Frequency and outcomes of ad hoc versus planned chronic total occlusion percutaneous coronary intervention: Insights from a multicenter registry

Background: Ad hoc chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is discouraged due to the perceived benefits of pre-planning, risk-benefit assessment, and understanding of the anatomic and clinical circumstances for this complex lesion/patient subset. Methods: We compared the characteristics and outcomes of patients undergoing planned vs. ad hocCTO PCI in a multicenter registry (NCT02061436). Results: Among 1,438 patients undergoing CTO PCI between 2012- 2016, 14% (n=206) were ad hoc. Patients undergoing ad hoc PCI were less likely to have prior CABG and prior PCI, but more likely to have diabetes, cerebrovascular disease, and peripheral arterial disease (all p\u3c0.05). They also had lower rates of moderate/severe calcification, prior failed CTO PCI, proximal cap ambiguity, and a lower J-CTO score (2.2 vs. 2.7, \u3c0.0001). Dual injection was less frequent in ad hoc vs. planned PCI (38% vs. 73%, p\u3c0.0001). An antegrade-wire escalation strategy was used more often in ad hoc PCI (94% vs. 76%, p\u3c0.0001), whereas antegrade-dissection reentry (22% vs. 37%) or retrograde (16% vs. 43%) approaches were more common in planned PCI (both p\u3c0.0001). There was no difference in ad hoc vs. planned PCI in technical and procedural success rates, and in-hospital major adverse cardiac events (Figure). Conclusion: In a large, contemporary US registry with expert operators, ad hoc CTO PCI occurred in 14% ofcases. Ad hoc CTO PCI was more commonly performed in less complex lesions but was associated with similarly high success

Use of the gaia guidewires in a contemporary multicenter registry of chronic total occlusion percutaneous coronary intervention

Background: We sought to examine the use of thecomposite core hydrophilic Gaia guidewires inchronic total occlusion (CTO) percutaneous coronaryintervention (PCI). Methods: Baseline clinical and angiographic characteristics and procedural outcomes of 847 CTO PCIs performed between 2015 and 2016 at 9 US centers in 825 patients were evaluated. Results: The mean patient age was 65.1±10 years and 87% were men. The Gaiaguidewires were increasingly being used (30.5% antegrade and 7.6% retrograde crossing attempts in2015 vs 47.9% antegrade and 20.5% retrograde crossing attempts in 2016; p\u3c0.0001 for both respectively). In antegrade crossing the Gaia wires were used in more complex lesions with higher Japanese chronic total occlusion scores (2.76±1.18 vs. 2.25±1.32, p\u3c.0001) and were associated with lower technical and procedural success rates (79.1% vs. 87.0%, p=0.006; 77.6% vs. 85.8%, p= 0.007) but similar incidence of major adverse events (MACE: 3.56% vs. 2.64%, p=0.501). In retrograde crossing useof the Gaia wires was associated with similar technical and procedural success rates (80.5% vs. 77.3%, p=0.645; 68.3% vs. 72.9%, p=0.0536), but higher incidence of MACE (17.07% vs. 5.48%, p=0.006). Conclusion: In a contemporary, multicenterregistry Gaia guidewires are commonly and increasingly being used, especially in more complex cases and are associated with high technical and procedural success rates. (Table presented)

Incidence, treatment, and outcomes of coronary perforation during chronic total occlusion percutaneous coronary interventions: Insights from a multicenter registry

Background: Coronary perforation is a potential procedural complication of chronic total occlusion (CTO) percutaneouscoronary intervention (PCI). Methods: We analyzed data from 1952 patients who underwent CTO PCI in amulticenter registry. Results: Mean patient age was 65±10 years, 85% were men, 36% had prior coronary artery bypass grafting (CABG). Overall technical and procedural success were 88% and 87%. A major adverse cardiovascular event (death, myocardial infarction, stroke, repeat revascularization, pericardiocentesis) occurred in 2.6%. Coronary perforation occurred in 80 patients (4.1%). Perforation was more frequent in older patients (71±9 vs. 65±10 years, p\u3c0.001) and with prior CABG (61% vs. 35%, p\u3c0.001). Perforation occurred at the CTO target vessel in 75%, an epicardial collateral in 16%, and a septal collateral in 9% of cases. Cases with perforation were angiographically more complex (moderate/severe calcification 81% vs. 56%, p\u3c0.001; blunt/no stump 75% vs. 53%, p=0.002; poor distal landing zone 52% vs. 36%, p=0.023; J-CTO score 3.0±1.2 vs. 2.5±1.2, p=0.001, PROGRESS-CTO Complications score 4.4±1.8 vs. 3.2±1.9, p\u3c0.001). Ten perforations resulted in tamponade requiring pericardiocentesis (12.5% of perforations, 0.5% of overall cohort). Figure 1 shows treatment and concurrent complications (related or unrelated to perforation) stratified by perforation Ellis type. Conclusion: Coronary perforationoccurs relatively infrequently in contemporary CTO PCI, and is associated with patient age, prior CABG, and angiographic complexity. A small proportion of perforations required pericardiocentesis

