ПРОГНОСТИЧЕСКАЯ МОДЕЛЬ ДЛЯ ВЫБОРА МЕТОДИКИ РЕКАНАЛИЗАЦИИ ХРОНИЧЕСКИХ ОККЛЮЗИЙ КОРОНАРНЫХ АРТЕРИЙ

Background. Despite signifcant progress in the feld of coronary interventions, chronic total occlusion (CTO) represents a signifcant challenge for interventional cardiologists.Aim. To develop the score, able to predict technical success of CTO PCI and facilitate the choice of recanalization strategy.Methods. A total of 665 CTO patients who underwent 681 PCI in the period from 2014 to 2018 in Meshalkin National Medical Research Center were included in this study. Clinical and angiographic characteristics were analyzed. 477 CTO PCI were randomly assigned to the derivation set, 204 CTO PCI – validation set. The prognostic model was developed by assigning a score for each independent predictor of procedural failure in accordance with beta coeffcients and summing up all scores.Results. Procedural success was 76.7%. Five predictors of procedural success were included into the fnal multivariable model: bending (1 score), calcifcation (1 score), ambiguous stump (1 score), “donor” artery disease (1 score), non-RCA CTO (0.5 scores). Based on these predictors, 4 categories of CTO complexity were highlighted: 0–1 scores (easy), 1–2 scores (intermediate), 2–3 scores (diffcult), > 3 scores (very diffcult). The score demonstrated a good discriminatory ability (AUC 0.709, 95% CI 0.658–0.760). According to the novel score retrograde approach may have an advantage in patients with a > 3 scores, which corresponds to the "very diffcult" class of complexity.Conclusion. The novel score can be used in clinical practice for predicting the success of CTO PCI and determining initial crossing strategy.Актуальность. Несмотря на значительный прогресс в области коронарных вмешательств хронические окклюзии коронарных артерий (ХОКА) представляют значимую проблему для интервенционных кардиологов.Цель. Разработать шкалу, которая позволит определить исходную стратегию реканализации ХОКА.Материалы и методы. Были проанализированы клинические и ангиографические характеристики 665 пациентов, у которых выполнялась 681 попытка реканализации в ФГБУ «НМИЦ им. ак. Е.Н. Мешалкина» с 2014-го по 2017 год. 477 чрескожных коронарных вмешательств (ЧКВ) ХОКА составили группу создания шкалы, 204 ЧКВ ХОКА – группу проверки. Прогностическая модель была разработана путем присвоения баллов для каждого независимого предиктора процедурного неуспеха в соответствии с бета-коэффициентами и суммирования всех полученных баллов.Результаты. Процедурный успех был достигнут в 76,7% случаев. При многофакторном анализе были получены следующие предикторы процедурного неуспеха: извитость в теле окклюзии (1 балл), кальциноз (1 балл), неопределенная культя (1 балл), поражение артерии донора (1 балл), локализация окклюзии в бассейне огибающей артерии (ОА) или передней нисходящей артерии (ПНА) (0,5 балла). На основании данных предикторов были выделены 4 категории сложности окклюзий: < 1 балла (легкие), ≥ 1 и < 2 баллов (умеренно трудные), ≥ 2 и < 3 баллов (трудные), ≥ 3 баллов (очень трудные). Полученная шкала продемонстрировала умеренную дискриминационную способность (площадь под ROC-кривой была 0,709 (95% ДИ 0,658–0,760). Согласно шкале «CHOICE» ретроградная реканализация должна рассматриваться в качестве первичной стратегии у пациентов с баллами 3 и более (очень трудные окклюзии).Заключение. Разработанная модель может быть использована в клинической практике для прогнозирования успеха ЧКВ при ХОКА и определения стратегии эндовас кулярной реканализации

