Procedural outcomes of chronic total occlusion percutaneous coronary interventions in patients with acute kidney injury

Background: The prognostic impact of contrast-associated acute kidney injury (CA-AKI) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains underestimated. Methods: We examined 2707 consecutive procedures performed in a referral CTO center between 2015 and 2019. CA-AKI was defined as an increase in serum creatinine ≥ 0.3 mg/dL or ≥ 50% within 48 h post-PCI. Primary endpoints were in-hospital major adverse cardiac and cerebrovascular events (MACCE, composite of all-cause death, myocardial infarction, target vessel revascularization, stroke) and at one year of follow-up. Results: The overall incidence of CA-AKI was 11.5%. Technical success was comparable (87.2% vs. 90.5%, p = 0.056) whereas procedural success was lower in the CA-AKI group (84.3% vs. 89.7%, p = 0.004). Overall in-hospital MACCE was 1.3%, and it was similar in patients with and without CA-AKI (1.6% vs. 1.3%, p = 0.655); however, the rate of pericardial tamponade requiring pericardiocentesis was significantly higher in patients with CA-AKI (2.2% vs. 0.5%, p = 0.001). In multivariate analysis, CA-AKI was not independently associated with higher risk for in-hospital MACCE (adjusted odds ratio [OR] 1.34, 95% confidence intervals [CI] 0.45–3.19, p = 0.563). At a median follow-up time of 14 months (interquartile range [IQR], 11 to 35 months), one-year MACCE was significantly higher in patients with vs. without CA-AKI (20.8% vs. 12.8%, p < 0.001), and CA-AKI increased the risk for one-year MACCE (adjusted hazard ratio [HR] 1.46, 95% CI 1.07–1.95, p = 0.017) following CTO PCI. Conclusions: CA-AKI in patients undergoing CTO PCI occurs in approximately one out of 10 patients. Our study highlights that patients developing CA-AKI are at increased risk for long-term MACCE

Derivation and Validation of a Chronic Total Coronary Occlusion Intervention Procedural Success Score From the 20,000-Patient EuroCTO Registry: The EuroCTO (CASTLE) Score.

OBJECTIVES: The aim was to establish a contemporary scoring system to predict the outcome of chronic total occlusion coronary angioplasty. BACKGROUND: Interventional treatment of chronic total coronary occlusions (CTOs) is a developing subspecialty. Predictors of technical success or failure have been derived from datasets of modest size. A robust scoring tool could facilitate case selection and inform decision making. METHODS: The study analyzed data from the EuroCTO registry. This prospective database was set up in 2008 and includes >20,000 cases submitted by CTO expert operators (>50 cases/year). Derivation (n = 14,882) and validation (n = 5,745) datasets were created to develop a risk score for predicting technical failure. RESULTS: There were 14,882 patients in the derivation dataset (with 2,356 [15.5%] failures) and 5,745 in the validation dataset (with 703 [12.2%] failures). A total of 20.2% of cases were done retrogradely, and dissection re-entry was performed in 9.3% of cases. We identified 6 predictors of technical failure, collectively forming the CASTLE score (Coronary artery bypass graft history, Age (≥70 years), Stump anatomy [blunt or invisible], Tortuosity degree [severe or unseen], Length of occlusion [≥20 mm], and Extent of calcification [severe]). When each parameter was assigned a value of 1, technical failure was seen to increase from 8% with a CASTLE score of 0 to 1, to 35% with a score ≥4. The area under the curve (AUC) was similar in both the derivation (AUC: 0.66) and validation (AUC: 0.68) datasets. CONCLUSIONS: The EuroCTO (CASTLE) score is derived from the largest database of CTO cases to date and offers a useful tool for predicting procedural outcome

Association of Prolonged Fluoroscopy Time with Procedural Success of Percutaneous Coronary Intervention for Stable Coronary Artery Disease with and without Chronic Total Occlusion

Background: In percutaneous coronary interventions (PCI), the impact of prolonged fluoroscopy time (FT) on procedural outcomes is poorly studied. Methods and Results: We analyzed the outcomes of 12,538 consecutive elective PCIs. The primary endpoint was procedure failure (PF), the composite of technical failure, and adverse in-hospital events including all-cause death, myocardial infarction, stroke, and target vessel revascularization (MACCE), as well as pericardial tamponade. We stratified the procedures as PCI for chronic total occlusion (CTO, n = 2720) and PCI for non-CTO (n = 9818). Logistic regression demonstrated a significant association between fluoroscopy time and procedural failure with a significant interaction with PCI type (both p < 0.001). The odds ratios (OR) of procedural failure for a 10-min increment in FT were 1.15 (confidence interval (CI) 95% 1.12–1.18, p < 0.001) in non-CTO PCI and 1.05 (CI 95% 1.03–1.06, p < 0.001) in CTO PCI. The optimal cut-point for prediction of PF was 21.1 min in non-CTO PCI (procedural success in 98.4% versus 95.3%, adjusted OR for PF 2.79 (CI 95% 1.93–4.04), p < 0.001) and 41 min in CTO PCI (procedural success in 92.3% versus 83.8%, adjusted OR for PF 2.18 (CI 95% 1.64–2.94), p < 0.001). In CTO PCI, the increase in PF with FT was largely driven by technical failure (adjusted OR 2.25 (CI 95% 1.65–3.10), p < 0.001), whereas in non-CTO PCI, it was driven by major complications (adjusted OR 2.94 (CI 95% 1.93–4.53), p < 0.001). Conclusions: Prolonged FT is strongly associated with procedural failure in both non-CTO and CTO PCI. In CTO PCI, this relation is shifted towards longer FT. The mechanisms of procedural failure differ between CTO and non-CTO PCI

Temporal changes in outcomes of women and men undergoing percutaneous coronary intervention for chronic total occlusion: 2005-2013

OBJECTIVE Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has undergone impressive progress during the last decade, both in strategies and equipment. It is unknown whether technical refinement has translated into improved outcomes in women undergoing CTO-PCI. METHOD AND RESULTS A total of 2002 consecutive patients (17% females, mean age 65.2 ± 10.7 years) undergoing PCI of at least one CTO lesion at our center between 01/2005 and 12/2013 were evaluated. The incidence of adverse events was compared between two time series (2005-2009 and 2010-2013). A significant increase in adverse lesion characteristics over time was noted in both, women and men (p < 0.001), while technical success rates significantly increased in men but not in women (ptrend < 0.001 in men and ptrend=0.9 in women). The incidence of procedural complications was significantly higher in women as compared to men and increased over the study period in women (p < 0.05) but not in men. Accordingly, multivariate logistic regression analysis identified female sex as a strong predictor of PCI-related complications in recent years, while this was not the case in earlier years (adjusted HR 2.03, 95% CI 0.62-6.6, p = 0.2 and adjusted HR 4.7, 95% CI 1.8-12.3, p = 0.002, respectively, p < 0.001 for log LH ratio). In addition, major adverse cardiovascular events (MACE) after a 3-year follow-up significantly declined in men (log rank = 0.046), while no changes were observed in women. CONCLUSION While higher success rates and a reduced rate of MACE have been achieved in men, the incidence of procedural complications in women undergoing CTO-PCI has increased over time

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p &lt; 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p &lt; 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p &lt; 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease