Impact of chronic total occlusion lesion length on six-month angiographic and 2-year clinical outcomes

Efficacy of drug-coated balloon angioplasty for coronary chronic total occlusion: A systematic review and meta-analysis

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is associated with worse outcomes compared to non-CTO lesions. Whether the implantation of drug-eluting stents (DES) is the cornerstone treatment after successful recanalization of CTO, recent evidence tested the clinical performance of DCB-based PCI, alone or in concert with DES (hybrid DCB/DES approach), in this context. We aimed to conduct a comprehensive, up-to-date systematic review and summary-level meta-analysis of clinical studies comparing outcomes of DCB-based versus DEB-only angioplasty for coronary CTOs. A systematic search was performed to identify all investigations comparing DCB-based versus DES-only angioplasty for coronary CTOs. The primary endpoint was the occurrence of target vessel failure (TVF), a composite outcome of cardiac death, nonfatal myocardial infarction and target vessel revascularization. A total of 5 observational studies (2087 patients) were included in the analysis. The DCB-based PCI group experienced a trend towards a lower rate of TVF (0.45 % (112/25045) vs. 0.76 % (238/31336) person-months, IRR = 0.56 [95 % CI 0.28 to 1.10], I2 = 81 %, p = 0.09) and cardiac death (0.05 % vs. 0.10 % person-months, IRR = 0.55 [95 % CI 0.27 to 1.10], I2 = 0 %, p = 0.09), although a high extent of heterogeneity was observed. Other endpoints were not different between the two groups. In the present meta-analysis, DCB-based PCI was associated with similar outcomes compared to second-generation DES PCI for the treatment of coronary CTOs. Future randomized controlled trials will provide more robust evidence on the effectiveness of DCB in treating coronary CTOs.

Give it time to SOBER up - GITSU- a new strategy in percutaneous coronary intervention for chronic total occlusion

BACKGROUND

The prevalence of coronary chronic total occlusion (CTO) in coronary angiography (CAG) has risen with ageing populations, along with the expansion of CTO percutaneous coronary interventions (CTO-PCI). However, CTO-PCI encounters challenges such as undersized stents, dissection risks, and limited access to intravascular imaging (IVI), particularly in regions with limited health budgets. This study introduces the 'GIVE IT TIME TO SOBER UP - GITSU strategy', a two-session CTO-PCI approach where Thrombolysis in Myocardial Infarction (TIMI-3) antegrade flow is achieved without stent placement in the first session. We aim to present its key attributes, outcomes, and implications for invasive cardiology.

METHODS

Demographic data, CTO lesion characteristics in the first PCI session, procedural features, in-hospital major adverse cardiovascular adverse events (MACE), technical features of the second PCI session, and in-hospital MACE were examined.

RESULTS

We applied the GITSU strategy to 53 CTO lesions between August 2020 and June 2023. The mean lesion length was shortened compared to the first session (21.3 ± 10.5%). There was an increase in mean distal reference vessel diameter (2.52 ± 0.49 mm), and the increase was 24.2%±11.3% compared to the first session. There was 24.4%±11.5% stent length savings. We achieved an increase in stent size of 20.3% to 10.1% compared to the mean stent diameter. The technical success and procedural success rate were 92.5% and 90.6%, respectively.

CONCLUSION

Patients who underwent GITSU used shorter and wider stents in the second PCI session. This strategy is likely to reduce TLR and ISR rates.

Long-term efficacy of drug-coated balloon-based treatment for de novo left anterior descending artery disease

Drug-coated balloons (DCB) are increasingly utilized in percutaneous coronary intervention (PCI), but their effectiveness in coronary artery disease (CAD) needs further exploration. This study investigates the efficacy and safety of a DCB-based strategy for de novo left anterior descending artery (LAD) disease. Patients with de novo LAD lesions treated with DCB alone or combined with drug-eluting stents (DES) and were retrospectively enrolled from 2010 to 2023 (n = 268). The comparator group consisted of patients treated with second-generation DES from a Korean multicenter registry (n = 4,147). The primary endpoint was three-year major adverse cardiovascular events (MACE), including cardiac death, myocardial infarction, target vessel revascularization, target lesion thrombosis, and major bleeding. In the DCB-based group (n = 268), 218 (81.3%) received DCB-only, while 50 (18.7%) underwent a hybrid approach. After propensity score-matching of 243 paired subjects, baseline characteristics were balanced. The DCB-based PCI reduced overall stent burden by 86.7% and significantly lowered the risk of MACE at three years compared to DES-only PCI (4.5% vs. 7.6%, HR 0.50, 95% CI 0.28-0.90; p = 0.020). The most significant reduction was in major bleeding. The DCB-based approach offers an alternative to DES-only strategy for LAD PCI by reducing three-year MACE risk, supporting its use in treating de novo CAD.

