Incidence and predictors of target lesion failure in patients undergoing contemporary DES implantation—Individual patient data pooled analysis from 6 randomized controlled trials

© 2019 Elsevier Inc. Background: Drug-eluting stents (DESs) have improved clinical outcomes of patients undergoing percutaneous coronary intervention (PCI). Nevertheless, adverse events related to previously treated lesion still occur. We sought to evaluate the incidence and predictors of target lesion failure (TLF) in patients undergoing contemporary DES implantation. Methods: Patient-level data from 6 prospective, randomized trials were pooled, and DES treatment outcomes were analyzed at up to 5 years. Primary outcome was TLF (cardiac death, target lesion revascularization, or target vessel myocardial infarction). Cox proportional-hazards model was used to identify predictors of TLF. Results: Overall, 10,072 patients were included in the analysis. TLF rate was 1.7%, 4.3%, and 11.9% at 30 days, 1 year, and 5 years, respectively. The only independent predictor of TLF at 30 days was stent length (hazard ratio [HR] 1.017, 95% CI 1.011-1.024, P \u3c .0001). Moderate/severe calcification, stent length and post procedural diameter sthenosis were predictors between 30 days to 1 year but not at 1 to 5 years. Reference vessel diameter was the only lesion-related predictor at 5 years (P = .003). Clinical predictors of TLF between 30 days and 1 year were diabetes and hypertension (P \u3c .01 for both), and between 1 and 5 years, diabetes (HR 1.40, 95% CI 1.13-1.73, P = .002), prior coronary artery bypass grafting (HR 2.52, 95% CI 1.92-3.30, P \u3c .0001), and prior PCI (HR 1.29, 95% CI 1.02-1.64, P = .04) predicted TLF. Conclusions: Predictors of TLF vary in the early, late, and very late postprocedural periods. Reference vessel diameter was the only lesion-related predictor of long-term TLF; clinical predictors were diabetes, prior coronary artery bypass grafting, and prior PCI

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

Radiation dose during CTO-PCI: Insights from the PROGRESS-CTO registry

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can be associated with increased risk of excessive radiation. Methods: We examined radiation dose in 5,635 patients undergoing CTO-PCI at 28 US and international centers between 2012 and 2019. We compared the group of patients that had fluoroscopy air kerma (AK) radiation dose above the median (\u3e2.4 Gy) and those who had AK radiation dose below the median (≤2.4 Gy). Results: Mean age was 64.5 ±10 years and 83% of patients were men. Median AK radiation dose was 2.4 [1.3-4.1] Gy. The proportion of procedures that had AK dose \u3e2.4 Gy decreased over time (Figure, Panel A). Median AK radiation dose was significantly lower in 2019 vs. 2012 (1.9 [1.1, 3.2] vs. 4.4 [2.5, 6.2] Gray, p\u3c0.0001) (Figure, Panel B). Median body mass index was higher in the higher radiation group (31.4 [27.9, 35.8] vs 28.4 [25.5, 32.3], p\u3c0.0001). Patients in the higher radiation dose group were more likely to have previous coronary artery bypass graft surgery compared with patients in the lower radiation group (41% vs. 28%, p\u3c0.0001). Median J-CTO score (3 [2,4] vs. 2 [1, 3], p\u3c0.0001) and median procedure time (167 [119,223] vs. 104 [72,143] min, p\u3c0.0001) were higher in the higher radiation group. Technical and procedural success were lower in the higher radiation group (84% vs. 91%, 82% vs. 90%, respectively, p\u3c0.0001) and the incidence of in-hospital major adverse cardiovascular events was higher (3.3% vs. 1.7%, p=0.0025). There was no reported radiation skin injury. Conclusions: AK radiation dose during CTO-PCI has significantly decreased in recent years among high-volume, experienced centers

Left main chronic total occlusion percutaneous coronary intervention: A case series

