Early Procedural and Health Status Outcomes After Chronic Total Occlusion Angioplasty

Ventricular arrhythmias in patients with chronic total occlusion of coronary arteries: a review focused on interventional treatments

A chronic total occlusion (CTO) of a coronary artery is present in almost one-fifth of patients undergoing a scheduled coronary angiography. A CTO may be classified as infarct related when there is evidence of myocardial dysfunction in the territory of the obstructed vessel or as non-infarct related when the myocardial substrate has preserved its systolic function. The presence of a CTO has been associated with an increased risk of malignant ventricular arrhythmias (VAs), appropriate ICD shocks, and cardiac mortality, with infarct-related CTOs exhibiting a worse prognosis. During the last decade, technological advancements have improved the success rates of transcatheter revascularization, a treatment that has been proven valuable for persistently symptomatic patients. However, the role of revascularization in reducing the arrhythmic burden is unclear. On the contrary, catheter ablation of VAs has been suggested to be effective, despite the presence of a CTO. As for device therapies, an increased prevalence of appropriate ICD shocks should be expected in this population, bringing into consideration the implementation of the presence of CTO as a risk modifier in sudden cardiac death prevention algorithms. The aim of this review is to present the existing literature on the role of all kinds of interventions in the management of patients with CTOs and VAs.

Multiple Biomarkers to Predict Major Adverse Cardiovascular Events in Patients With Coronary Chronic Total Occlusions

There are limited tools available to predict the long-term prognosis of persons with coronary chronic total occlusions (CTO). A previously described blood biomarker panel to predict cardiovascular (CV) events was evaluated in patients with CTO. From 1,251 patients in the CASABLANCA study, 241 participants with a CTO were followed for an average of 4 years for occurrence of major adverse CV events (MACE, CV death, nonfatal myocardial infarction or stroke) and CV death/heart failure (HF) hospitalization. Results of a biomarker panel (kidney injury molecule-1, N-terminal pro-B-type natriuretic peptide, osteopontin, and tissue inhibitor of metalloproteinase-1) from baseline samples were expressed as low-, medium-, and high-risk. By 4 years, a total of 67 (27.8%) MACE and 56 (23.2%) CV death/HF hospitalization events occurred. The C-statistic of the panel for MACE through 4 years was 0.79 (p < 0.001). Considering the low-risk group as referent, the hazard ratio (HR) of MACE by 4 years was 6.65 (95% confidence interval [CI]: 2.98 to 14.8) and 12.4 (95% CI:5.17 to 29.6) for the medium and high-risk groups (both p < 0.001). The C-statistic for CVD/HF hospitalization by 4 years was 0.84 (p < 0.001). Compared to the low-risk score group, the medium and high-risk groups had HR of 5.61 (95% CI: 2.33 to 13.5) and 15.6 (95% CI: 6.18, 39.2; both p value <0.001). In conclusion, a multiple biomarker panel assisted in discriminating a broad range of risk for adverse outcomes in patients with coronary CTO. These results may have implications for risk stratification, patient care and could have a role for clinical trial enrichment.

Impact of complete revascularization on long-term clinical outcomes in patients with multi-vessel disease, including chronic total occlusion

To compare the long-term prognostic effect of complete percutaneous coronary intervention (PCI) on cardiovascular events in chronic total occlusion (CTO) patients with the multi-vessel disease (MVD) compared with medical therapy (MT). We enrolled 441 patients with CTO and MVD who underwent PCI. The study population was divided into the CTO-PCI (n = 231) and the CTO-MT (n = 210) groups. Active PCI for non-CTO lesions was permitted in both groups. The primary endpoint was defined as the composite of all-cause death or myocardial infarction (MI). The primary endpoint occurred more frequently in the CTO-MT group (13.5%) than in the CTO-PCI group (4.7%; P = 0.002). However, the target vessel revascularization (TVR), as a secondary endpoint, occurred more in the CTO-PCI group (16.3% vs. 5.5%, P = 0.001). After propensity score matching (PSM) analysis, the primary endpoint was higher in the CTO-MT group (12.6%) than in the PCI group (2.3%): all-cause death (8.4% vs. 2.3%, P = 0.042) and MI (4.3% vs. 0.0%, P = 0.023). Moreover, TVR of the CTO lesions occurred more frequently in the CTO-PCI group (18.1% vs. 6.8%, P = 0.009). Significant improvement in the left ventricular ejection fraction (LVEF) was observed in both groups. According to the results of the subgroup analysis, CTO-PCI may be more effective in patients with diabetes, preserved LVEF (> 50%), and well-developed collateral vessels (> grade II). In this study, complete revascularization in CTO with MVD reduced the incidence of all-cause death, MI, and a composite of both over a 5 year follow-up compared to medical treatment for CTO lesions.

Can multiparametric FDG-PET/MRI analysis really enhance the prediction of myocardial recovery after CTO revascularization? A machine learning study

PURPOSE

To comprehensively evaluate the effectiveness of FDG-PET/MRI multiparametric analysis in predicting myocardial wall motion recovery following revascularization of chronic coronary total occlusions (CTO), incorporating both traditional and machine learning approaches.

METHODS

This retrospective study assessed fluorine-18 fluorodeoxyglucose uptake (FDG), late gadolinium enhanced MR imaging (LGE), and MR wall motion abnormalities (WMA) of the left ventricle walls of a clinical cohort with 21 CTO patients (62 ± 9 years, 20 men). All patients were examined using a PET/MRI prior to revascularization and a follow-up cardiac MRI six months later. Prediction models for wall motion recovery after perfusion restoration were developed using linear and nonlinear algorithms as well as multiparametric variables. Performance and prediction explainability were evaluated in a 5x2 cross-validation framework, using ROC AUC and McNemar's test modified for clustered matched-pair data, and Shapley values.

RESULTS

Based on 79 CTO-subtended myocardial wall segments with wall motion abnormalities at baseline, the reference logistic regression model LGE + FDG obtained 0.55(SE = 0.07) in the clustered ROC AUC (cROC AUC) and 0.17(0.05) in the Global Absolute Shapley value. The reference outperformed FDG standalone in cROC AUC (-35(17) %, p < 0.0001), but not LGE standalone (11(12) %, p > 0.05). There were no statistically significant differences between the marginal probabilities of success of these three models. Moreover, no significant improvements (differences < 10 % in cROC AUC, and < 20 % in Global Absolute Shapley, p > 0.05) were found when using mixed effects logistic regression, decision tree, k-nearest neighbor, Naive Bayes, random forest, and support vector machine, with multiparametric combinations of FDG, LGE, and/or WMA.

CONCLUSION

In this clinical cohort, adding more complex interactions between PET/MRI imaging of cardiac function, infarct extension, and/or metabolism did not enhance the prediction of wall motion recovery after perfusion restoration. This finding raises the question whether multiparametric FDG-PET/MRI analysis has demonstrable benefits in risk stratification for CTO revascularization. Further studies with larger cohorts and external validation datasets are crucial to clarify this question and refine the role of multiparametric imaging in this context.

Effect of Interval Time after Subintimal Plaque Modification on the Success Rate of Future Recanalization for Chronic Total Occlusion Percutaneous Coronary Interventions

Background

Chronic total occlusion (CTO) is a complex and difficult type of coronary lesion for which elective secondary intervention after subintimal plaque modification (SPM) can improve the success rate. This study sought to determine the most appropriate timing for secondary interval interventions to maximize the benefit to the patient.

Methods

This study retrospectively included patients who failed their first CTO percutaneous coronary intervention (PCI) at Beijing Anzhen Hospital Department of Cardiology from January 2019 to December 2022. We reviewed the clinical characteristics, procedural features, and outcomes of patients who underwent SPM and returned to our institution for a second CTO-PCI.

Results

Of the 2847 patients who visited our institution between January 2019 and December 2022, 528 underwent SPM and returned to our institution on an elective basis for a secondary procedure. Of these, 236 procedures were performed within 30 days (Group I), and 292 were performed between 30 and 90 days (Group II). After the intervention, the occluded segment was successfully opened in 170 (72.0%) Group I and 248 (84.9%) Group II participants. When analyzing the factors for operational failure, we found that different intervals, diabetes mellitus, hyperlipidemia, and a history of previous PCI or percutaneous coronary angioplasty (PTCA) were the reasons for the secondary intervention failure. When analyzing the safety of the procedure, we found that pericardial effusion was the most common complication after the procedure, with an incidence of 7.4%. There was no notable variation in the incidence of pericardial effusion between the two groups, 8.9% vs. 6.2% (p = 0.232).

Conclusions

Higher success rates were observed when secondary procedures were performed between 30 and 90 days instead of within 30 days after the initial CTO-PCI SPM, with no significant difference in safety noted between the two groups.