Impact of cigarette smoking on long-term clinical outcomes in patients with coronary chronic total occlusion lesions

Cigarette smoking is a significant risk factor for coronary artery disease. However, there is insufficient evidence regarding the long-term clinical effects of smoking in Asian populations with chronic total occlusion (CTO). This study aimed to assess the effects of smoking on 5-year (median follow-up period, 4.2 ± 1.5 [interquartile range, 4.06-5.0] years) clinical outcomes in patients with CTO lesions who underwent percutaneous coronary intervention (PCI) or medical treatment (MT). We enrolled 681 consecutive patients with CTO who underwent diagnostic coronary angiography and subsequent PCI or MT. The patients were categorized into smokers (n = 304) and nonsmokers (n = 377). The primary endpoint was major adverse cardiovascular events (MACE), including a composite of all-cause death, myocardial infarction, and revascularization over a 5-year period. Propensity score matching (PSM) analysis was performed to adjust for potential baseline confounders. After PSM analysis, two propensity-matched groups (200 pairs, n = 400) were generated, and the baseline characteristics of both groups were balanced. The smokers exhibited a higher cardiovascular risk of MACE (29.5% vs. 18.5%, p = 0.010) and non-TVR (17.5 vs. 10.5%, p = 0.044) than the nonsmokers. In a landmark analysis using Kaplan-Meier curves at 1 year, the smokers had a significantly higher rate of MACE in the early period (up to 1 year) (18.8% and 9.2%, respectively; p = 0.008) compared with the nonsmokers. The Cox hazard regression analysis with propensity score adjustment revealed that smoking was independently associated with an increased risk of MACE. These findings indicate that smoking is a strong cardiovascular risk factor in patients with CTO, regardless of the treatment strategy (PCI or MT). In addition, in the subgroup analysis, the risk of MACE was most prominently elevated in the group of smokers who underwent 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 lesion length on the outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry

BACKGROUND

The impact of occlusion length on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.

METHODS

We examined the clinical and angiographic characteristics and procedural outcomes of 10,335 CTO PCIs at 42 US and non-US centers between 2012 and 2022. The cohort was divided into two groups based on lesion length (≥20 mm vs. <20 mm).

RESULTS

Long lesions were present in 7208 (70%) patients. Comorbidities were more common in patients with long CTOs. Compared with short lesions, long lesions had higher J-CTO score (2.8 ± 1.1 vs. 1.3 ± 1; p < 0.001) and retrograde wiring was more often the initial (15.5% vs. 4.0%; p < 0.001) and successful (22.8% vs. 8.2%; p < 0.001) crossing strategy. Long lesions were more likely to require longer procedure (123 vs. 91 min; p < 0.001) and fluoroscopy (47.1 vs. 32.2 min; p < 0.001) time, larger contrast volume (218 vs. 200 mL; p < 0.001) and higher air kerma radiation dose (2.4 vs. 1.7 Gy; p < 0.001). After adjusting for potential confounders, long lesions were associated with lower technical success (odds ratio [OR]: 0.91 per 10 mm increase; 95% confidence interval [CI]: 0.88, 0.94) and higher major adverse cardiovascular events (MACE) (OR: 1.08 per 10 mm increase; 95% CI: 1.02, 1.15).

CONCLUSIONS

CTO PCI of long occlusions is independently associated with lower rates of technical success and higher rates of in-hospital MACE.

Extraplaque versus intraplaque tracking in chronic total occlusion percutaneous coronary intervention

OBJECTIVE

To compare the clinical outcomes after extraplaque (EP) versus intraplaque (IP) tracking in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

The impact of modern dissection and reentry (DR) techniques on the long-term outcomes of CTO PCI remains controversial.