Treatment of left anterior descending coronary artery chronic total occlusion: Insights form a contemporary multicenter registry

Background: To examine the impact of calcification on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: The outcomes of 1,862 consecutive CTO PCIs performed in 1,825 patients (65.1±10 years; 86% male) between 2012 and 2016 at 11 US centers were evaluated. Results: Left anterior descendingcoronary artery target vessels (LAD) represented 27% of the cases. LAD CTOs were less complex than leftcircumflex and right coronary artery lesion, with lower Japanese CTO scores (2.02±1.18 vs. 2.53±1.27 vs. 2.74±1.20, p\u3c.0001). LAD CTOs were also less tortuous (15% vs. 55% vs. 38%, p\u3c.0001) and less likely required retrograde crossing attempt (24% vs. 32% vs. 50%, p\u3c.0001). LAD CTOs were associated with shorter procedure and fluoroscopy time and lower air kerma radiation dose and contrast volume. LAD CTOs were associated with higher technical (91.6% vs. 85.4% vs. 87.7%, p=0.019) and procedural (90.9% vs. 85.2% vs. 85.2%, p=0.010) success rates but similar incidence of major adverse cardiac events (1.40% vs. 2.38% vs. 3.44%, p=0.085) compared to the other vessels (Figure 1.) Conclusion: In a contemporary, multicenter registry, LAD CTOs were present in 27% of attempted CTO lesions and were associated with higher success rates and similar complication rates

Utilization of the hybrid approach for percutaneous coronary interventions for chronic total occlusions: Update from a multicenter global registry

BACKGROUND We sought to examine thecontemporary outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI). METHODS We examined the clinical, angiographic and procedural characteristics of 2,733 CTO interventions of 2677 patients that were performed in 18 centers from the United States and Europe. RESULTS Mean age was 65±10 years and 85% of thepatients were men. There was a high prevalence ofdiabetes (44%), prior myocardial infarction (46%), prior coronary artery bypass surgery (33%), and prior PCI (66%). The most common target vessels were theright coronary artery (55%), left anterior descending artery (24%), and left circumflex artery (20%). Themean J-CTO and PROGRESS-CTO score was 2.5±1.3 and 1.4±1.0, respectively. The overall technical and procedural success rate was 88% and 86% respectively and the rate of in-hospital major complications was 2.9%. The initial crossing strategy was successful in 55% (Figure). The final successful crossing strategy was antegrade wire escalation in 50%, retrograde in 28%, and antegrade dissection reentry in 22%. Median contrast volume, air kerma radiation dose, procedure and fluoroscopy time were 270 (200-365) ml, 2.9 (1.7-4.8) Gray, 125 (82-191) and 46 (29-76) minutes, respectively. CONCLUSION Application of the hybrid approach for CTO PCI is associated with high technical success and low major adverse complication rates among various operators and patient populations. (Figure presented)

Retrograde CTO PCI of native coronary arteries via left internal mammary artery grafts: Insights from a multicenter US registry

BACKGROUND Retrograde percutaneous interventions (PCI) of native coronary artery chronic total occlusions (CTOs) via left internal mammaryartery (LIMA) grafts have received limited study. METHODS We compared the clinical and procedural characteristics and outcomes of retrograde CTO PCIthrough LIMA grafts vs. via other vessels in acontemporary multicenter registry. RESULTS The LIMA was used as collateral channel in 20 of 990 retrograde CTO PCIs (2.0%) performed at 18 USCenters. The mean age of the study patients was 69±7 years, and 95% were men. The most common CTO target vessel was the right coronary artery (55%). The mean J-CTO score in the LIMA group was high (3.45±0.76). The technical and procedural success rate of retrograde PCI via LIMA grafts was 70% and 70%, respectively, vs. 81.0% and 78.2% (p=0.247, and p=0.412), respectively for retrograde via other conduits (Figure). The incidence of major in-hospital complications was also similar between the LIMA and non- LIMA retrograde groups (5% vs. 6%, p=1.000). Use of guide catheter extensions (40% vs. 28%, p=0.217), intravascular ultrasound (45% vs. 31%, p=0.197), and left ventricular assist devices (24% vs. 10%, p=0.769) were numerically higher in retrogradeCTO PCIs via LIMA grafts. CONCLUSION RetrogradeCTO PCI is infrequently performed via LIMA graftsand is associated with numerically lower success but similar major in-hospital complication rates as retrograde CTO PCI performed via other vessels. (Figure presented)