Laser for balloon uncrossable and undilatable chronic total occlusion interventions

BACKGROUND: There is limited information on use of laser in complex percutaneous coronary interventions (PCI). We examined the impact of laser on the outcomes of balloon uncrossable and balloon undilatable chronic total occlusion (CTO) PCI. METHODS: We reviewed baseline clinical and angiographic characteristics and procedural outcomes of 4845 CTO PCIs performed between 2012 and 2020 at 32 centers. RESULTS: Of the 4845 CTO lesions, 752 (15.5%) were balloon uncrossable (523 cases) or balloon undilatable (356 cases) and were included in this analysis. Mean patient age was 66.9 ± 10 years and 83% were men. Laser was used in 20.3% of the lesions. Compared with cases in which laser was not used, laser was more commonly used in longer length occlusions (33 [21, 50] vs. 25 [15, 40] mm, p = 0.0004) and in-stent restenotic lesions (41% vs. 20%, p \u3c 0.0001). Laser use was associated with higher technical (91.5% vs. 83.1%, p = 0.010) and procedural (88.9% vs. 81.6%, p = 0.033) success rates and similar incidence of major adverse cardiac events (3.92% vs. 3.51%, p = 0.805). Laser use was associated with longer procedural (169 [109, 231] vs. 130 [87, 199], p \u3c 0.0001) and fluoroscopy time (64 [40, 94] vs. 50 [31, 81], p = 0.003). CONCLUSIONS: In a contemporary, multicenter registry balloon uncrossable and balloon undilatable lesions represented 15.5% of all CTO PCIs. Laser was used in approximately one-fifth of these cases and was associated with high technical and procedural success and similar major complication rates

Percutaneous coronary intervention of chronic total occlusions involving a bifurcation: Insights from the PROGRESS-CTO registry

BACKGROUND: The impact of bifurcations at the proximal or distal cap on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We analyzed the clinical, angiographic, and procedural data of 4,584 cases performed in patients between 2012 and 2020 in a global CTO PCI registry. We compared 4 groups according to the bifurcation location: proximal cap, distal cap, proximal and distal cap, and no bifurcation. RESULTS: The CTO involved a bifurcation in 67% cases, as follows: proximal cap (n = 1451, 33%), distal cap (n = 622, 14%), or both caps (n = 954, 21%). Proximal and distal cap cases had higher J-CTO compared with proximal cap, distal cap, and no bifurcation cases (2.9 ± 1.1 vs 2.5 ± 1.1 vs 2.4 ± 1.2 vs 2.0 ± 1.2, P \u3c 0.0001), and they were also associated with a lower technical success rate (79% vs 85% vs 85% vs 90%, P \u3c 0.0001), higher pericardiocentesis rate (1% vs 1% vs 0.2% vs 0.3%, P = 0.02), and higher emergency coronary artery bypass graft surgery rate (0.3% vs 0% vs 0% vs 0%, P = 0.01). CONCLUSION: More than two-thirds of CTO PCIs involve a bifurcation, which is associated with lower technical success and higher risk of complications

Angiographic Features and Clinical Outcomes of Balloon Uncrossable Lesions during Chronic Total Occlusion Percutaneous Coronary Intervention

Background: Balloon uncrossable lesions are defined as lesions that cannot be crossed with a balloon after successful guidewire crossing. Methods: We analyzed the association between balloon uncrossable lesions and procedural outcomes of 8671 chronic total occlusions (CTOs) percutaneous coronary interventions (PCIs) performed between 2012 and 2022 at 41 centers. Results: The prevalence of balloon uncrossable lesions was 9.2%. The mean patient age was 64.2 ± 10 years and 80% were men. Patients with balloon uncrossable lesions were older (67.3 ± 9 vs. 63.9 ± 10, p < 0.001) and more likely to have prior coronary artery bypass graft surgery (40% vs. 25%, p < 0.001) and diabetes mellitus (50% vs. 42%, p < 0.001) compared with patients who had balloon crossable lesions. In-stent restenosis (23% vs. 16%. p < 0.001), moderate/severe calcification (68% vs. 40%, p < 0.001), and moderate/severe proximal vessel tortuosity (36% vs. 25%, p < 0.001) were more common in balloon uncrossable lesions. Procedure time (132 (90, 197) vs. 109 (71, 160) min, p < 0.001) was longer and the air kerma radiation dose (2.55 (1.41, 4.23) vs. 1.97 (1.10, 3.40) min, p < 0.001) was higher in balloon uncrossable lesions, while these lesions displayed lower technical (91% vs. 99%, p < 0.001) and procedural (88% vs. 96%, p < 0.001) success rates and higher major adverse cardiac event (MACE) rates (3.14% vs. 1.49%, p < 0.001). Several techniques were required for balloon uncrossable lesions. Conclusion: In a contemporary, multicenter registry, 9.2% of the successfully crossed CTOs were initially balloon uncrossable. Balloon uncrossable lesions exhibited lower technical and procedural success rates and a higher risk of complications compared with balloon crossable lesions