Vascular Access-Site Complications in Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND

Vascular access-site complications (VASC) can occur during chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

METHODS

We compared the baseline and procedural characteristics, and outcomes of patients with versus without VASC in a large multicenter CTO PCI registry. VASC was defined as any of the following: small hematoma (hematoma < 5 cm), large hematoma (hematoma ≥ 5 cm), arteriovenous fistula, pseudoaneurysm and acute arterial closure.

RESULTS

VASC occurred in 158 of 16,810 CTO PCIs (0.9%). VASC patients were older (67 ± 11 vs. 64 ± 10 years, p < 0.001), more likely to be women (28.4% vs. 19.1%, p = 0.004) and less likely to be current smokers (18.9% vs. 27.2%, p = 0.026). They were more likely to have at least one femoral access (89.2% vs. 75.3%, p < 0.001) and less likely to have any radial access (38.0% vs. 52.3%, p < 0.001). Transfemoral access was more common in patients with VASC (60.1% vs. 45.7%, p < 0.001). VASC cases had higher J-CTO (2.57 vs. 2.38, p = 0.05) and PROGRESS-CTO major adverse cardiac events (MACE) scores (3.27 vs. 2.58, p < 0.001). They had similar technical (87.3% vs. 87.1%, p > 0.9) and procedural (82.3% vs. 85.9%, p = 0.2) success, but higher MACE (6.3% vs. 1.9%, p < 0.001) and bleeding (23.4% vs. 0.4%, p < 0.001). Female gender (odds ratio [OR] 1.95, 95% confidence intervals [CI] 1.24-3.00, p = 0.003), at least one femoral access (OR 2.02, 95% CI 1.09-4.04, p = 0.034) and sheath size (7-F: OR 2.16, 95% CI 1.12-4.60, p = 0.031; 8-F: OR 2.11, 95% CI 1.03-4.70,p = 0.051) were associated with VASC in multivariable analysis.

CONCLUSION

Female sex, femoral access and larger sheaths ≥ 7 F were associated with VASC in patients undergoing CTO PCI.

Myocardial infarction in multivessel disease: Does presence of chronic total occlusion make a difference?

BACKGROUND AND AIMS

Myocardial infarction (MI) in multivessel disease (MVD) and chronic total occlusion (CTO) is associated with high mortality. However, all-cause mortality of matched cohort without a CTO is unclear. Our aim was to analyse clinical characteristics, presenting symptoms, and survival of patients with MI in MVD and the possible impact of CTO on 1-year mortality.

METHODS

All MI patients with MVD (two or three vessel disease) hospitalized in our center from January 2020 to September 2022 (1309 patients) were selected. We conducted a propensity score matching (PSM) analysis based on age, gender, type of MI, and compared patients with CTO (CTO group, n = 90) and without CTO (Control group, n = 90).

RESULTS

We observed no difference in presenting clinical symptoms and initial heart rhythm between the groups. 1-year follow-up shows all-cause mortality rate of 23.3 % (n = 21) in the CTO group (Mean survival [MS] = 292.1 days, 95 % CI = 263.8 to 320.4) and 18.9 % (n = 17) in the Control group (MS = 310.2 days, 95 % CI = 285.3 to 335.2), p = 0.44. PCI alone was performed in 64.4 % (n = 58) in both groups, CABG in 18.8 % (n = 17) and 24.4 % (n = 22) (CTO vs. Control group respectively). Combination of PCI and CABG occurred in 8.8 % (n = 8) in both groups. Conservative treatment was chosen for 7 CTO and 2 Control group patients.

CONCLUSION

We observed no 1-year mortality difference in patients with MI, MVD and a CTO compared to a matched cohort of patients with MI, MVD without CTO. Excellent 1-year survival was observed in patients treated by CABG, irrespective of CTO presence.

Recent Advances in Coronary Chronic Total Occlusions

Coronary chronic total occlusions (CTOs) have been a point of interest of the medical community for the last decade. The natural history of CTOs was for a long time unknown, as the presence of a single CTO was the most frequent cause for the exclusion of patients from randomized controlled trials (RCTs). Recent CTO RCTs have failed to show any benefit in terms of hard endpoints as major adverse cardiovascular events, but have shown a significant improvement in quality of life, as well in the frequency of angina; however, these studies are characterized by the limitation of the short duration of their follow-up period. Real-world data from observational studies indicate a significant improvement in cardiovascular death and overall mortality, suggesting that the results depend on the duration of the follow-up, and not on the procedure per se. The aim of the current review is to summarize all the existing RCTs, and to analyze the most important registries, as well as to present the current development of techniques to boost the successful interventional treatment of CTOs.

Improvement of Radiation Management in Percutaneous Interventions of Chronic Total Occlusions in a Multicenter Registry

BACKGROUND

Excess radiation exposure is a limiting factor in percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO).

OBJECTIVES

The aim of this study was to analyze changes in radiation dose for CTO PCI with increasing risk awareness during the past decade and the determinants of these changes.

METHODS

A total of 16,439 procedures performed by 14 operators continuously participating in the European Registry of CTO-PCI from 2012 to 2023 were analyzed. Changes in air kerma (AK) were assessed, and a dose rate index (DRI) was calculated as AK per fluoroscopy time (FT).

RESULTS

Lesion complexity increased from a median J-CTO (Multicenter CTO Registry in Japan) score of 2 (Q1-Q3: 1-3) to 3 (Q1-Q3: 2-3) (P < 0.001), and technical success improved from 89.1% to 94.9% (P < 0.001), with stable FT. AK decreased from 2.50 Gy (Q1-Q3: 1.54-4.04 Gy) to 1.20 Gy (Q1-Q3: 0.66-2.12 Gy), a reduction of 52.0% (P < 0.001). Excess radiation of AK >5 Gy was reduced from 15.8% in 2012-2013 to 3.7% in 2022-2023. Clinical determinants of excess radiation were body mass index, gender, and previous bypass surgery; procedural determinants were FT, retrograde approach, and intravascular ultrasound use; and equipment determinants were radiographic equipment updates and fluoroscopy dose mode. Operators reduced DRI by 21.7% from 62.6 mGy/min (Q1-Q3: 44.7-89.3 mGy/min) to 49.0 mGy/min (Q1-Q3: 35.4-71.2 mGy/min) before a radiographic equipment update; after the update, DRI was further reduced to 31.5 mGy/min (Q1-Q3: 22.0-45.6 mGy/min), a decrease of 28.0% (P < 0.001) The interoperator comparison of DRI indicated considerable variability in radiation management.

CONCLUSIONS

AK for CTO PCI was reduced during the past decade to a level such that most procedures no longer must be aborted because of excess radiation. Equipment updates were instrumental, but interoperator differences remained.

Chronic total occlusion location and outcomes after percutaneous coronary intervention or medical therapy: ten-year follow-up of a single-center registry

INTRODUCTION AND OBJECTIVES

The clinical benefits of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) remain controversial. This study aimed to investigate whether PCI for CTO located in the left anterior descending artery (LAD) could have beneficial effects on clinical outcomes.

METHODS

Patients were retrospectively selected from a single-center CTO registry and followed up for approximately 10 years. The patients were grouped based on the presence of LAD CTO and whether the CTO was revascularized. Inverse probability weighting adjustment was also performed. The primary outcome was the composite of cardiac death or myocardial infarction at 10 years.

RESULTS

Among 1323 patients with CTO, 1034 were male, and 417 had LAD CTO. PCI was attempted in 72.2% of participants in the LAD CTO group and in 49.9% of those in the non-LAD CTO group. In the non-LAD CTO group, PCI did not significantly affect the primary outcome (medical therapy vs PCI, 20.7% vs 13.4%, adjusted HR: 0.72, 95%CI, 0.47-1.10; P=.13). However, a significant difference in the incidence of the primary outcome between the treatment methods was observed in the LAD CTO group (30.8% vs 15.4%; adjusted HR: 0.44; 95%CI, 0.25-0.81; P=.007). A significant interaction was observed between LAD CTO and treatment method (P for interaction=.011).

CONCLUSIONS

The benefits of PCI compared with medical therapy for CTO might be more apparent when the CTO is located in the LAD.

The impact of the Naples prognostic score in long-term outcomes after percutaneous coronary intervention for chronic total occlusions

BACKGROUND

Chronic total occlusions (CTOs) of coronary arteries present a significant challenge in cardiology, with long-term outcomes following percutaneous coronary intervention (PCI) for CTOs remaining variable and unpredictable. The Naples prognostic score (NPS), which incorporates markers of nutritional status and systemic inflammation, has shown potential in predicting outcomes in various cardiovascular settings. This study evaluates the NPS as a predictor of long-term outcomes after PCI for CTOs.

METHODS

A retrospective analysis was conducted on 287 patients who underwent coronary angiography. Patients were categorized into non-CTO-PCI and CTO-PCI groups. Patients were further stratified based on survival status. Cox regression and Kaplan-Meier survival analyses were used to evaluate the association between NPS and long-term outcomes.

