Percutaneous coronary interventions of chronic total -occlusions; a review of clinical indications, treatment strategy and current practice

Clinical Profile of Patients With Chronically Occluded Coronary Arteries: A Single Center Study

Background

A chronic total occlusion (CTO) is defined as an angiographically documented or clinically suspected complete interruption of antegrade coronary flow (Thrombolysis in Myocardial Infarction (TIMI)-0 flow) of greater than 3 months standing. Coronary CTOs represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. Decision to treat or not to treat a CTO is always confusing. This is an attempt to provide clinical profile of patients having totally occluded coronary arteries and their natural history.

Methods

The observational study was carried out in tertiary health center in Mumbai. Totally 117 patients who had CTO on angiography were selected. Their clinical presentation and angiography correlation was done and results were analyzed.

Results

Out of a total of 117 patients, 86 (73.50 %) were males, female 31(26%). All of the patients studied were above 40 years. Age group 40 - 49 years had 25 (21.36%) patients, 50 - 59 years had 32 (27.35%), 60 - 69 years had 43 (36.75%), > 70 years had 17 (14.52%) patients. Smoking as a risk factor was present in 32 (27.35%), tobacco in 45 (38.46%), alcohol in six (5%), no addictions in 35 (29.91%) patients. Diabetes in 63 (53.84%), hypertension in 78 (66.67%) patients, both were present in 49 (41.88%), dyslipidemia in 37 (31.62%) patients. Sixty-three (53.84 %) patients presented with unstable angina (UA)/non ST elevated myocardial infarction (NSTEMI), 32 (27.35%) with chronic stable angina (CSA), ST elevated myocardial infarction (STEMI) in 22 (18.80%). History of prior myocardial infarction (MI) was present in 36 (30.76%), prior coronary artery bypass graft (CABG) in nine (7.6%), prior percutaneous intervention (PCI) in 18 (15.38%). Triple vessel disease (TVD) in 38 (32.47%), double vessel disease (DVD) in 53 (45.29%), single vessel disease (SVD) in 26 (22.22%) patients. Left anterior descending artery (LAD) CTO was present in 40 (34.18%), right coronary artery (RCA) in 61 (52.14%), left circumflex artery (LCX) obtuse marginal (OM) in 16 (13.67%) patients.

Conclusions

Patients having CTO of coronary arteries are mostly above age of 40 years. Most common age group was 60 - 69 years. It was most common in males than females. Tobacco chewing was more commonly associated followed by smoking. Hypertension and diabetes were strongly associated with CTO. Most patients presented with unstable angina/NSTEMI followed by chronic stable angina. Old MI was present in one third of patients. Most common artery to be affected was RCA followed by LAD.

Assessing the landscape of percutaneous coronary chronic total occlusion treatment in Belgium and Luxembourg: the Belgian Working Group on Chronic Total Occlusions (BWGCTO) registry

Background: Important developments in materials, devices, and techniques have improved outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), and resulted in a growing interest in CTO-PCI. The Belgian Working Group on Chronic Total Occlusions (BWGCTO) working group aims to assess the evolution within the CTO-PCI landscape over the next years. Methods: From May 2016 onwards, patients undergoing CTO-PCI were included in the BWGCTO registry by 15 centres in Belgium and Luxemburg. Baseline, angiographic, and procedural data were collected. Here, we report on the one-year in-hospital outcomes. Results: Over the course of one year, 411 procedures in 388 patients were included with a mean age of 64 ± 11 years. The majority were male (81%). Relatively complex CTOs were treated (Japanese CTO score =2.2 ± 1.2) with a high procedure success rate (82%). Patient- and lesion-wise success rates were 83 and 85%, respectively. Major adverse in-hospital events were acceptably low (3.4%). Antegrade wire escalation technique was applied most frequently (82%). On the other hand, antegrade dissection and re-entry and retrograde strategies were more frequently applied in higher volume centres and successful for lesions with higher complexity. Conclusion: Satisfactory procedural outcomes and a low rate of adverse events were obtained in a complex CTO population, treated by operators with variable experience levels. Antegrade wire escalation was the preferred strategy, regardless of operator volume.