METHODS

We performed a systematic review and meta-analysis of studies that compared EP versus IP tracking in CTO PCI. Odds ratios (ORs) with 95% confidence intervals (CIs) are calculated using the Der-Simonian and Laird random-effects method.

RESULTS

Our meta-analysis included seven observational studies with 2982 patients. Patients who underwent EP tracking had significantly more complex CTOs with higher J-CTO score, longer lesion length, and more severe calcification and had significantly longer stented segments. During a median follow-up of 12 months (range 9-12 months), EP tracking was associated with a higher risk of major adverse cardiovascular events (MACE) (OR 1.50, 95% CI (1.10-2.06), p = 0.01) and target vessel revascularization (TVR) (OR 1.69, 95% CI (1.15-2.48), p = 0.01) compared with IP tracking. There was no difference in the incidence of all-cause death (OR 1.37, 95% CI (0.67-2.78), p = 0.39), myocardial infarction (MI) (OR 1.48, 95% CI (0.82-2.69), p = 0.20), stent thrombosis (OR 2.09, 95% CI (0.69-6.33), p = 0.19), or cardiac death (OR 1.10, 95% CI (0.39-3.15), p = 0.85) between IP and EP tracking.

CONCLUSION

EP tracking is utilized in more complex CTOs and requires more stents. EP tracking is associated with a higher risk of MACE, driven by a higher risk of TVR at 1 year, but without an increased risk of death or MI compared with IP tracking. EP tracking is critically important for contemporary CTO PCI.

The impact of J-CTO score on in-stent chronic total occlusion percutaneous coronary intervention

AIM

The purpose of this study was to investigate the impact of J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) score on in-stent chronic total occlusion (IS-CTO) percutaneous coronary intervention (PCI).

METHODS

A retrospective data collection was conducted on 474 patients undergoing a difficult IS-CTO PCI from January 2015 to December 2018. The primary endpoint (major adverse cardiovascular events [MACE]) consisted of target-vessel myocardial infarction (MI), cardiac death or ischemia-driven target-vessel revascularisation (TVR) at follow-up. The cut-off points were estimated by the Youden index.

RESULTS

The overall procedural success rate was 77.6%. On multivariable analysis, factors including proximal bending (beta coefficient [β] = 3.465), tortuosity (β = 3.064), stent under expansion (β = 3.109) and poor distal landing zone (β = 1.959) were associated with technical failure via antegrade approach but not the J-CTO score (OR = 0.632; 95% CI [0.352-1.134]; P = .124). After a median follow-up of 30 months (interquartile range: 17-42 months), multivariable analysis revealed that receiving >18 months of dual antiplatelet therapy (DAPT) was an independent predictor of decreased risk of MACE (HR: 2.690; 95% CI: 1.346-5.347; P = .005). But the J-CTO score was not an independent predictor of MACE (HR: 1.018; 95% CI: 0.728-1.424; P = .917).

CONCLUSIONS

J-CTO score system is not a helpful tool to predict the technical success of difficult IS-CTO PCI via antegrade approach, nor does it correlate with long-term outcomes in patients undergoing IS-CTO PCI. Nevertheless, factors associated with technical failure include proximal bending of ≥30 degrees, under expansion of ≥10 mm, moderate or severe tortuosity (bending) ≥20 and poor distal target. Long-term DAPT therapy contributes significantly to decreased MACE.

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion by treated segment length

BACKGROUND

Long lesions are known to have worse outcomes following percutaneous coronary intervention (PCI), but there are limited data assessing the association between lesion length and clinical outcomes in PCI procedures undertaken in chronic total occlusions (CTO).