RESULTS

The mean age of the study population was 63.5 ± 10.6 years, with 28.6% being female. The NPS was significantly higher in the CTO-PCI group compared to the non-CTO-PCI group ( P = 0.004) and was also elevated in the non-survival group ( P = 0.004). Multivariable Cox regression analysis identified NPS as an independent predictor of mortality ( P = 0.015). Kaplan-Meier analysis demonstrated significantly higher mortality in patients with an elevated NPS ( P = 0.009).

CONCLUSION

The NPS is a valuable independent predictor of long-term mortality in patients undergoing CTO-PCI. Incorporating NPS into existing risk stratification models could improve predictive accuracy and guide individualized patient management. Further prospective studies are warranted to validate these findings and explore interventions targeting inflammation and nutrition in this high-risk population.

Short- and long-term outcomes of antegrade versus retrograde approaches in patients undergoing percutaneous coronary intervention for chronic total occlusion: A meta-analysis

BACKGROUND

Chronic Total Occlusion (CTO) involves severe coronary artery blockage that impairs blood flow and affects 15-20 % of patients undergoing coronary angiography and over 40 % with diabetes or heart failure. Percutaneous Coronary Intervention (PCI) is used to restore blood flow in such cases. The retrograde approach, developed due to lower success with the antegrade method in complex cases, improves outcomes but increases complications. This meta-analysis compares the efficacy and safety of both approaches to guide clinical practice.

METHODS

A comprehensive literature search was conducted on PubMed, Embase, Google Scholar, and Scopus until June 5, 2024, to find studies comparing antegrade and retrograde approaches in CTO-PCI patients. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were calculated using R software (version 4.4.1), with significance set at p < 0.05. Random-effects models were used for all analyses.

RESULTS

Our analysis included 22 observational studies with 49,152 CTO-PCI patients: 35,844 in the antegrade arm and 13,308 in the retrograde arm. The antegrade approach showed significantly lower risks of in-hospital outcomes, including mortality [RR: 0.45; p < 0.001], myocardial infarction [RR: 0.37; p < 0.001], major adverse cardiovascular events [RR: 0.34; p < 0.001], and cerebrovascular events [RR: 0.50; p = 0.011]. Long-term outcomes, such as all-cause mortality [RR: 0.71; p = 0.157] and myocardial infarction [RR: 0.76; p = 0.438], were comparable between both approaches.

CONCLUSION

The antegrade technique shows better outcomes and procedural advantages over retrograde revascularization, though long-term outcomes are similar. Further studies, especially randomized controlled trials are needed to confirm these findings.

Preprocedural Planning for Chronic Total Occlusion Percutaneous Coronary Intervention

Chronic total occlusions (CTO) are frequently encountered in clinical practice. Although the success rates and safety of CTO percutaneous coronary intervention (PCI) have significantly improved with the development of newer equipment, use of an algorithmic approach, and advancement in procedural techniques, CTO PCI has a higher rate of complication than does non-CTO PCI. Therefore, meticulous preprocedural planning before CTO PCI is paramount to improve success and reduce the risk of complications. In this report, we review multiple aspects of preprocedural CTO PCI planning, including procedural indications, efficacy, safety, diagnostic angiography, scoring tools for procedural success and risk prediction, and preprocedural use of computed tomography coronary angiography.

Antegrade approach versus retrograde approach percutaneous coronary intervention for chronic total occlusion: An updated meta-analysis

BACKGROUND

Retrograde approach has notably improved success rates of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). However, longer procedural time, increase use of fluoroscopy and contrast dye have been reported in retrograde techniques in CTO PCI. We aimed to study in-hospital and long-term outcomes of retrograde approach versus antegrade approach in CTO PCI.

METHODS

We searched PubMed, Scopus, WOS, and Cochrane Central until June 2023 to include all relevant studies that compared retrograde approach versus antegrade approach in patients with CTO PCI. We synthesized the outcome data using a random-effects model, expressing the effect estimates as odds ratios (OR) or mean difference (MD) with corresponding 95 % confidence intervals (CI).

RESULTS

A total of 18 studies comprising 21,276 patients were included in the analysis. Regarding in-hospital outcomes, antegrade approach was associated with lower odds of MACE (OR= 0.34, 95 % CI: 0.23 to 0.51), all-cause mortality (OR= 0.35, 95 % CI: 0.19 to 0.64), MI (OR= 0.36, 95 % CI: 0.25 to 0.53), urgent pericardiocentesis (OR= 0.27, 95 % CI: 0.16 to 0.46), CIN (OR= 0.46, 95 % CI: 0.33 to 0.65), procedural complications (OR= 0.52, 95 % CI: 0.33 to 0.83), target vessel perforation (OR= 0.45, 95 % CI: 0.32 to 0.64). while antegrade was associated with higher success rates (OR= 1.16, 95 % CI: 1.1 to 1.22).

CONCLUSION

Compared to antegrade technique, retrograde was associated with higher risk for in-hospital and long-term adverse events, and preferably should be performed in more complex CTO lesions.

Sub-Intimal Tracking and Re-Entry and Investment Procedures: Current Applications and Future Directions

In seeking to improve upon chronic total occlusion (CTO) percutaneous coronary intervention success rates and minimize risk, CTO modification procedures (investment procedures) have been developed and utilized with increasing frequency. Two key techniques have emerged: subintimal tracking and re-entry (STAR) and subintimal plaque modification (SPM). Both require a staged approach with an index procedure for plaque modification and a second procedure weeks later for stenting. Both approaches require entry and wiring with a polymer-jacketed wire in the extra-plaque space, yet unlike SPM, which exclusively requires angioplasty of the extra-plaque space throughout the CTO segment, STAR also involves re-entry into the true luminal distal to the CTO before angioplasty. STAR and SPM, in many ways, represent a paradigm shift in our approach to CTO percutaneous coronary intervention from a 1-step to a 2-step approach in complex cases. In this review, we discuss the technical aspects of the procedures, and controversies and ongoing trials pointing to the future of these techniques. We also highlight non-device-based and intravascular ultrasound-based approaches to anterograde dissection and re-entry, which add to the CTO operator's toolkit for challenging cases.

Wire Escalation And De-escalation Techniques in Antegrade and Retrograde Approaches to Chronic Total Occlusion Percutaneous Coronary Interventions

Coronary chronic total occlusions (CTO) are frequently identified during coronary angiography and remain the most challenging subset of coronary artery lesions to treat; however, advancements in techniques and materials have greatly improved success rates. Various crossing algorithms have been developed to standardise the approach to CTO interventions based on angiographic criteria. Antegrade wiring is typically the initial strategy of choice, particularly in cases of short and straight CTOs with tapered proximal cap. Similarly, retrograde crossing can be achieved through retrograde wiring, although this approach has a very low success rate. This review aims to outline how to perform a CTO analysis, clarify the fundamental features of guidewires and provide insights into both antegrade and retrograde wire-based approaches.

Retrograde approach for recanalization in stumpless chronic total occlusion: A case report

Chronic total occlusive disease of the coronary arteries is the most challenging disease in the field of coronary intervention. When the anterograde approach is not feasible, the retrograde approach remains the only strategy.

Future Training Pathways in Percutaneous Coronary Interventions: Interventional Critical Care, Complex Coronary Interventions, and Interventional Heart Failure

While there has been a proliferation of training and practice paradigms in the realm of noncoronary interventions, coronary disease remains the predominant pathology necessitating interventional cardiology expertise. The landscape of coronary disease has also experienced a significant transformation due to rapidly evolving technologies, clinical application of mechanical circulatory support and other device innovations, and increasing acuity and complexity of patients. The modern interventional cardiologist is subject to challenges including decreasing coronary procedural volume, need to maintain clinical and financial productivity, and often also requirements of continued scholastic pursuit. Therefore, in the coming decade, there will be greater impetus to develop expertise in multiple new domains of practice. In this document, we propose 3 training paradigms that may assist the tertiary/quaternary center coronary interventional cardiologist to develop a unique clinical/scholastic niche, maintain clinical skills and productivity, and develop care models for complex patients within local and regional tertiary/quaternary hospitals.

The impacts of percutaneous coronary intervention to treat chronic total occlusion of right coronary artery on the 5-year prognosis: A single-centered retrospective study

BACKGROUND

Chronic total occlusions (CTO) occur in about 20% of patients referred for coronary angiography, and right coronary artery (RCA) CTO has been reported in 38-50% of the entire CTO population. Limited data on angiographic and procedural characteristics of RCA-CTO and the risk of adverse cardiac events asks for a detailed study.