ЭНДОВАСКУЛЯРНЫЕ ВМЕШАТЕЛЬСТВА ПРИ ХРОНИЧЕСКОЙ ОККЛЮЗИИ КОРОНАРНЫХ АРТЕРИЙ

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) has been referred to as the “last frontier” in interventional cardiology. In recent years, new devices, improved imaging techniques and innovative technologies significantly increased the success rate and safety of PCI for treatment of CTO remarkably. Favorable long-term data on the outcomes of interventions, and excellent performance drug-eluting stents show a preference for CTO recanalisation. Detailed knowledge about the histopathological characteristics of CTO is crucial to understand the basic principles of advanced interventional techniques. Understanding the principle of antegrade and retrograde approaches are completing the armamentarium essential for interventional cardiologists dealing with this challenging lesion subset. As strategies fortreating complex lesions are continuously volving. Our goal was to present a systematic review of the current methods for CTO revascularization in the context of the published results of the application of these approaches are different centers, as well as solve the problem of choosing a revascularization method in specific clinical conditions.Чрезкожное коронарное вмешательство (ЧКВ) при хронических окклюзиях коронарных артерий (ХОКА) представляется как «последний рубеж» в интервенционной кардиологии. В последние годы новые устройства, усовершенствованные методы визуализации и инновационные технологии значительно повысили уровень успеха и безопасность ЧКВ для лечения ХОКА. Благоприятные отдаленные результаты вмешательств и отличные характеристики стентов с лекарственным покрытием демонстрируют предпочтение ЧКВ для реканализации ХОКА. Подробные знания гистопатологической характеристики ХОКА имеют решающее значение, чтобы понять основные принципы передовых интервенционных методов. Понимание принципа антеградного и ретроградного подходов завершают арсенал необходимых навыков для интервенционных кардиологов, занимающихся этой сложной проблемой. Что касается стратегий, методы прохождения сложных поражений постоянно развиваются. Нашей целью было представить систематический обзор текущих методик реваскуляризации ХОКА в контексте опубликованных результатов применения данных подходов различными центрами, а также решить вопрос о выборе метода реваскуляризации в конкретных клинических условиях

Предикторы улучшения качества жизни пациентов с хроническими окклюзиями коронарных артерий в зависимости от тактики ведения

Highlights. The impact of clinical, angiographic and procedure-related factors on the quality of life of patients with chronic coronary total occlusions has been reported.Background. The impact of patient-related factors including clinical and angiographic data and procedure-related factors on the quality of life remains debating.Aim. To assess the impact of baseline and procedure-related factors on the quality of life in patients with chronic coronary total occlusion.Methods. 140 patients with chronic single-vessel disease randomly assigned either to the invasive-strategy group or the conservative-strategy group. Quality of life was measured in all patients using the Seattle Angina Questionnaire, European Quality of Life Survey, and Rose Dyspnea Scale after 3 and 12 months. To determine the predictors to the quality of life improvements in both groups, simple and multivariate regression analysis were performed. The baseline clinical, angiographic and procedure-related factors were included in the analysis.Results. The technical success of the procedure was the independent predictor to quality of life improvement in the invasive-strategy group (OR: 5.8, 95%, CI: 3,26-9.18, p = 0.001). The absence of diabetes mellitus (OR: 0.19, 95%, CI: 0.09-0.84, p = 0.04), CTO of other than left anterior descending artery (OR: 2.1, 95%, CI: 1.09-4.0, p = 0.03) and higher SAQ - 7 score at baseline (OR: 1.1, 95%, CI: 1.04-1.21, p = 0.02) independently predicted the improvements in the quality of life. The indicators of quality of life between the subgroups of subintimal and intraluminal recanalization did not differ significantly in the long-term period. The total SAQ-7 score in the subintimal recanalization subgroup was 85.5 ± 9.1 versus 89.3 ± 9.6 in the intraluminal recanalization subgroup (p = 0.21).Conclusion. The decision on the management of patients with chronic coronary total occlusions should be made individually, taking into account baseline clinical and instrumental data. The recanalization technique does not affect the quality of life. Its choice should be made individually in order to achieve technical success.Основные положения. В статье проанализировано влияние клинических, ангиографических и процедурных характеристик на показатели качества жизни пациентов с хроническими окклюзиями коронарных артерий.Актуальность. До сих пор неизвестно, могут ли характеристики (клинические и ангиографические) пациента и процедуры влиять на качество жизни.Цель. Оценить влияние исходных и процедурных факторов на показатели качества жизни пациентов с хроническими окклюзиями коронарных артерий (ХОКА).Материалы и методы. В исследование включены 140 пациентов с однососудистой ХОКА, случайно распределенных в группу инвазивной или консервативной стратегий лечения. Через 3 и 12 мес. у всех больных оценивали качество жизни по данным сиэтловского, европейского опросников и шкалы одышки Rose. Для определения предикторов улучшения качества жизни в обеих группах проводили одно- и многофакторный регрессионный анализы. Учитывали исходные клинические, ангиографические и процедурные (в группе инвазивного лечения) характеристики больных.Результаты. В группе инвазивного подхода независимым предиктором улучшения качества жизни являлся технический успех процедуры (отношение шансов, ОШ, 5,8; 95% доверигельный интервал, ДИ 3,26-9,18; p = 0,001), в группе консервативного - отсутствие сахарного диабета (ОШ 0,19, 95% ДИ 0,09-0,84; p = 0,04), локализация ХОКА не в бассейне передней нисходящей артерии (ОШ 2,1, 95% ДИ 1,09-4,0; p = 0,03) и исходно более высокий суммарный балл по SAQ-7 (ОШ 1,1, 95% ДИ 1,04-1,21; p = 0,02). Показатели качества жизни в группах субинтимальной и внутрипросветной методик реканализации ХОКА в отдаленном периоде статистически значимо не отличались: суммарный балл по SAQ-7 в группе субинтимальной реканализации составил 85,5±9,1, в группе внутрипросветной реканализации - 89,3±9,6; p = 0,21.Заключение. Решение вопроса о выборе стратегии ведения пациентов с ХОКА следует принимать с учетом исходных клинико-инструментальных данных. Методика реканализации не влияет на показатели качества жизни, ее выбор должен осуществляться индивидуально с целью достижения технического успеха

