, and both in 1.45%. Intravascular imaging was used for stent sizing (26.3%), stent optimization (38.0%), and CTO crossing (35.7%, antegrade in 27.9%, and retrograde in 7.8%). Intravascular imaging to facilitate crossing was used more frequently in lesions with proximal cap ambiguity (49% versus 26%, P<0.0001) and with retrograde as compared with antegrade-only cases (67% versus 31%, P<0.0001). Despite higher complexity (Japanese CTO score: 2.86±1.19 versus 2.43±1.19, P=0.001), cases in which imaging was used for crossing had similar technical and procedural success (92.8% versus 89.6%, P=0.302 and 90.1% versus 88.3%, P=0.588, respectively) and similar incidence of major cardiac adverse events (2.7% versus 3.2%, P=0.772). Use of intravascular imaging was associated with longer procedure (192 minutes [interquartile range 130, 255] versus 131 minutes [90, 192], P<0.0001) and fluoroscopy (71 minutes [44, 93] versus 39 minutes [25, 69], P<0.0001) time.

CONCLUSIONS

Intravascular imaging is frequently performed during CTO percutaneous coronary intervention both for crossing and for stent selection/optimization. Despite its use in more complex lesion subsets, intravascular imaging was associated with similar rates of technical and procedural success for CTO percutaneous coronary intervention.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02061436.

Usefulness of Intraprocedural Coronary Computed Tomographic Angiography During Intervention for Chronic Total Coronary Occlusion

Although intraprocedural coronary computed tomographic angiography (CCTA) allows for scanning during intervention without relocation of the patient, studies have yet to report on its use during chronic total occlusion (CTO) intervention. Therefore, we investigated the role of CCTA during CTO intervention, particularly whether CCTA could be used to evaluate the location of guidewires. A total of 61 patients scheduled for elective CTO intervention were consecutively enrolled and underwent CCTA and on-site analyses during intervention. Transverse axial and the curved multiplanar images in a 360-degree view were interactively used together to identify the location of guidewires, along with the adjustment of window condition. Intracoronary contrast injection was used for specific cases requiring enhancement of the distal part of the CTO. Most CCTAs were performed to confirm the location of a single guidewire; CCTA was also performed to evaluate parallel (3 patients) or retrograde wires (5 patients). The initial identification rate for guidewire location was 56% with immediate transaxial images, but it significantly increased to 87% after interactive on-site uses of the curved multiplanar images (p <0.001). Cases in which guidewire location could be predicted with CCTA evaluation show a numerically higher success rate than those that could not (83% vs 63%) but not statistical significance (p = 0.174). The mean time for CCTA evaluation and mean radiation dose were 8.6 minutes and 2.9 mSv, respectively. No specific complications occurred after CCTA and CTO procedures. Intraprocedural CCTA for identifying the location of the guidewires is feasible and safe when used for various CTO procedural steps.

Intravascular ultrasound-guided drug-eluting stent implantation: An updated meta-analysis of randomized control trials and observational studies

The use of intravascular ultrasound (IVUS) guidance for drug-eluting stent (DES) optimization is limited by the number of adequately powered randomized control trials (RCTs). We performed an updated meta-analysis, including data from recently published RCTs and observational studies, by reviewing the literature in Medline and the Cochrane Library to identify studies that compared clinical outcomes between IVUS-guided and angiography-guided DES implantation from January 1995 to January 2016. This meta-analysis included 25 eligible studies, including 31,283 patients, of whom 3192 patients were enrolled in 7 RCTs. In an analysis of all 25 studies, the summary results for all the events analyzed were significantly in favor of IVUS-guided DES implantation [major adverse cardiac events (MACE, odds ratio [OR] 0.76, 95% confidence intervals [CI]: 0.70-0.82, P<0.001); death (OR 0.62, 95% CI: 0.54-0.72, P<0.001); myocardial infarction (OR 0.67, 95% CI: 0.56-0.80, P<0.001); stent thrombosis (OR 0.58, 95% CI: 0.47-0.73, P<0.001); target lesion revascularization (TLR, OR 0.77, 95% CI: 0.67-0.89, P=0.005); target vessel revascularization (TVR, OR 0.85, 95% CI: 0.76-0.95, P<0.001)]. However, in a separate analysis of RCTs, a favorable result for IVUS-guided DES implantation was found only for MACE (OR 0.66, 95% CI: 0.52-0.84, P=0.001), TLR (OR 0.61, 95% CI: 0.43-0.87, P=0.006), and TVR (OR 0.61, 95% CI: 0.41-0.90, P=0.013). IVUS-guided percutaneous coronary intervention was associated with better overall clinical outcomes than angiography-guided DES implantation. However, in a solely RCT meta-analysis, this benefit was mainly driven by reduced rates of revascularizations.