METHODS AND RESULTS

We formed a longitudinal cohort (2006-2018, n = 27,205) of stable angina patients who underwent PCI to CTO in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographical, procedural, and outcome data were analyzed in three groups by treated segment length, < 30 mm (n = 11,782), 30-59 mm (n = 10,415), ≥ 60 mm (n = 5008). Prevalence of previous myocardial infarction and PCI were higher in patients in 30-59 mm group or ≥ 60 mm group compared with < 30 mm group. Following multivariable analysis, no significant difference was observed in in-patient death (OR = 30-59 mm group = 1.10, CI:0.55-2.19, p = 0.78) (OR ≥ 60 mm group = 0.82, CI: 0.33-2.05, p = 0.67), and 1-year death (OR = 30-59 mm group = 1.06, CI: 0.81-1.37, p = 0.69) (OR ≥ 60 mm group =1.01, CI: 0.70-1.43, p = 0.99) (< 30 mm group = reference) but in-patient MACE was higher in > = 60 mm group (OR: 1.52, CI: 1.15-2.01, p = 0.06) but similar in 30-59 mm group (OR: 1.16, CI: 0.91-1.48, p = 0.22) compared with < 30 mm group. The adjusted rates of procedural complications were higher in ≥ 60 mm group (OR: 1.61, CI: 1.40-1.85, p < 0.001) but were similar in 30-59 mm group (OR: 1.06, CI: 0.94-1.20, p < 0.31) compared with < 30 mm group. For every 10 mm increase, there was an increased adjusted risk of in-patient procedural complications and coronary perforation but not in-patient MACE or death.

CONCLUSION

Patients with very long CTO lesions have higher risk of procedural complications and in-patient MACE but similar risk of short or long-term mortality compared with short CTO lesions.

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.

Angiographic Scoring System for Predicting Successful Percutaneous Coronary Intervention of In-Stent Chronic Total Occlusion

The purpose of this study was to develop a scoring model to predict the technical success of recanalizing via antegrade approach in-stent chronic total occlusion (IS-CTO) by percutaneous coronary intervention (PCI). We retrospectively collected data from 474 patients who underwent an uneasy IS-CTO PCI via antegrade approach from January 2015 to December 2018, consecutively. We selected clinical and angiographic factors and utilized a derivation and validation cohort (4:1 sampling ratio) analysis. Factors with strong correlations with technical failure, according to multivariable analysis, were assigned 1 point, and a scoring system with a 4-point maximum was established. The model was then validated with a validation cohort. The overall procedural success rate was 77.4%. On multivariable analysis, the factors that correlated with technical failure were proximal bending (beta coefficient [β] = 2.142), tortuosity (β = 2.622), stent under expansion (β = 3.052), and poor distal landing zone (β = 2.004). The IS-CTO score demonstrated good calibration and excellent predicting capacity in the derivation (receiver-operator characteristic [ROC] area = 0.973 and Hosmer-Lemeshow chi-squared = 5.252; p = 0.072) and validation (ROC area = 0.976 and Hosmer-Lemeshow chi-squared = 0.916; p = 0.632) cohorts. In the validation subset, the IS-CTO score demonstrated superior performance to the Japanese chronic total occlusion score (J-CTO) and PROGRESS CTO scores for predicting technical success (area under the a curve [AUC] 0.976 vs. 0.642 vs. 0.579, respectively; difference in AUC between the IS-CTO score and J-CTO score = 0.334, p < 0.01; difference in AUC between the IS-CTO score and PROGRESS score = 0.397, p < 0.01). Our results suggest that the IS-CTO score system is a helpful tool to predict the technical success of IS-CTO PCI via antegrade approach in china. Graphical Abstract.

Prognostic significance of occlusion length in recanalized chronic total occlusion lesion: a retrospective cohort study with 5-year follow-up

OBJECTIVES

This study sought to investigate the relationship between occlusion length and long-term outcomes of patients with recanalised chronic total occlusion (CTO) lesion.

DESIGN

A retrospective cohort study.

SETTING

Fuwai Hospital, National Center for Cardiovascular Disease, Beijing, China PARTICIPANTS: Consecutive patients with successfully recanalised CTO were included from January 2010 to December 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint of the present study was a composite event of all-cause death and myocardial infarction (MI). The secondary endpoints included target lesion revascularisation (TLR) and target vessel revascularisation (TVR).

RESULTS

A total of 1987 patients were included and 1801 (90.6%) subjects completed 5-year follow-up in this study. Based on occlusion length, the patients were divided equally into two groups: short (length <15 mm, n=957) and long (length ≥15 mm, n=1030) CTO group. Kaplan-Meier survival curve showed no significant difference in the risk of the composite primary endpoint between short and long CTO groups (p=0.242). Receiver operating characteristic curve analysis also established occlusion length ≥15 mm as a cut-off value for predicting TLR and TVR, with an area under the curve of 0.604 (95% CI: 0.569 to 0.638, p<0.001) and 0.605 (95% CI: 0.572 to 0.638; p<0.001). Kaplan-Meier analysis revealed that the risks for TLR (p=0.002) and TVR (p=0.002) were higher in a patient with long CTO lesion. Multivariate Cox analysis also identified long CTO lesion as an independent predictor of TLR (HR: 1.539, 95% CI: 1.033 to 2.293; p=0.034) and TVR (HR: 1.476, 95% CI: 1.012 to 2.151; p=0.043).