ВЫБОР ХИРУРГИЧЕСКОЙ ТАКТИКИ ПРИ СОЧЕТАНИИ КОРОНАРНОГО АТЕРОСКЛЕРОЗА СО СТЕНОЗОМ АОРТАЛЬНОГО КЛАПАНА

The article presents analytical review of literature data on the problem of combined lesions of the aortic valve and coronary arteries. It outlines the current views on the assessment approach to the selection of methods and volume of surgical intervention and reflects the current state of the problem of endovascular treatment of patients with concomitant coronary artery in patients with severe aortic stenosis in the era of transcatheter aortic valve implantation.В статье представлен аналитический обзор литературных данных по проблеме сочетанного поражения аортального клапана и коронарных артерий. Изложены современные взгляды на оценку подхода к выбору методики и объему хирургического вмешательства. Отражено современное состояние проблемы эндоваскулярного лечения пациентов с сопутствующим поражением коронарных артерий при выраженном аортальном стенозе в эру транскатетерного протезирования аортального клапана.

Follow-up outcomes after chronic total occlusion percutaneous coronary intervention according to target vessel: Insights from the PROGRESS-CTO Registry

Background: Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) according to target vessel have received limited study. Methods: We compared clinical, angiographic, procedural characteristics and outcomes of 1,568 right coronary artery (RCA), left anterior descending artery (LAD) and Left Circumflex (LCX) CTO PCIs with follow-up outcomes available. Results: Mid RCA was the most common target vessel (Figure 1). The J-CTO score was 2 [1,3] vs 3 [2,4] vs 3 [2,4], p\u3c0.0001 (LAD vs LCX vs RCA respectively). Technical success was lower in RCA (89% vs 85% vs 84%, p=0.05). In-hospital MACE did not differ significantly (2.7% vs 4.8% vs 2.9%, p=0.3). LCX CTO had higher incidence of the composite of death, myocardial infarction (MI) and revascularization rates at 1 year (Figure 2) (plog-rank=0.05). Conclusions: LCX lesions are associated with the worst and RCA lesions with the best 1-year outcomes, while LAD CTOs are the least complex. (Figure Presented)

Prevalence, presentation and treatment of \u27balloon undilatable\u27 chronic total occlusions: Multicenter us experience

BACKGROUND The prevalence, treatment and outcomes of balloon undilatable chronic totalocclusions (CTOs) is poorly studied. METHODS We examined the prevalence, clinical and angiographic characteristics, and procedural outcomes ofpercutaneous coronary interventions (PCI) for balloon undilatable CTO lesions in a contemporary multicenter US registry. Between 2015 and 2017 data on balloon undilatable lesions were available for 425 consecutive CTO PCIs in 415 patients in whom guidewire crossing was successful. RESULTS Mean patient age was 65±10 years and most patients were men (84%). Fifty-two of 425 CTOs successfully crossed with a guidewire were balloon undilatable (13%). Patients with balloon undilatable CTOs were more likely to be diabetic (67% vs. 41%, p=0.0006) and have heart failure (43% vs. 28%%, p=0.03). Balloon undilatable CTOs were longer (40 mm [IQR 20-50] vs. 30mm [IQR 15-40], p=0.02), more likely to have moderate/severe calcification (87% vs. 53%, p\u3c0.01), and had higher J-CTO score (3.2±1.1 vs. 2.5±1.3, p\u3c0.01) and PROGRESS Complication score (3.8±1.7 vs. 3.1±2.0, p\u3c0.01). They were associated with lower technical and procedural success (92% vs. 98%, p=0.02; and 88% vs. 96%, 0.03) and higher risk for in-hospital major adverse events (8% vs. 2%, p=0.02). The most frequent treatments for \u27balloon undilatable\u27 CTOs were high-pressure balloon inflation (64%), rotational atherectomy (31%), laser (21%), and cutting balloons (15%). CONCLUSION Balloon undilatable CTOs are common (13%) and are associated with lower technical success and higher complication rates. (Figure Presented)

Temporal Trends in Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the PROGRESS-CTO Registry