METHODS

From 2010 to 2013, patients with attempted revascularization of at least one CTO lesion were included and followed up to 5 years after PCI. Eligible patients are assigned to RCA-CTO and non-RCA-CTO groups based on their target vessels. The primary endpoint was major adverse cardiovascular events (MACEs; a composite of all-cause death, myocardial infarction (MI) or rehospitalization for heart failure), and secondary endpoints were cardiac death, target lesion revascularization (TLR) and target vessel revascularization (TVR).

RESULTS

The present study included 2659 eligible patients, among which 1285 patients were assigned to the RCA-CTO group, whereas 1374 patients were assigned to the non-RCA-CTO group. Lesions in RCA had longer lesion length, higher J-CTO score, higher rates of severe vessel tortuosity, a higher percentage of Rentrop grade 2-3, and more likely to be re-try lesion than those in LAD or LCX (all P < 0.01). CTO lesions in RCA reached less successful recanalization and post-procedural TIMI 3 flow (all <0.01). Multivariate Cox analysis revealed that RCA-CTO was not associated with primary outcome MACEs. Besides MACEs, RCA-CTO was also not associated with cardiac death, but was significantly associated with TLR and TVR (adjusted HR: 1.37 [95% CI:1.07-1.76], P = 0.01; adjusted HR: 1.43 [95% CI:1.13-1.82], P = 0.003).

CONCLUSION

RCA-CTO lesions, which had more complex angiographic features, independently contributed to TLR and TVR but not to MACEs or cardiac death in the 5 years of follow-up.

Validation of the coronary artery specific chronic total occlusion percutaneous coronary intervention angiographic difficulty scores in the PROGRESS-CTO registry

BACKGROUND

The J-CTO investigators recently developed angiographic difficulty scores for each of the three major coronary arteries in patients undergoing first-attempt chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in de novo occlusions.

METHODS

We examined the performance of the individual J-CTO scores in a large multicenter registry.

RESULTS

The CTO lesion location was as follows: right coronary artery (RCA) 3,805 (54%), left anterior descending artery (LAD) 2,303 (33%), and left circumflex (LCX) 935 (13%). Patients in the PROGRESS-CTO registry were younger, more likely to be female, and had higher J-CTO scores compared with the J-CTO registry. Increasing difficulty scores were associated with lower technical success in the PROGRESS-CTO registry (score 0: 94.4 % - score ≥3: 82.6% for the RCA difficulty score; score 0: 96.4% - score ≥3: 86.1 for the LAD difficulty score; and score 0: 95.4% - score ≥3: 81.2% for the LCX difficulty score). The C-statistic of the coronary artery specific J-CTO scores in the PROGRESS-CTO registry were: LAD 0.69 (95% confidence intervals [CI], 0.64-0.73), LCX 0.63 (95% CI, 0.57-0.69), and RCA 0.61 (95-% CI, 0.58-0.64) with good calibration (Hosmer-Lemeshow p-value >0.05 for all). The AUC of the classic J-CTO score for LAD lesions was similar with the LAD J-CTO score (p-for-difference = 0.26), but worse for LCX (p-for-difference = 0.04) and RCA lesions (p-for-difference = 0.04).

CONCLUSION

In the PROGRESS-CTO registry, the coronary artery specific J-CTO scores did not improve prediction of the technical success of CTO-PCI compared with the classic J-CTO score.

Percutaneous Coronary Intervention Versus Robotic Coronary Bypass for Left Anterior Descending Artery Chronic Total Occlusion

Background

Both percutaneous coronary interventions (PCIs) and robotic-assisted coronary artery bypass (CAB) offer viable options for left anterior descending (LAD) chronic total occlusion (CTO) revascularization. Our study aims to compare long-term clinical outcomes associated with these 2 strategies.

Methods

In this retrospective study, we analyzed data from 273 patients diagnosed with LAD CTO who underwent either PCI (n = 129) or CAB (n = 144) at a single institution. Long-term follow-up was available for 96 PCI and 125 CAB patients. We employed Kaplan-Meier curves and the log-rank test to conduct cumulative survival analyses free of major adverse cardiovascular events (MACE), cumulative survival, survival free of myocardial infarction, and repeat revascularization.

Results

In the study cohort, patients who underwent PCI exhibited a higher prevalence of comorbidities including diabetes (48.9% vs 24.6%; P < .001), lower ejection fraction (44 ± 14 vs 52 ± 10; P < .001), prior heart failure (36.6% vs 22.2%; P = .02), and prior bypass surgery (16% vs 0, P < .001). PCI to non-LAD vessels was performed as part of initial complete revascularization in 40.3% of PCI and 40.6% of CAB patients. Upon a median 3.4 years of follow-up, CAB patients had significantly higher rates of survival free of MACE compared to PCI patients (unadjusted hazard ratio, 2.39; 95% CI, 1.13-5.03). Although PCI patients had similar unadjusted mortality, they experienced higher myocardial infarction and repeat revascularizations compared to CAB. However, the risk of repeat revascularization was attenuated after adjusting for prior bypass, diabetes, and ejection fraction.

Conclusions

Among patients with LAD CTO, those undergoing robotic-assisted CAB had a higher 5-year overall survival free of MACE compared to those who underwent PCI. This discrepancy in outcomes can be attributed in part to the greater burden of comorbidities among PCI patients.

The impact of successful chronic total occlusion percutaneous coronary intervention on clinical outcomes: a tertiary single-center analysis

Background

The benefit of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI) is controversial because of a lack of high-quality evidence. We aim to evaluate the impact of CTO-PCI on symptoms, quality of life and mortality.

Methods

We conducted a retrospective single center study of patients with CTO-PCI in a tertiary center in Austria. The study outcomes were Canadian Cardiovascular Society (CCS) angina score, quality of life measured by Seattle Angina Questionnaire (SAQ), and death at median follow up for patients with successful vs. failed CTO-PCI.

Results

A total of 300 patients underwent CTO-PCI for coronary artery disease, of which 252 (84%) were technically successful with median follow up of 3.4 years. There were no significant differences in in-hospital or all-cause mortality, major adverse cardiovascular event, or stent-related complications between the groups of failed and successful CTO-PCI. Among patients with successful CTO-PCI there was a significant improvement in CCS score, which was not found for the group with failed CTO-PCI. Successful reopening was associated with significant benefits of the SAQ domains of angina with stressful activity [3.7 ± 0.9 vs. 3.1 ± 0.5, p = 0.004, use of nitrates (4.7 ± 0.5 vs. 3.0 ± 1.0) p = 0.005] and satisfaction from angina relief (4.4 ± 1.1 vs. 3.6 ± 1.4 p < 0.001).

Conclusion

While there was no significant difference in mortality, successful CTO-PCI was associated with greater reduction in angina and the use of nitrates compared to unsuccessful CTO-PCI.

Who Should Undergo Chronic Total Occlusions Percutaneous Coronary Intervention and When?: An Evidence-Based Approach to the Patient Referred for Percutaneous Coronary Intervention of Chronic Total Occlusion

Chronic total occlusions (CTO) of the coronary arteries are common among patients presenting to the cardiac catheterization laboratory, and data suggests a worse overall prognosis in patients with CTOs. Percutaneous coronary intervention (PCI) of CTOs has been shown to improve anginal symptoms in observational studies and in a limited number of randomized trials. However, CTO PCI has not been shown to lead to a reduction in other important end points such as myocardial infarction or death. Furthermore, despite recent advances in the field, CTO PCI still carries higher risks and a lower likelihood of success compared with non-CTO PCI. Thus, determining which patients may be appropriate for CTO PCI is challenging and must involve a comprehensive risk-benefit analysis and discussion with the patient. Therefore, we review the currently available data regarding CTO PCI, including the clinical outcomes, the role of preprocedural ischemia testing, and various procedural success and risk stratification scores. Finally, we present our approach to the patient referred for CTO PCI.

Impact of Bifurcation Involvement and Location in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the EuroCTO Registry

Bifurcation involvement close to or within the occluded segment poses increasing difficulties for chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). However, this variable is not considered in the angiography-based CTO scoring systems nor has been extensively investigated in large multicenter series. Accordingly, we analyzed a CTO-PCI registry involving 92 European centers to explore the incidence, angiographic and procedural characteristics, and outcomes specific to CTO-PCIs with bifurcation involvement. A total of 3,948 procedures performed between January and November 2023 were examined (33% with bifurcation involvement). Among bifurcation lesions, 38% and 37% were located within 5 mm of the proximal and distal cap, respectively, 16% within the CTO body, and in 9% of cases proximal and distal bifurcations coexisted. When compared with lesions without bifurcation involvement, CTO bifurcation lesions had higher complexity (J-CTO 2.33 ± 1.21 vs 2.11 ± 1.27, p <0.001) and were associated with higher use of additional devices (dual-lumen microcatheter in 27.6% vs 8.4%, p <0.001, and intravascular ultrasound in 32.2% vs 21.7%, p <0.001). Radiation dose (1,544 [836 to 2,819] vs 1,298.5 [699.1 to 2,386.6] mGy, p <0.001) and contrast volume (230 [160 to 300] vs 190 [130 to 250] ml, p <0.001) were also higher. Technical success was similar (91.5% with bifurcation involvement vs 90.4% without bifurcation involvement, p = 0.271). However, the bifurcation lesions within the CTO segment (intralesion) were associated with lower technical success than the other bifurcation-location subgroups (83.7% vs 93.3% proximal, 93.4% distal, and 89.0% proximal and distal, p <0.001). On multivariable analysis, the presence of an intralesion bifurcation was independently associated with technical failure (odds ratio 2.04, 95% confidence interval 1.24 to 3.35, p = 0.005). In conclusion, bifurcations are present in approximately one-third of CTOs who underwent PCI. PCI of CTOs with bifurcation can be achieved with high success rates except for bifurcations within the occluded segment, which were associated with higher technical failure.