Background: Left main coronary artery (LMCA) chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods: We reviewed between 2012 and 2018 4,436 CTO PCIs performed in 4,340 patients at 25 sites in the US, Europe and Asia, of which LMCA CTO PCI was performed in 20 (0.45%) cases at 11 sites. We examined the clinical and angiographic characteristics and procedural outcomes of these cases. Results: Mean patient age was 68±11 and 65% were men. Most patients (85%), had undergone prior coronary artery bypass surgery (CABG) and had patent grafts to the left anterior descending or circumflex artery. Mean J-CTO score was 2.7±1.3. Antegrade wire escalation (AWE) was the crossing strategy that was used more often (90%), followed by retrograde crossing (50%) and antegrade dissection/reentry (ADR) (15%). The most common successful crossing technique was AWE (50%), followed by retrograde crossing (30%) and ADR (10%). Technical and procedural success rates were 85% for both endpoints while only one in-hospital major adverse cardiac event was recorded: a periprocedural myocardial infarction (Figure 1). In addition, three patients had perforation that was treated conservatively without pericardiocentesis or emergent surgery and one patient developed a femoral pseudoaneurysm that was corrected surgically. A left ventricular assist device was used in 20%. Median procedure time was 178 (123, 250) min, median contrast volume was 190 (133, 339) ml and patient air kerma radiation dose was 2.6 (1.3, 3.9) Gray. Conclusions: LMCA CTO PCI is infrequently performed but is associated with good procedural outcomes. (Figure Presented)

Retrograde Chronic Total Occlusion Percutaneous Coronary Interventions via Saphenous Vein Grafts

Background: The use of saphenous vein grafts (SVGs) for retrograde crossing during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods: We examined 1,615 retrograde CTO PCIs performed between 2012 and 2019 at 25 centers. We compared the clinical, angiographic, and technical characteristics and procedural outcomes among retrograde cases via SVGs (SVG group) versus other collateral vessels (non-SVG group). Results: Retrograde CTO PCI via SVGs was performed in 189 cases (12%) (Figure). Patients in the SVG group were older (70 ± 9 years vs. 64 ± 10 years; p \u3c 0.01) and had higher rates of prior myocardial infarction (62% vs. 51%; p \u3c 0.01) and PCI (81% vs. 70%; p \u3c 0.01). They were more likely to have moderate or severe calcification (81% vs. 65%; p \u3c 0.01) and moderate or severe tortuosity (53% vs. 44%; p = 0.02) and had similar J-CTO scores (3.2 ± 1.0 vs. 3.1 ± 1.1; p = 0.13) and higher PROGRESS-CTO scores (4.7 ± 1.7 vs. 3.1 ± 1.1; p \u3c 0.01). Femoral access was used more often in the SVG group (88% vs. 82%; p = 0.04). Technical (85% vs. 78%; p = 0.04) and procedural (81% vs. 74%; p = 0.04) success rates were higher in the SVG group, with no difference in in-hospital major adverse cardiac events (MACE) (6.4% vs. 4.4%; p = 0.22). Contrast volume was lower in the SVG group (225 ml [173 to 325 ml] vs. 292 ml [202 to 400 ml]; p \u3c 0.01). [Figure presented] Conclusion: The use of SVGs for retrograde crossing is associated with higher rates of technical and procedural success and similar rates of in-hospital MACE compared with retrograde CTO PCI via other collateral types. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

Contrast utilization patterns during CTO-PCI: Insights from the PROGRESS-CTO registry

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) may require large contrast volume. Methods: We examined contrast utilization in 5,440 patients undergoing CTO PCI at 30 US and international centers between 2012 and 2019. We compared the group of patients that had contrast volume above vs. below the median (240 mL). Results: Mean age was 64.5 ±10 years, 83% of patients were men and 42% had diabetes mellitus. Median pre-procedural creatinine was 1.01 [0.76-1.2] mg/dL and 2% of patients were on dialysis. Median contrast volume was 240 [170,320] mL and decreased over time (Figure). Patients with high contrast volume were more likely to have undergone ad-hoc CTO-PCI (13.2% vs. 8.9%, p\u3c0.0001) and had higher median J-CTO score (3 [2,3] vs. 2 [1, 3], p\u3c0.0001). The higher contrast volume group had higher use of retrograde crossing strategy (43% vs. 27%, p\u3c0.0001), lower procedural and technical success (82% vs. 88% and 84% vs 89%, respectively, p\u3c0.0001), higher incidence of in-hospital major adverse events (3% vs. 1.5%, p=0.0001), and longer procedure time (139 [98,201] vs. 96 [62,148] min, p\u3c0.0001). The use of intravascular ultrasound was associated with lower contrast volume (57% vs 43%, p\u3c0.0001). Conclusions: Contrast volume used during CTO-PCI has been decreasing over the years. Higher lesion complexity, procedural failure, and the occurrence of complications are associated with higher contrast volume