Clinical Impact of Intravascular Ultrasound-Guided Chronic Total Occlusion Intervention With Zotarolimus-Eluting Versus Biolimus-Eluting Stent Implantation: Randomized Study

BACKGROUND

There have been no randomized studies comparing intravascular ultrasound (IVUS)-guided versus conventional angiography-guided chronic total occlusion (CTO) intervention using new-generation drug-eluting stent Therefore, we conducted a prospective, randomized, multicenter trial designed to test the hypothesis that IVUS-guided CTO intervention is superior to angiography-guided intervention.

METHODS AND RESULTS

After successful guidewire crossing, 402 patients with CTOs were randomized to the IVUS-guided group (n=201) or the angiography-guided group (n=201) and secondarily randomized to Resolute zotarolimus-eluting stents or Nobori biolimus-eluting stents. The primary and secondary end points were cardiac death and a major adverse cardiac event defined as the composite of cardiac death, myocardial infarction, or target-vessel revascularization, respectively. After 12-month follow-up, the rate of cardiac death was not significantly different between the IVUS-guided group (0%) and the angiography-guided group (1.0%; P by log-rank test=0.16). However, major adverse cardiac event rates were significantly lower in the IVUS-guided group than that in the angiography-guided group (2.6% versus 7.1%; P=0.035; hazard ratio, 0.35; 95% confidence interval, 0.13-0.97). Occurrence of the composite of cardiac death or myocardial infarction was significantly lower in the IVUS-guided group (0%) than in the angiography-guided group (2.0%; P=0.045). The rates of target-vessel revascularization were not significantly different between the 2 groups. In the comparison between Resolute zotarolimus-eluting stent and Nobori biolimus-eluting stent, major adverse cardiac event rates were not significantly different (4.0% versus 5.7%; P=0.45).

CONCLUSIONS

Although IVUS-guided CTO intervention did not significantly reduce cardiac mortality, this randomized study demonstrated that IVUS-guided CTO intervention might improve 12-month major adverse cardiac event rate after new-generation drug-eluting stent implantation when compared with conventional angiography-guided CTO intervention.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01563952.

Angiographic and clinical comparisons of intravascular ultrasound- versus angiography-guided drug-eluting stent implantation for patients with chronic total occlusion lesions: two-year results from a randomised AIR-CTO study

AIMS

This study sought to compare angiographic endpoints at one-year follow-up after a drug-eluting stent implantation guided by either intravascular ultrasound (IVUS) or angiography in patients with chronic total occlusion (CTO) lesions.

METHODS AND RESULTS

Patients with at least one CTO lesion recanalised successfully were randomly assigned to the IVUS-guided or the angiography-guided group. The use of IVUS for penetration of the true lumen and optimisation of stent expansion was only done in the IVUS-guided group. The primary endpoint was in-stent late lumen loss (LLL) at one-year follow-up. A total of 230 patients with CTO lesions after successful recanalisation were enrolled and followed with office visits or telephone contact up to 24 months. In-stent LLL in the IVUS-guided group was significantly lower compared to the angiography-guided group at one-year follow-up (0.28±0.48 mm vs. 0.46±0.68 mm, p=0.025), with a significant difference in restenosis of the "in-true-lumen" stent between the two groups (3.9% vs.13.7%, p=0.021). The minimal lumen diameter and minimal stent cross-section area significantly and negatively correlated with LLL (all p<0.001). The rates of adverse clinical events were comparable between the IVUS- and angiography-guided groups at two-year follow-up (21.7% vs. 25.2%, p=0.641).