Temporal trends of case-fatality in patients undergoing dual-injection coronary chronic total occlusion recanalization

AIMS

Recently, interventional techniques and material to treat chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) have evolved significantly. Nevertheless, it is still unknown whether this progress improved treatment success and patients' outcome. In a nationwide sample, we sought to analyze trends of patients' characteristics, complications and in-hospital case-fatality of patients undergoing CTO revascularization in Germany.

METHODS AND RESULTS

We analyzed data on characteristics, treatments, and in-hospital outcomes for all coronary artery disease (CAD) patients (ICD-code I25) undergoing dual-injection CTO recanalization (OPS procedural code: 8-839.9) in Germany from 2009 to 2020. Overall, 4,998,457 inpatients aged ≥ 18 years with diagnosis of CAD were treated in German hospitals in this period. Among these, 52,879 patients (1.1%) underwent CTO recanalization. Annual number of CTO PCIs increased from 1263 in 2009 to 6435 in 2020 (β 3.48 [95% CI 3.44-3.52]; p < 0.001) in parallel with a significant decrease of case-fatality (2.2% in 2009 to 1.4% in 2020; β  - 0.60 [95% CI  - 0.82 to  - 0.39]; p < 0.001). Overall, 754 (1.4%) patients with CTO recanalization died during the in-hospital stay and in-hospital case-fatality grew exponentially with age (β 0.82 [95% CI 0.73-0.90]; p < 0.001). Significant predictors of in-hospital case fatality with an OR > 3 were cancer, stroke, hemopericardium, acute renal failure, pulmonary embolism and shock.

CONCLUSION

Annual number of CTO procedures performed in Germany increased from 2009 to 2020 with a concomitant anti-proportional decrease in the case-fatality. Our findings may help to draw more attention to predictors of in-hospital case fatality in patients hospitalized for CTO recanalization.

Is it Worthy Enough to Revascularize Chronically Occluded Coronaries?

Chronic total occlusions (CTOs) represent the "final frontier" of coronary interventions with the lowest procedural success rates and the most common reason for incomplete revascularization and referral to coronary artery bypass graft surgery (CABG). CTO lesions are not an infrequent finding during coronary angiography. They are often responsible for enhancing the complexity of the coronary disease burden thereby affecting the final interventional decision in the process. Notwithstanding the modest technical success of CTO-PCI, most of the earlier observational data demonstrated a clear survival benefit free of major cardiovascular events (MACE) in patients undergoing successful CTO revascularization. However, data from recent randomized trials fail to uphold the same survival advantage albeit, showing some trend toward improvement in left ventricular function, quality of life indicators and freedom from fatal ventricular arrythmia. Various guidance statements propose a well-defined role for CTO intervention in specific situations provided criterions for patient selection, appreciable inducible ischemia, myocardial viability and cost-risk-benefit analysis are met.

Emergency coronary artery bypass surgery after chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry

BACKGROUND

Emergency coronary artery bypass surgery (eCABG) is a serious complication of chronic total occlusion (CTO) percutaneous coronary artery intervention (PCI).

METHODS

We examined the incidence and outcomes eCABG among 14,512 CTO PCIs performed between 2012 and 2023 in a large multicenter registry.

RESULTS

The incidence of eCABG was 0.12% (n = 17). Mean age was 68 ± 6 years and 69% of the patients were men. The most common reason for eCABG was coronary perforation (70.6%). eCABG patients had larger target vessel diameter (3.36 ± 0.50 vs. 2.90 ± 0.52; p = 0.003), were more likely to have moderate/severe calcification (85.7% vs. 45.8%; p = 0.006), side branch at the proximal cap (91.7% vs. 55.4%; p = 0.025), and balloon undilatable lesions (50% vs. 7.4%; p = 0.001) and to have undergone retrograde crossing (64.7% vs. 30.8%, p = 0.006). eCABG cases had lower technical (35.3% vs. 86.7%; p < 0.001) and procedural (35.3% vs. 86.7%; p < 0.001) success and higher in-hospital mortality (35.3% vs. 0.4%; p < 0.001), coronary perforation (70.6% vs. 4.6%; p < 0.001), pericardiocentesis (47.1% vs. 0.8%; p < 0.001), and major bleeding (11.8% vs. 0.5%; p < 0.001).

CONCLUSIONS

The incidence of eCABG after CTO PCI was 0.12% and associated with high in-hospital mortality (35%). Coronary perforation was the most common reason for eCABG.

Chronic Total Occlusions: A State-of-the-Art Review

The percutaneous management of chronic total occlusions (CTO) is a well-established sub-specialty of Interventional Cardiology, requiring specialist equipment, training, and techniques. The heterogeneity of approaches in CTO has led to the generation of multiple algorithms to guide operators in their management. The evidence base for management of CTOs has suffered from inconsistent descriptive and quantitative terminology in defining the nature of lesions and techniques utilised, as well as seemingly contradictory data about improvement in ventricular function, symptoms of angina, and mortality from large-scale registries and randomised controlled trials. Through this review, we explore the history of CTO management and its supporting evidence in detail, with an outline of limitations of CTO-percutaneous coronary intervention and a look at the future of this growing field within cardiology.

Impact of successful antegrade and retrograde CTO PCI on short-term prognosis

BACKGROUND

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) carries risk of complications and should be attempted when the anticipated benefits exceed the potential risks. The primary indication for CTO-PCI is symptom improvement. However, the impact of CTO-PCI on angina and subsequent incidence of major adverse cardiovascular event (MACE) rate remains controversial. Our aim was to study the impact of technically successful elective CTO-PCI on the procedural success rate and short-term MACE. The current study was a prospective cohort study that included a total of 80 patients who were referred to our center (Ain Shams University Hospitals) for elective CTO-PCI and underwent technically successful CTO-PCI. Data were collected on patient arrival to our department, and then, the patients were observed during hospital admission to record any In-Hospital MACE. These patients were then followed up for 6 months to record improvement or worsening of their symptoms and to assess occurrence of any MACE including hospitalization and undergoing symptom-driven coronary angiography.

RESULTS

The mean age of our patients was 56 ± 9.6 years, and 73 patients (91%) were men. Sixty-two patients (77.5%) were done via an antegrade approach, and 18 patients (22.5%) were done via a retrograde approach with an overall procedural success rate of 91.25% (antegrade 93.5%, retrograde 83.3%). The overall mean procedure time was 102 min, the mean contrast volume used was 371 ml, and the mean cumulative air kerma dose was 7.2 Gy. The retrograde group required longer procedure times, larger volumes of contrast and higher exposure to radiation. The overall in-hospital MACE was 8.75%. Sixty-five patients in our study (81.25%) showed an improvement in the grade of their exertional dyspnea or angina within the 6-month follow-up period. Thirteen patients in our study (16.25%) needed re-hospitalization within a 6-month period after PCI. The overall target lesion revascularization rate at 6 months was 8.75%.

CONCLUSIONS

Technically successful CTO PCI in a well-equipped center with highly qualified CTO operators resulted in high procedural success rates and low incidence of short-term MACE.

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

Background

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has evolved a great deal over recent years, with increased procedural success and lower complication rates being reported. This study aims to evaluate the feasibility, safety and success of a dedicated CTO programme in a large UK PCI centre without on-site cardiothoracic surgery facilities.

Methods

Clinical and procedural data were retrospectively collected for consecutive unselected patients undergoing CTO PCI between 2015 and 2019 from the local database and regional electronic patient records. In-hospital outcomes and long-term major adverse cardiovascular events (all-cause mortality, MI, stroke and target vessel revascularisation) were recorded.

