Coronary Chronic Total Occlusion (CTO): A Review

Health Status Outcomes in Older Adults Undergoing Chronic Total Occlusion Percutaneous Coronary Intervention

Background Although chronic total occlusions (CTOs) are common in older adults, they are less likely to be offered CTO percutaneous coronary intervention for angina relief than younger adults. The health status impact of CTO percutaneous coronary intervention in adults aged ≥75 years has not been studied. We sought to compare technical success rates and angina-related health status outcomes at 12 months between adults aged ≥75 and <75 years in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion) registry. Methods and Results Angina-related health status was assessed with the Seattle Angina Questionnaire (score range 0-100, higher scores denote less angina). Technical success rates were compared using hierarchical modified Poisson regression, and 12-month health status was compared using hierarchical multivariable linear regression between adults aged ≥75 and <75 years. Among 1000 participants, 19.8% were ≥75 years with a mean age of 79.5±4.1 years. Age ≥75 years was associated with a lower likelihood of technical success (adjusted risk ratio=0.92 [95% CI, 0.86-0.99; P=0.02]) and numerically higher rates of in-hospital major adverse cardiovascular events (9.1% versus 5.9%, P=0.10). There was no difference in Seattle Angina Questionnaire Summary Score at 12 months between adults aged ≥75 and <75 years (adjusted difference=0.9 [95% CI, -1.4 to 3.1; P=0.44]). Conclusions Despite modestly lower success rates and higher complication rates, adults aged ≥75 years experienced angina-related health status benefits after CTO-percutaneous coronary intervention that were similar in magnitude to adults aged <75 years. CTO percutaneous coronary intervention should not be withheld based on age alone in otherwise appropriate candidates.

Risk Factor Analysis and Construction of a Prognostic Model after Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

Methods

The clinical data of 82 patients with CTO who underwent PCI in Lianshui County People's Hospital were collected in this study. The patients were divided into training set (n = 54) and validation set (n = 28) by random sampling method. Statistical difference test was performed for clinical features of patients. Univariate and multivariate Cox regression analyses were performed to determine the risk factors affecting progression of CTO. Nomogram was used to construct a prediction model for disease progression. C-index was calculated, and the accuracy of the model was tested by calibration curve.

Results

No statistically significant differences were incorporated in baseline characteristics of included patients (p > 0.05). There were 25 patients with adverse cardiac events during follow-up in the training set and 13 in the validation set. The results of multivariate Cox regression analysis demonstrated that the important factors affecting postoperative disease progression mainly came down to age, BMI, diabetes, creatinine clearance rate, and left ventricular fraction < 40%. A nomogram was constructed and C-index was calculated. The calibration curve was then used to evaluate and predict risk model of disease progression. The result showed an internal validation C-index of 0.6219 and an external validation C-index of 0.6453, which indicated the good prediction performance of the model.

Conclusion

The risk of disease progression in CTO patients treated with PCI can be effectively predicted by the risk model constructed in this study, which opens up a great possibility for enriching the means of predicting the prognosis of these patients in clinical practice.

Progressive Collateral Stenosis Leading to Symptomatic Chronic Total Occlusion

We present a case of chronic total occlusion (CTO) in a functional 79-year-old female with no past history of coronary artery disease, who was previously asymptomatic due to robust collateral circulation. A 79-year-old Caucasian female presented to the emergency department complaining of chest pain radiating to the neck, jaw, left arm with associated numbness in the left fingers, that had started earlier in the day. She has no previous cardiac history and never had similar symptoms before. Troponin levels were negative. Nuclear stress test showed findings worrisome for ischemia and was a high-risk exam. The patient underwent diagnostic angiography. There was complete total occlusion of the mid right coronary artery, with collateral circulation supplying the distal right coronary artery territory. Ultimately, it found that progressive stenosis of the left anterior descending (LAD) artery led to inadequate collateral circulation and completely occluded the right coronary artery's territory, causing the patient's new-onset angina. Afterwards, the patient underwent percutaneous coronary intervention (PCI). Successful implantation of two drug-eluting stents occurred. The final angiographic result was 0% residual stenosis and Thrombolysis in Myocardial Infarction (TIMI)-3 flow. CTO affecting one or more coronary arteries is not uncommon in patients taken to the catheterization laboratory. However, despite recent advancements in PCI outcomes, treatment of CTO by PCI remains relatively low, due to fear of adverse outcomes such as cardiac perforations. Recent research has supported the safety of performing PCIs on patients with CTO. This case report further reinforces the need to approach treating CTO via angioplasty.

Correlation between lumbar multifidus fat infiltration and lumbar postoperative infection: a retrospective case-control study

Background

The aim of this study was to investigate the correlation between lumbar multifidus fat infiltration and lumbar postoperative surgical site infection (SSI). Several clinical studies have found that spine postoperative SSI is associated with age, diabetes, obesity, and multilevel surgery. However, few studies have focused on the correlation between lumbar multifidus fat infiltration and SSI.

Method

A retrospective review was performed on patients who underwent posterior lumbar interbody fusion (PLIF) between 2011 and 2016 at our hospital. The patients were divided into SSI and non-SSI groups. Data of risk factors [age, diabetes, obesity, body mass index (BMI), number of levels, and surgery duration] and indicators of body mass distribution (subcutaneous fat thickness and multifidus fat infiltration) were collected. The degree of multifidus fat infiltration was analyzed on magnetic resonance images using Image J.

Results

Univariate analysis indicated that lumbar spine postoperative SSI was associated with urinary tract infection, subcutaneous fat thickness, lumbar multifidus muscle (LMM) fat infiltration, multilevel surgery (≥2 levels), surgery duration, drainage duration, and number of drainage tubes. In addition, multiple logistic regression analysis revealed that spine SSI development was associated with sex (male), age (> 60 years), subcutaneous fat thickness, LMM fat infiltration, and drainage duration. Receiver operating characteristic curve analysis indicated that the risk of SSI development was higher when the percentage of LMM fat infiltration exceeded 29.29%. Furthermore, Pearson’s correlation analysis demonstrated that LMM fat infiltration was correlated with age but not with BMI.

Conclusion

Indicators of body mass distribution may better predict SSI risk than BMI following PLIF. Lumbar Multifidus fat infiltration is a novel spine-specific risk factor for SSI development.