CONCLUSION

Patients with long CTO lesion did not show a higher risk of death and MI after recanalisation, but had higher risks of TLR and TVR. Lesion with occlusion length ≥15 mm should be under close surveillance for restenosis after recanalisation.

Predictors for Target Vessel Failure after Recanalization of Chronic Total Occlusions in Patients Undergoing Surveillance Coronary Angiography

(1) Background: Knowledge about predictors for the long-time patency of recanalized chronic total coronary occlusions (CTOs) is limited. Evidence from invasive follow-up in the absence of acute coronary syndrome (routine surveillance coronary angiography) is scarce. (2) Methods: In a monocentric-retrospective analysis, we obtained baseline as well as periprocedural data of patients undergoing routine invasive follow-up. We defined target vessel failure (TVF) as a combined primary endpoint, consisting of re-occlusion, restenosis, and target vessel revascularization (TVR). (3) Results: We included 93 consecutive patients (15.1% female) from October 2013 to May 2018. After a follow-up period of 206 ± 129 days (median 185 (IQR 127–237)), re-occlusion had occurred in 7.5%, restenosis in 11.8%, and TVR in 5.4%; the cumulative incidence of TVF was 15.1%. Reduced TIMI-flow immediately after recanalization (OR for TVR: 11.0 (95% CI: 2.7–45.5), p = 0.001) as well as female gender (OR for TVR: 11.0 (95% CI: 2.1–58.5), p = 0.005) were found to be predictive for pathological angiographic findings at follow-up. Furthermore, higher blood values of high-sensitive troponin after successful revascularization were associated with all endpoints. Interestingly, neither the J-CTO score nor the presence of symptoms at the follow-up visit could be correlated to adverse angiographic results. (4) Conclusions: In this medium-sized cohort of patients with surveillance coronary angiography, we were able to identify reduced TIMI flow and female gender as the strongest predictors for future TVF.

Acute, in-Hospital Outcome of Percutaneous Coronary Intervention for In-Stent Chronic Total Occlusion

BACKGROUND

Percutaneous coronary intervention (PCI) of total chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. Recanalization of in-stent CTO (IS-CTO) is associated with inferior success rates. This present study aims to comparatively evaluate the acute outcome of patients with IS-CTO and de novo CTO.

METHODS

Between 2012 and 2018 we included 600 patients. Antegrade and retrograde CTO-PCI techniques were used and the primary endpoint was a composite safety endpoint comprising in-hospital death, vascular complications, cardiac tamponade, stroke and acute myocardial infarction.

RESULTS

IS-CTO predominantly occurred in the right coronary artery (71.2%). The success (p = 0.495) and complication rates (p = 0.255) were independent of the target vessel. The lesion lengths of IS-CTO were longer than in de-novo CTO (40 mm vs. 30 mm, statistical trend p = 0.081) alongside with the implanted stent lengths (76 mm vs. 63 mm, statistical trend p = 0.070) and their diameter (3.5 mm vs. 3.0 mm, p < 0.001). We determined that procedural and fluoroscopy time were longer in patients with IS-CTO (115.0 min vs. 93.0 min, p = 0.018 and 40.0 min vs. 30.0 min, p = 0.040) and that in this group of patients the amount of contrast medium was higher (250 ml vs. 200 ml, p = 0.015). Overall success rates were comparable between the two group of patients (87.9% vs. 84.4%, p = 0.586). In-hospital, acute procedural complications regarding the composite safety were rare and showed no statistically significant difference (3.0% vs. 5.6%; p = 0.563).

CONCLUSIONS

Recanalization of in-stent CTO lesions go along with long procedural and high fluoroscopy times as well as an increased amount of contrast medium. Compared to de novo CTO they can be performed safe in experienced hands with similar success rates.