Use of the Limited Antegrade Subintimal Tracking Technique in Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND There are limited data on the limited antegrade subintimal tracking (LAST) technique for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).OBJECTIVES The aim of this study was to analyze the frequency of use and outcomes of the LAST technique for CTO PCI.METHODS We analyzed 2,177 CTO PCIs performed using antegrade dissection and re-entry (ADR) in the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) registry between 2012 and January 2022 at 39 centers. ADR was attempted in 1,465 cases (67.3%).RESULTS Among antegrade re-entry cases, LAST was used in 163 (11.1%) (primary LAST in 127 [8.7%] and secondary LAST [LAST after other ADR approaches failed] in 36 [2.5%]), the Stingray system (Boston Scientific) in 980 (66.9%), subintimal tracking and re-entry in 387 (26.4%), and contrast-guided subintimal tracking and re-entry in 29 (2.0%). The mean patient age was 65.2 similar to 10 years, and 85.8% were men. There was no significant difference in technical (71.8% vs 77.8%; P 1/4 0.080) and procedural (69.9% vs 75.3%; P 1/4 0.127) success and major cardiac adverse events (1.84% vs 3.53%; P 1/4 0.254) between LAST and non-LAST cases. However, on multivariable analysis, the use of LAST was associated with lower procedural success (OR: 0.61; 95% CI: 0.41-0.91). Primary LAST was associated with higher technical (76.4% vs 55.6%; P 1/4 0.014) and procedural (75.6% vs 50.0%; P 1/4 0.003) success and similar major adverse cardiac event (1.57% vs 2.78%; P 1/4 0.636) rates compared with secondary LAST.CONCLUSIONS LAST was used in 11.1% of antegrade re-entry CTO PCI cases and was associated with lower procedural success on multivariable analysis, suggesting a limited role of LAST in contemporary CTO PCI. (J Am Coll Cardiol Intv 2022;15:2284-2293) (c) 2022 by the American College of Cardiology Foundation

TCT-128 Saphenous Vein Graft Occlusion Following Native Vessel Chronic Total Occlusion Percutaneous Coronary Intervention

Background: The practice of occluding patent saphenous vein grafts (SVGs) after successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of the native vessel has received limited study. Methods: We analyzed baseline clinical and angiographic characteristics and procedural outcomes of 51 patients who following successful CTO PCI of the native vessel underwent attempted SVG occlusion between 2015 and 2022 at 14 centers. Results: Mean patient age was 71 ± 8 years and 80% were men. The most common CTO target vessel was the right coronary artery (41%), followed by the left circumflex artery (35%). Retrograde crossing was the successful crossing strategy in 78% (n = 40) and the SVG was the collateral used for all the retrograde cases. Recurrent SVG failure (51%) was the most common reason for treating the native vessel instead of the SVG supplying the same vessel. Coils were used in 71% (n = 36) to occlude the SVG with a mean number of 1.9 ± 1.1 coils, and Amplatzer vascular plugs were used in 29% (n = 15) of the cases. All procedures were technically successful and the SVG was occluded completely (TIMI 0 flow) in 75% (n = 38) of the cases. Follow up was available for 38 patients (75%): during a mean follow up of 312 days, the incidence of target lesion failure was 5.4% (n = 2). There were no other associated periprocedural or in-hospital complications. Conclusion: SVG occlusion after successful native vessel CTO PCI, is associated with favorable periprocedural and mid-term outcomes. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

TCT-117 Impact of Proximal Cap Ambiguity on the Outcomes of Chronic Total Occlusion Intervention: Insights From the PROGRESS-CTO Registry

Background: The impact of proximal cap ambiguity on procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods: We examined the clinical and angiographic characteristics and procedural outcomes of 11,169 CTO PCIs performed in 10,932 patients at 42 US and non-US centers between 2012 and 2022. Results: Proximal cap ambiguity was present in 35% of CTO lesions. Patients whose lesions had proximal cap ambiguity were more likely to have had prior PCI (65% vs 59%; P \u3c 0.01) and prior coronary artery bypass graft surgery (37% vs 24%; P \u3c 0.01). Lesions with proximal cap ambiguity were more complex with higher J-CTO score (3.1 ± 1.0 vs 2.0 ± 1.2; P \u3c 0.01) and lower technical (79% vs 90%; P \u3c 0.01) and procedural success (77% vs 89%; P \u3c 0.01) rates compared with non-ambiguous CTO lesions. The incidence of major adverse cardiovascular events (MACE) was higher in cases with proximal cap ambiguity (2.5% vs 1.7%; P \u3c 0.01). The retrograde approach was more commonly used among cases with ambiguous proximal cap (51% vs 21%; P \u3c 0.01) and was more likely to be the final successful crossing strategy (29% vs 13%; P \u3c 0.01). PCIs of CTOs with ambiguous proximal cap required longer procedure time (140 [95-195] vs 105 [70-150] min; P \u3c 0.01) and more contrast volume (225 [160-305] vs 200 [150-280] mL; P \u3c 0.01). Conclusion: Proximal cap ambiguity in CTO lesions is associated with higher utilization of the retrograde approach, lower technical and procedural success rates, and higher incidence of in-hospital MACE. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

TCT-171 Predicting the Risk of Perforation Requiring Pericardiocentesis in Chronic Total Occlusion Percutaneous Coronary Intervention: The PROGRESS-CTO Pericardiocentesis Score

Background: Estimating the risk for complications facilitates risk-benefit assessment and procedural planning in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We analyzed the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) and created a risk score for pericardiocentesis. Patients with histories of coronary artery bypass graft surgery were excluded. Logistic regression prediction modeling was used to identify independently associated variables, and the model was internally validated with bootstrapping. Results: Of the 7,672 CTO PCI cases performed between 2012 and 2022 at 40 centers, 83 (1.1%) required pericardiocentesis. The final prediction model identified predictors of pericardiocentesis: age ≥ 65 years (OR: 2.10; 95% CI: 1.27-3.46), 1 point; female sex (OR: 2.25; 95% CI: 1.39-3.63), 1 point; moderate to severe calcification (OR: 3.28; 95% CI: 1.96-5.49), 1 point; antegrade dissection re-entry (OR: 2.83, 95% CI: 1.45-5.51), 1 point; and retrograde strategy (OR: 3.50; 95% CI: 2.08-5.87), 2 points; with a bootstrap corrected C statistic of 0.78 (95% CI: 0.72-0.83). The calculated risk percentages for pericardiocentesis on the basis of the PROGRESS-CTO mortality score ranged from 0.18% to 8.74% for pericardiocentesis, and 55% of patients had PROGRESS-CTO pericardiocentesis scores of 1 or 2, corresponding to a pericardiocentesis risk of 0.4% to 1.6%. Conclusions: The PROGRESS-CTO pericardiocentesis risk score can facilitate risk-benefit assessment and procedural planning in patients undergoing CTO PCI. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

TCT-113 Predicting the Risk of In-Hospital Major Adverse Cardiovascular Events in Chronic Total Occlusion Percutaneous Coronary Intervention: The PROGRESS-CTO MACE Score

Background: Estimating the risk of complications in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) facilitates risk-benefit assessment and procedural planning. Methods: We analyzed the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO; NCT02061436) and created a risk score for in-hospital major adverse cardiovascular events (MACE). Logistic regression prediction modeling was used to identify independently associated variables and the model was internally validated with bootstrapping. Results: Of the 10,480 CTO PCI cases performed between 2012-2022 at 40 US and non-US centers, in-hospital MACE occurred in 215 (2.05%). The final prediction model identified 5 independent predictors of MACE: age ≥65 years, odds ratio (OR) 1.57, 95% confidence interval (CI) 1.10-2.26, 1 point; female sex, OR 2.46, 95% CI 1.72-3.53, 2 points; moderate to severe calcification, OR 1.71, 95% CI 1.20-2.44, 1 point; Blunt stump, OR 1.63, 95% CI 1.14-2.33, 1 point; and Antegrade dissection re-entry, OR 2.21, 95% CI 1.32-3.72, 1 point; and retrograde strategy, OR 2.86, 95% CI 1.94-4.22, 2 points; with a bootstrap corrected c-statistic of 0.72, 95% CI 0.68-0.76. The calculated risk percentages for MACE based on the PROGRESS-CTO MACE score ranged from 0.4% to 9.4% for MACE; 42% of patients had PROGRESS-CTO MACE score of 2-3, corresponding to a MACE risk of 1.1%-2.0%. Conclusion: The PROGRESS-CTO in-hospital MACE risk score can facilitate risk-benefit assessment and procedural planning in patients undergoing CTO PCI. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