Results

A total of 170 patients underwent 191 CTO procedures during the study period. The mean age was 63 ± 10 years and 80.6% of patients were male (n=137). The clinical indications were: stable chronic coronary syndromes in 88.5% (n=169) of patients; staged procedures in the context of acute coronary syndromes in 1.6% (n=3); and presentation with acute coronary syndrome in 9.9% (n=19). The procedural success rate was 50.0% (n=25) for general interventional cardiologists and 90.1% (n=127) for dedicated CTO operators. In-hospital major adverse cardiovascular events occurred once (0.5%) and interhospital transfer for emergency salvage cardiac surgery was not required. Long-term follow-up data at a median duration of 3.8 years revealed 4 (2.4%) cardiac deaths, 14 (8.3%) spontaneous MI events and 10 (5.9%) target vessel revascularisations.

Conclusion

These data suggest CTO PCI using contemporary techniques is both safe and effective when undertaken in a high-volume non-surgical centre by experienced operators.

Practice differences and knowledge gaps in complex and high-risk interventions between Japan and the USA: A case-based discussion

Advances in percutaneous coronary intervention (PCI) devices and techniques have expanded the pool of eligible patients for revascularization, including those with comorbidities, reduced left ventricular function, or anatomical complexity (defined as CHIP: complex and high-risk interventions in indicated patients). CHIP interventions are typically performed by selected operators who specialize in complex PCI. This review presents two cases performed in the USA, to discuss the similarities and differences in practice patterns between CHIP operators in Japan and the USA. The first case involves a 58-year-old male presenting with myocardial infarction and cardiogenic shock, and the second case involves a 51-year-old female with a history of coronary artery bypass grafting presenting with a chronic total occlusion and PCI complicated by vessel perforation. The discussion focuses on appropriate patient selection, the role of the heart team approach for decision-making, the use of hemodynamic support devices, and other relevant factors. By comparing practices in Japan and the USA, this review highlights opportunities for knowledge exchange and potential areas for improving patient outcomes.

Clinical outcomes of percutaneous coronary intervention in chronic total occlusion in patients with type 2 diabetes mellitus

INTRODUCTION AND OBJECTIVES

Coronary chronic total occlusions (CTOs) are relatively common findings in patients with type 2 diabetes mellitus (T2DM). However, the indication for percutaneous coronary intervention (PCI) and its clinical benefit in these patients remain controversial.

METHODS

A single-center retrospective cohort study with prospectively collected outcomes was carried out with CTO patients undergoing PCI in 2019 and 2020. Patients were divided into two groups according to previous T2DM diagnosis (T2DM and non-T2DM). The primary outcome was recurrence of angina and/or heart failure symptoms and secondary outcomes were myocardial infarction and all-cause mortality.

RESULTS

A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome (total symptom recurrence) occurred in 16.6% of the sample, with no difference between groups (non-T2DM 13.6% vs. T2DM 21.2%, p=0.194) in a two-year follow-up. Angina recurrence was significantly more frequent in T2DM patients (15.2%, p=0.043). The presence of T2DM was not an independent predictor of symptom recurrence (p=0.429, HR 1.37, 95% CI 0.62-2.98). Myocardial infarction and all-cause mortality were also not different between groups (T2DM 1.5%, p=0.786 and 4.5%, p=0.352, respectively, on survival analysis). Independent predictors of all-cause mortality were left ventricular function and creatine clearance (p=0.039, HR 0.92, 95% CI 0.85-0.99 and p=0.013, HR 0.96, 95% CI 0.93-0.99, respectively).

CONCLUSIONS

T2DM did not influence outcomes in CTO patients undergoing PCI, and its presence should not be a limiting factor in deciding on CTO revascularization.

Comparative Analysis of Polymer Versus Non-Polymer Jacketed Wires in Chronic Total Occlusion Percutaneous Coronary Intervention

There is significant variation in wire utilization patterns for chronic total occlusion (CTO) percutaneous coronary intervention. This study aimed to compare the outcomes of polymer-jacketed wires (PJWs) versus non-PJWs in anterograde procedures. We analyzed clinical and angiographic characteristics, and procedural outcomes of 7,575 anterograde CTO percutaneous coronary interventions that were performed at 47 centers between 2012 and 2023. Cases in which PJWs were exclusively used were classified in the PJW group, whereas cases where at least one non-PJW was employed were classified in the non-PJW group. Study end points were as follows: technical success, coronary perforation, major adverse cardiac event. PJWs were exclusively used in 3,481 cases (46.0%). These cases had lower prevalence of proximal cap ambiguity, blunt stump, and moderate/severe calcification. They also had lower Japanese CTO (J-CTO), Prospective Global Registry for the Study of Chronic Total Occlusion (PROGRESS-CTO), and PROGRESS-CTO complications scores, higher technical success (94.3% vs 85.7%, p <0.001), and lower perforation rates (2.2% vs 3.2%, p = 0.013). Major adverse cardiac event rates did not differ between groups (1.3% vs 1.5%, p = 0.53). Exclusive use of PJWs was independently associated with higher technical success in both the multivariable (odds ratio [OR] 2.66, 95% confidence interval [CI] 2.13 to 3.36, p <0.001) and inverse probability of treatment weight analysis (OR 2.43, 95% CI 2.04 to 2.89, p <0.001). Exclusive use of PJWs was associated with lower risk of perforation in the multivariable analysis (OR 0.69, 95% CI 0.49 to 0.95, p = 0.02), and showed a similar trend in the inverse probability of treatment weight analysis (OR 0.77, 95% CI 0.57 to 1.04, p = 0.09). Exclusive use of PJWs is associated with higher technical success and lower perforation risk in this non-randomized series of patients.

Clinical results of percutaneous coronary intervention in chronic total occlusions of the right coronary artery

INTRODUCTION AND OBJECTIVES

Coronary chronic total occlusions (CTOs) of the right coronary artery (RCA) are a relatively common finding in the context of coronary angiography. However, the benefit of revascularization remains controversial.

METHODS

A single-center retrospective cohort analysis prospectively collected outcomes of CTO patients undergoing percutaneous coronary intervention (PCI) in 2019 and 2020. Patients were divided into two groups according to the CTO vessel treated (left coronary artery [LCA]-CTO or RCA-CTO). The primary outcome was defined as the recurrence of angina and/or heart failure (HF) symptoms and secondary outcomes were myocardial infarction (MI) and all-cause mortality.

RESULTS

A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome occurred in 28 (16.6%) patients and was significantly more frequent in RCA-CTO patients (19, 24.7%, p=0.010) in a mean follow-up of 18 months. This was mainly driven by recurrence of HF symptoms (12, 15.6%, p=0.013). Treated RCA-CTO was an independent predictor of the primary outcome (p=0.019, HR 2.66, 95% CI 1.17-6.05). MI and mortality rates were no different between groups (RCA-CTO with 1.3%, p=0.361 and 2.6%, p=0.673, respectively, on survival analysis). Left ventricular ejection fraction was an independent predictor of mortality (p=0.041, HR 0.93, 95% CI 0.87-0.99).

CONCLUSIONS

Revascularization of CTO lesions by PCI was associated with low rates of symptom recurrence, and clinical outcomes showed no differences regardless of which artery was treated. Recanalization of RCA-CTO was less beneficial in reducing the recurrence of HF symptoms.

A non-interventional cardiologist's guide to coronary chronic total occlusions

Coronary chronic total occlusions (CTO) are present in up to one-third of patients with coronary artery disease (CAD). It is thus essential for all clinical cardiologists to possess a basic awareness and understanding of CTOs, including optimal evaluation and management. While percutaneous coronary intervention (PCI) for CTO lesions has many similarities to non-CTO PCI, there are important considerations pertaining to pre-procedural evaluation, interventional techniques, procedural complications, and post-procedure management and follow-up unique to patients undergoing this highly specialized intervention. Distinct from other existing topical reviews, the current manuscript focuses on key knowledge relevant to non-interventional cardiologists.

Contemporary outcomes of chronic total occlusion percutaneous coronary intervention in Europe: the ERCTO registry

BACKGROUND

Percutaneous coronary interventions (PCI) of chronic total occlusions (CTO) have reached high procedural success rates thanks to dedicated equipment, evolving techniques, and worldwide adoption of state-of-the-art crossing algorithms.

AIMS

We report the contemporary results of CTO PCIs performed by a large European community of experienced interventionalists. Furthermore, we investigated the impact of different risk factors for procedural major adverse cardiac and cerebrovascular events (MACCE) and trends of employment of specific devices like dual lumen microcatheters, guiding catheter extensions, intravascular ultrasound and calcium-modifying tools.

METHODS

We evaluated data from 8,673 CTO PCIs included in the European Registry of Chronic Total Occlusion (ERCTO) between January 2021 and October 2022.