CONCLUSIONS

The IVUS-guided stenting of the CTO lesion was associated with less LLL and a lower incidence of "in-true-lumen" stent restenosis. Additional study is required to identify the clinical benefit of the IVUS-guided procedure for CTO lesions. [ChiCTR-TRC-10000996].

Comparison of second- and first-generation drug eluting stent for percutaneous coronary chronic total occlusion intervention

BACKGROUND

The performance of contemporary second-generation drug-eluting stents (DESs) for percutaneous chronic total occlusion (CTO) intervention is not well established. The present study compared the efficacy and safety outcomes of second-generation DESs with those of first-generation DESs in CTO-percutaneous coronary intervention (PCI).

METHODS

This retrospective analysis included 1049 consecutive CTO patients who underwent successful DES implantation (first-generation; 487 vs. second-generation; 562 patients) between March 2003 and August 2014. The primary endpoint was the composite of all-cause death, Q-wave myocardial infarction (MI), or target-vessel revascularization (TVR).

RESULTS

During a follow-up of 3 years, the primary endpoint incidence was 10.1% for second- and 7.7% for first-generation DES (p=0.30). After multivariable adjustment, there was no significant difference between these groups in terms of the risk of composite of death, Q-wave MI, or TVR (Hazard ratio [HR] 1.42, 95% confidence interval [CI] 0.88-2.28, p=0.15) nor in the individual risks of death (adjusted HR 1.33, 95% CI 0.69-2.56, p=0.39), Q-wave MI (adjusted HR 1.15, 95% CI 0.30-4.47, p=0.84) and TVR (adjusted HR 1.06, 95% CI 0.52-2.15, p=0.87). The incidence of definite/probable stent thrombosis was relatively low (0.5% vs.0.9%, p=0.17) throughout the follow-up period.

CONCLUSION

The 3-year clinical outcomes of patients treated with second-generation DESs are comparable to those treated with first-generation DESs for CTO-PCI.

Comparison of intravascular ultrasound guided versus angiography guided drug eluting stent implantation: a systematic review and meta-analysis

Background

Intravascular ultrasound (IVUS) can be a useful tool during drug-eluting stents (DES) implantation as it allows accurate assessment of lesion severity and optimal treatment planning. However, numerous reports have shown that IVUS guided percutaneous coronary intervention is not associated with improved clinical outcomes, especially in non-complex patients and lesions.

Methods

We searched the literature in Medline, the Cochrane Library, and other internet sources to identify studies that compare clinical outcomes between IVUS-guided and angiography-guided DES implantation. Random-effects model was used to assess treatment effect.

Results

Twenty eligible studies with a total of 29,068 patients were included in this meta-analysis. The use of IVUS was associated with significant reductions in major adverse cardiovascular events (MACE, odds ratios [OR] 0.77, 95 % confidence intervals [CI] 0.71-0.83, P < 0.001), death (OR 0.62, 95 % CI 0.54-0.71, p < 0.001), and stent thrombosis (OR 0.59, 95 % CI: 0.47-0.73, P < 0.001). The benefit was also seen in the repeated analysis of matched and randomized studies. In stratified analysis, IVUS guidance appeared to be beneficial not only in patients with complex lesions or acute coronary syndromes (ACS) but also patients with mixed lesions or presentations (MACE: OR 0.69, 95 % CI: 0.60-0.79, p < 0.001, OR 0.81, 95 % CI 0.74-0.90, p < 0.001, respectively). By employing meta-regression analysis, the benefit of IVUS is significantly pronounced in patients with complex lesions or ACS with respect to death (p = 0.048).

Conclusions

IVUS guidance was associated with improved clinical outcomes, especially in patients with complex lesions admitted with ACS. Large, randomized clinical trials are warranted to identify populations and lesion characteristics where IVUS guidance would be associated with better outcomes.