TCT-109 Use of Subintimal Tracking and Reentry Technique in Chronic Total Occlusion Percutaneous Coronary Intervention

Background: There are limited data on the use of the subintimal tracking and reentry (STAR) technique for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We analyzed 2,353 CTO PCIs performed using antegrade dissection re-entry (ADR) in the PROGRESS-CTO Registry, between 2012 and June 2022 at 41 centers. Results: STAR was used in 450 cases (19.1%), primary STAR in 325 (13.8%) and secondary STAR (STAR after other ADR approaches) in 125 (5.3%). The Stingray system was used in 1,048 (44.5%), limited antegrade subintimal tracking (LAST) in 177 (7.5%), and contrast-guided STAR in 31 (1.3%) of re-entry cases. The mean patient age was 65.3 ± 10 years and 86.0% were men. STAR cases were more complex with higher Japan-CTO (3.05 ± 1.08 vs 2.87 ± 1.14, P = 0.002) and PROGRESS (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) CTO (1.58 ± 1.14 vs 1.20 ± 1.04, P \u3c 0.001) scores compared to non-STAR cases. The cases where STAR was used had lower technical (69.3% vs 79.1%, P \u3c 0.001) and procedural (67.7% vs 76.3%, P \u3c 0.001) success compared with cases where STAR was not used. The incidence of major cardiac adverse events was similar (3.70% vs 3.52%, P = 0.858) between STAR and non-STAR cases. Primary STAR was associated with higher technical and procedural success and similar MACE compared with secondary STAR (Figure). Conclusion: STAR is used in 19.1% of antegrade re-entry CTO PCI cases and is associated with higher angiographic complexity, lower technical and procedural success rates and similar major complication rates compared to antegrade re-entry cases that did not use STAR. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

Angiographic Features and Clinical Outcomes of Balloon Uncrossable Lesions during Chronic Total Occlusion Percutaneous Coronary Intervention

Background: Balloon uncrossable lesions are defined as lesions that cannot be crossed with a balloon after successful guidewire crossing. Methods: We analyzed the association between balloon uncrossable lesions and procedural outcomes of 8671 chronic total occlusions (CTOs) percutaneous coronary interventions (PCIs) performed between 2012 and 2022 at 41 centers. Results: The prevalence of balloon uncrossable lesions was 9.2%. The mean patient age was 64.2 ± 10 years and 80% were men. Patients with balloon uncrossable lesions were older (67.3 ± 9 vs. 63.9 ± 10, p \u3c 0.001) and more likely to have prior coronary artery bypass graft surgery (40% vs. 25%, p \u3c 0.001) and diabetes mellitus (50% vs. 42%, p \u3c 0.001) compared with patients who had balloon crossable lesions. In-stent restenosis (23% vs. 16%. p \u3c 0.001), moderate/severe calcification (68% vs. 40%, p \u3c 0.001), and moderate/severe proximal vessel tortuosity (36% vs. 25%, p \u3c 0.001) were more common in balloon uncrossable lesions. Procedure time (132 (90, 197) vs. 109 (71, 160) min, p \u3c 0.001) was longer and the air kerma radiation dose (2.55 (1.41, 4.23) vs. 1.97 (1.10, 3.40) min, p \u3c 0.001) was higher in balloon uncrossable lesions, while these lesions displayed lower technical (91% vs. 99%, p \u3c 0.001) and procedural (88% vs. 96%, p \u3c 0.001) success rates and higher major adverse cardiac event (MACE) rates (3.14% vs. 1.49%, p \u3c 0.001). Several techniques were required for balloon uncrossable lesions. Conclusion: In a contemporary, multicenter registry, 9.2% of the successfully crossed CTOs were initially balloon uncrossable. Balloon uncrossable lesions exhibited lower technical and procedural success rates and a higher risk of complications compared with balloon crossable lesions