RESULTS

The overall technical success rate was 89.1% and was higher in antegrade as compared with retrograde cases (92.8% vs 79.3%; p<0.001). Compared with antegrade procedures, retrograde procedures had a higher complexity of attempted lesions (Japanese CTO [J-CTO] score: 3.0±1.0 vs 1.9±1.2; p<0.001), a higher procedural and in-hospital MACCE rate (3.1% vs 1.2%; p<0.018) and a higher perforation rate with and without tamponade (1.5% vs 0.4% and 8.3% vs 2.1%, respectively; p<0.001). As compared with mid-volume operators, high-volume operators had a higher technical success rate in antegrade and retrograde procedures (93.4% vs 91.2% and 81.5% vs 69.0%, respectively; p<0.001), and had a lower MACCE rate (1.47% vs 2.41%; p<0.001) despite a higher mean complexity of the attempted lesions (J-CTO score: 2.42±1.28 vs 2.15±1.27; p<0.001).

CONCLUSIONS

The adoption of different recanalisation techniques, operator experience and the use of specific devices have contributed to a high procedural success rate despite the high complexity of the lesions documented in the ERCTO.

Prevalence of Collateral Typology in Coronary Chronic Total Occlusion and Its Impact on Percutaneous Intervention Performance

The presence of collateral channels providing distal blood supply is a distinctive characteristic of chronic total occlusion (CTO) lesions. However, data about the distinct baseline and procedural characteristics of each collateral subset are scarce. Accordingly, we sought to explore the procedural aspects specific for each collateral typology (ipsilateral collaterals [ICs], contralateral collaterals [CCs] or mixed) in CTO-percutaneous coronary intervention (PCI). A retrospective analysis of our CTO-PCI registry was performed to investigate the prevalence, procedural characteristics, and outcomes specific for each CTO-PCI subset, defined according to the inter-arterial connection anatomy. A total of 209 cases were included. Of the included cases, 45 (22%) and 92 (44%) patients displayed solely IC or CC, respectively, whereas in 72 (34%) both IC and CC were present (mixed). The procedural success rate was high (91.1%) and comparable among the different groups, despite greater lesion complexity in the CC group. The most frequent target vessel was the left circumflex in the IC group (51% of cases) and the right coronary artery in the CC (63%) and mixed (57%) groups. Among the IC cases, 42% showed a poor collateral connection function (2% and 10% for the CC and mixed group, respectively), and 46% showed a suboptimal collateral recipient artery filling (21% and 20% for the CC and mixed group, respectively). Most of the IC cases were performed using a single access (96%). In conclusion, the success and complication rates were comparable among the collateral typology groups, irrespective of the differences in the baseline and procedural characteristics. Phenotyping CTO as hereby proposed might be helpful for targeted procedural considerations.

Long-term clinical outcomes of drug-coated balloon for the management of chronic total occlusions

OBJECTIVES

This study aims to compare the clinical outcomes of patients with de novo chronic total occlusion (CTO) lesions treated by hybrid strategy and drug-coated balloons (DCB)-only strategy.

BACKGROUNDS

DCBs have been used as an alternative to or in combination with drug-eluting stents in CTO lesions. However, the clinical impact of DCB treatment on CTO lesion remains uncertain.

METHODS

We retrospectively enrolled 154 patients with de novo CTO lesions treated by DCB, including 57 cases in hybrid group and 97 cases in DCB-only group.

RESULTS

The lesions in hybrid group were more complicated than those in DCB-only group as shown by higher J-CTO score, and therefore higher percentage of retrograde approach, more IVUS guidance, more CTO guidewires, and longer procedural time were demonstrated. Although the percentage of non-flow-limiting dissection and residual stenosis of more than 30% were lower in hybrid group, TIMI flow grade, satisfactory and acceptable recanalization rate were not significantly different between two groups. During a median follow-up was 470 days, the incidence of target lesion revascularization (TLR), myocardial infarction and cardiac death was 11.0%, 1.3% and 1.9%, respectively. The long-term TLR-free survival was comparable between hybrid and DCB-only groups. By multivariate analysis, DCB length and age were predictors of TLR.

CONCLUSION

DCB treatment appears effective and safe in selected de novo CTO lesions during long-term follow up. The recanalization results and long-term outcomes are comparable between hybrid and DCB-only group despite more complicated lesions in hybrid group.

Long-term improvement of symptoms of angina pectoris after successful revascularization of coronary artery chronic total occlusions

Objectives. To compare long-term angina pectoris relief of successful versus failed percutaneous coronary intervention of chronic total occlusions (CTO PCI). Background. Previous studies demonstrate better short-term angina pectoris relief of CTO PCI than with optimal medical treatment (OMT), however, data on the long-term effects are lacking. Methods. 295 patients undergoing CTO PCI were analyzed retrospectively, with a follow-up evaluation of symptoms of angina pectoris and all-cause death one to four years after the intervention. The primary outcome was long-term relief of symptoms of angina pectoris. Secondary outcomes included a composite of major adverse cardiovascular events (MACE), including all-cause death, myocardial infarction, stroke, and later target vessel revascularization (TVR). At follow-up, patients were interviewed for symptoms of angina pectoris at 1, 6, 12, and 22 to 48 months after the intervention. Results. CTO PCI was successful in 225 (76%) patients and failed in 70 (24%) patients. Short-term (six months) relief of angina pectoris was observed in both groups, but only the successful CTO PCI group showed long-term relief. The Kaplan-Meier curves of all-cause death did not differ between the groups (p = .715). The final follow-up was a mean (range) of 37 (25 to 44) months after the intervention in the successful CTO PCI group, and 33 (28 to 48) months in the failed CTO PCI group. Conclusions. Successful CTO PCI is associated with better long-term relief of symptoms of angina pectoris compared to failed CTO PCI.

Long-term clinical outcomes following successful percutaneous coronary intervention in patients with extremely long coronary chronic total occlusion lesions

BACKGROUND

Lesion length is related to worse clinical outcomes following percutaneous coronary intervention (PCI) for the treatment of chronic total occlusion (CTO). However, the data to confirm the association between extremely long lesions and clinical hard endpoints have been limited. Therefore, we investigated the impact of extremely long CTO lesions (≥50 mm, treated lesion length) on the long-term clinical outcomes following successful PCI.

METHODS

A total of 333 consecutive patients with CTO who underwent successful PCI with drug-eluting stents (DESs) were allocated to either the extremely long or the short CTO group according to their CTO lesion length. The 5-year clinical outcomes were compared between the two groups. The incidence of myocardial infarction, cardiac death (CD), revascularization, and major adverse cardiovascular events (MACE) was higher in the extremely long CTO group. The 5-year clinical outcomes were analyzed using the Cox hazard ratio (HR) model.

RESULTS

In the entire study population, the extremely long CTO lesion was an independent predictor for higher rate of revascularization, MACE, CD, or mortality.

CONCLUSIONS

In our study, CTO patients with extremely long lesions (≥50 mm) who underwent successful PCI were associated with a higher risk of worse long-term clinical outcomes, including hard clinical endpoints such as CD and mortality even in the DESs era.

Impact of calcium on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention

BACKGROUND

Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

METHODS

We examined the impact of calcium on procedural outcomes of 13,079 CTO PCIs performed in 12,799 patients at 46 US and non-US centers between 2012 and 2023.

RESULTS

Moderate or severe calcification was present in 46.6% of CTO lesions. Patients whose lesions were calcified were older and more likely to have had prior coronary artery bypass graft surgery. Calcified lesions were more complex with higher J-CTO score (3.0 ± 1.1 vs. 1.9 ± 1.2; p < 0.001) and lower technical (83.0% vs. 89.9%; p < 0.001) and procedural (81.0% vs. 89.1%; p < 0.001) success rates compared with mildly calcified or non-calcified CTO lesions. The retrograde approach was more commonly used among cases with moderate/severe calcification (40.3% vs. 23.5%; p < 0.001). Balloon angioplasty (76.6%) was the most common lesion preparation technique for calcified lesions, followed by rotational atherectomy (7.3%), laser atherectomy (3.4%) and, intravascular lithotripsy (3.4%). The incidence of major adverse cardiovascular events (MACE) was higher in cases with moderate or severe calcification (3.0% vs. 1.2%; p < 0.001), as was the incidence of perforation (6.5% vs. 3.4%; p < 0.001). On multivariable analysis, the presence of moderate/severe calcification was independently associated with lower technical success (odds ratio, OR = 0.73, 95% CI: 0.63-0.84) and higher MACE (OR = 2.33, 95% CI: 1.66-3.27).

CONCLUSIONS

Moderate/severe calcification was present in nearly half of CTO lesions, and was associated with higher utilization of the retrograde approach, lower technical and procedural success rates, and higher incidence of in-hospital MACE.

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.