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly evolved in recent years. Methods: We compared the clinical, angiographic, and technical characteristics and procedural outcomes of CTO PCI in a multicenter registry between the “early era” (2012 to 2016, 1,986 CTO PCIs) and the “current era” (2017 to 2019, 1,675 CTO PCIs). Results: As compared with “early era” patients, “current era” patients more often had class III or IV angina (71% vs. 66%; p = 0.029) and were less likely to undergo ad hoc CTO PCI (13% vs. 16%; p = 0.035). The J-CTO score was slightly higher in the “early era” (2.3 ± 1.4 vs. 2.5 ± 1.3; p = 0.035). Use of antegrade wire escalation was higher in the current era (92% vs. 83%; p \u3c 0.001), whereas use of retrograde crossing (29% vs. 39%; p \u3c 0.001) and antegrade/dissection re-entry (23% vs. 32%; p \u3c 0.001) was lower. Technical (85% vs. 86%, p = 0.687) and procedural (83% vs. 85%, p = 0.151) success rates were similar, whereas the incidence of in-hospital major cardiovascular events (MACE) was lower in the “current era” (2% vs. 3%; p = 0.037) (Figure). Procedure time (105 min [67, 164 min] vs. 136 min [91, 203 min]; p \u3c 0.001), contrast volume (225 ml [164, 300 ml] vs. 280 ml [200, 370 ml]; p \u3c 0.001), and air kerma radiation dose (2.4 Gy [1.3, 4.1 Gy] vs. 2.8 Gy [1.7, 4.5 Gy]; p \u3c 0.001) were lower during the “current era” (Figure). [Figure presented] Conclusion: During recent years, the complexity of CTO PCI attempted lesions decreased and ad hoc CTO PCI decreased, along with lower use of retrograde crossing and antegrade dissection and re-entry. Technical and procedural success rates remained stable, whereas the incidence of in-hospital MACE decreased. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

TCT-68 Chronic Total Occlusion Percutaneous Coronary Intervention for Patients With Previous CABG: Insights From a Pooled Analysis of 4 Multicenter Registries

Background: The outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) in patients with previous coronary artery bypass graft surgery (CABG) have received limited study. Methods: We examined the clinical angiographic characteristics and procedural outcomes of 11,503 CTO-PCIs performed on 11,397 patients at 108 US and international centers between 2012 and 2020, pooling patient-level data from 4 multicenter registries. In-hospital major adverse cardiovascular events included death, myocardial infarction, stroke, and tamponade. Results: There were 2,776 patients with previous CABG (24.4% of the total cohort). Patients with previous CABG were older (68 vs 64 years old, P \u3c 0.01) and more likely to have diabetes (48% vs 36%, P \u3c 0.001). Patients with previous CABGs had higher J-CTO scores (2.7 ± 1.2 vs 2.1 ± 1.3, P \u3c 0.001) and more proximal-cap ambiguity (43% vs 32%, P \u3c 0.001) compared with patients who did not have previous CABGs. Antegrade wiring was the most used strategy in the previous CABG group (46% vs 66%), followed by retrograde crossing (35% vs 18%) and antegrade dissection and re-entry (19% vs 15%, P \u3c 0.001). Patients with previous CABG required more contrast material (250 [175,350] vs 240 [170,331] mL, P \u3c 0.001), and intravascular imaging was used more often (36% vs 33%, P = 0.02). Technical (80% vs 87%, P \u3c 0.001) and procedural (79% vs 86%, P \u3c 0.001) success rates were lower in patients who had previous CABGs but had similar incidence of in-hospital major adverse cardiovascular events (MACE) (2.5% vs 2.4%, P = 0.77). Conclusion: CTO-PCI in patients with previous CABG is associated with lower technical and procedural success but similar in-hospital rates of major adverse cardiovascular events

Outcomes of “Investment Procedures” in Chronic Total Occlusion Interventions

Background: In cases of failed re-entry into the distal true lumen during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification to restore some antegrade flow may facilitate subsequent lesion recanalization (“investment procedure”). Methods: We examined the subsequent outcomes of 58 CTO PCI “investment procedures” of 4,657 CTO PCIs in total (1.2%) from a large, multicenter registry between years 2012 and 2019. Results: Mean patient age was 67 ± 9 years, and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%), and diabetes (48%); prior PCI (61%); and prior coronary artery bypass surgery (47%). The target CTO lesions were highly complex as illustrated by the high frequency of proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J-CTO score 3.2 ± 1.1. The rate of technical and procedural success achieved during subsequent CTO PCI was high (85% and 82%, respectively) with an acceptable rate of in-hospital major adverse cardiac events (3.3%). Median subsequent procedure time was 148 min (101, 221 min), median contrast volume was 188 ml (150, 262 ml), and median air kerma radiation dose was 2.5 Gy (1.4, 4.2 Gy) (Figure). [Figure presented] Conclusion: “Investment procedures” as bailout strategy in CTO PCI are associated with likelihood for successful revascularization during repeat CTO PCI attempt