Chronic Total Occlusion is Not a Risk Factor for Mortality in Patients With Successful Percutaneous Coronary Intervention: A Cohort Study

Background Fifteen percent of patients with coronary artery disease undergoing angiography have a chronic total occlusion (CTO). The current study aimed to investigate the long-term prognosis after successful and unsuccessful CTO percutaneous coronary intervention (PCI) compared with PCI for non-CTO lesions. Methods and Results The current study was designed as an observational, region-wide, register-based cohort study enrolling all patients undergoing PCI in the Central Region of Denmark in 2009 to 2019. Patients were stratified into non-CTO, successful CTO, and unsuccessful CTO revascularization. Patients were followed until an event or January 1, 2022. The primary end point was all-cause mortality. In 21 141 patients enrolled, 2108 underwent CTO PCI. Clinical presentation was acute coronary syndrome in 11 879 patients and chronic coronary syndrome in 7887 patients. After a median of 5.7 years (interquartile range, 3.3-8.8), long-term all-cause mortality was higher after CTO PCI compared with non-CTO PCI, but the difference was statistically insignificant when adjusting for clinical factors (unadjusted hazard ratio [HR], 1.19 [95% CI, 1.09-1.29], adjusted HR, 1.08 [95% CI, 0.97-1.20]; P=0.165). After successful CTO PCI, no difference compared with non-CTO PCI was observed (unadjusted HR, 0.99 [95% CI, 0.90-1.10], adjusted HR, 0.99 [95% CI, 0.87-1.12]; P=0.873). After unsuccessful CTO PCI, long-term all-cause mortality was higher than non-CTO PCI (unadjusted HR, 1.82 [95% CI, 1.59-2.08], adjusted HR, 1.35 [95% CI, 1.13-1.63]; P<0.001). Conclusions Patients undergoing PCI for CTO have elevated long-term mortality compared with patients without CTO. Successful opening of the CTO(s) is associated with equal mortality compared with non-CTO PCI. In contrast, failed CTO PCI is associated with worse long-term mortality. These findings suggest the need for CTO programs with high success rates and low complication rates.

Percutaneous Coronary Intervention of Chronic Total Occlusion Associated with Higher Inpatient Mortality and Complications Compared With Non-CTO Lesions

BACKGROUND

Percutaneous coronary intervention (PCI) in patients with chronic total occlusion is commonly performed despite unclear long-term benefits. The goal of this study was to evaluate the postprocedural outcome of patients with chronic total occlusion intervention.

METHODS

The National Inpatient Sample database, years 2016-2020, was studied using International Classification of Diseases, Tenth Revision codes. Patients with chronic total occlusion interventions were compared with patients without chronic total occlusion. We evaluated postprocedural mortality and complications.

RESULTS

PCI in patients with chronic total occlusion was associated with higher total inhospital mortality and all postprocedural complications. A weighted total of 10,059,269 patients underwent PCI, with 259,574 having chronic total occlusion. The chronic total occlusion group had a 3.17% mortality rate vs 2.57% of nonchronic total occlusion PCIs (odds ratio [OR] 1.24; 95% confidence interval [CI], 1.18-1.31; P < .001). Using multivariate analysis adjusting for basline charcteristics and high risk features such as age, sex, race, diabetes mellitus, chronic kidney disease, systolic heart failure, 3-vessel PCI, hypertension, chronic obstructive pulmonary disease, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, prior PCI, history of coronary artery bypass graft, history of anemia, smoking status, atrial fibrillation/flutter, valvular heart disease, and , history of stroke, chronic total occlusion PCI remained significantly associated with higher total mortality (OR 1.07; 95% CI, 1.02-1.13; P = .02). Patients with chronic total occlusion compared with nonchronic total occlusion PCI had also higher rates of myocardial infarction (OR 2.85; 95% CI, 2.54-3.21; P < .001), coronary perforation (OR 6.01; 95% CI, 5.25-6.89; P < .001), tamponade (OR 3.36; 95% CI, 2.91-3.88; P < .001), contrast-induced nephropathy (OR 2.05; 95% CI, 1.45-2.90; P < .001), procedural bleeding (OR 3.57; 95% CI, 3.27-3.89; P < .001), and acute postprocedural respiratory failure (OR 2.07; 95% CI, 1.81-2.36; P < .001). All postprocedural complications were more than 3 times the nonchronic total occlusion patients (OR 3.45; 95% CI, 3.24-3.67; P < .001).

CONCLUSION

Using a large national inpatient database, PCI performed in patients with chronic total occlusion was associated with significantly much higher mortality and postprocedural complications compared with PCI in nonchronic total occlusion patients.

Evaluation of right-ventricular function by two-dimensional echocardiography and two-dimensional speckle-tracking echocardiography in patients with successful RCA CTO recanalization

OBJECTIVES

Chronic total occlusion (CTO) of the right coronary artery (RCA) is common in patients with coronary artery disease. Although revascularization techniques and success rates have improved significantly in recent years, there are still no studies investigating possible effects of successful recanalization of RCA CTO on the right-ventricular (RV) function. With this study, we aimed to evaluate RV function after recanalization of the RCA by two-dimensional transthoracic echocardiography (2DE) and additional two-dimensional speckle-tracking echocardiography (2DSTE).

METHODS AND RESULTS

Our analysis included 102 patients undergoing successful RCA CTO recanalization at the University Medical Center of Mainz. All patients underwent 2DE and 2DSTE to assess RV function before PCI procedure and 6 months after successful revascularization. We found an altered RV function in our collective at baseline assessed by 2DSTE with a significant improvement at 6 month follow-up (baseline RV free wall strain: - 20.7 [- 6.3 to - 32.0] % vs. - 23.4 [- 8.3 to - 39.3] % at follow-up, p < 0.001 and baseline RV global strain - 15.9 [- 6.0 to - 25.7] % vs. - 17.9 [- 7.0 to - 29.5] % at follow-up, p < 0.001).

CONCLUSION

RV function was altered in patients with RCA CTO and showed significant improvement after successful recanalization. We also noticed an improvement in patient-reported clinical symptoms. Our study suggests that CTO procedure is a beneficial treatment option in symptomatic patients with RCA CTO.

Three-year outcomes of A Randomized Multicentre Trial Comparing Revascularization and Optimal Medical Therapy for Chronic Total Coronary Occlusions (EuroCTO)

BACKGROUND

Percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTO) improves clinical symptoms and quality of life. The longer-term safety of PCI compared to optimal medical therapy (OMT) remains uncertain.

AIMS

We sought to evaluate the long-term safety of PCI for CTO in a randomised trial as compared to OMT.

METHODS

A total of 396 patients with a symptomatic CTO were enrolled into a randomised, multicentre clinical trial comparing PCI and OMT. Half of the patients had a single CTO; the others had multivessel disease. Non-CTO lesions were treated prior to randomisation (2:1 ratio). During follow-up, crossover from OMT to PCI occurred in 7.3% (1 year) and 17.5% (3 years) of patients.

RESULTS

At 3 years, the incidence of cardiovascular death or nonfatal myocardial infarction was not significantly different between the groups (OMT 3.7% vs PCI 6.2%; p=0.29). By per-protocol analysis, the difference remained non-significant (OMT 5.7% vs PCI 4.7%; p=0.67). Overall, major adverse cardiovascular events (MACE) were more frequent with OMT (OMT 21.2% vs PCI 11.2%), largely because of ischaemia-driven revascularisation. The rates of stroke or hospitalisation for bleeding were not different between the groups.

CONCLUSIONS

At 3 years there was no difference in the rate of cardiovascular death or myocardial infarction between PCI or OMT among patients with a remaining single coronary CTO. The MACE rate was higher in the OMT group due largely to ischaemia-driven revascularisation. CTO PCI appears to be a safe option for patients with a single remaining significant coronary CTO. CinicalTrials.gov: NCT01760083.

The Utility of CT Coronary Angiography in Chronic Total Occlusion Percutaneous Coronary Intervention

Chronic total occlusion (CTO) of the coronary arteries is a relatively common finding in routine coronary angiography. Of late, there has been considerable improvement in the success rate of percutaneous intervention for coronary CTO, attributed to technological advancement and skills development. CT coronary angiogram (CTCA) is a simple, non-invasive, and cost-effective test that aids in the diagnosis and management of coronary artery disease, including CTOs. The development of multi-slice CT and the use of 3D volume rendering images has revolutionised the diagnostic abilities of CTCA, with improvements in imaging quality and detailed anatomical and morphological characterisation of the plaque disease. In CTO percutaneous intervention, CTCA is used in pre-procedural planning, applying scoring systems to predict the likely success of the intervention as well as the post-procedural evaluation and follow-up. This review examines the different uses of CTCA in CTO intervention, its impact on successful recanalisation and the areas for future consideration.

Vascular Access in Percutaneous Coronary Intervention of Chronic Total Occlusions: A State-of-the-Art Review

The outcomes of chronic total occlusion percutaneous coronary intervention have considerably improved during the last decade with continued emphasis on improving procedural safety. Vascular access site bleeding remains one of the most frequent complications. Several procedural strategies have been implemented to reduce the rate of vascular access site complications. This state-of-the-art review summarizes and describes the current evidence on optimal vascular access strategies for chronic total occlusion percutaneous coronary intervention.