TCT-121 Extraplaque Versus Intraplaque Tracking in Chronic Total Occlusion Percutaneous Coronary Intervention

Background: The impact of modern extraplaque (EP) tracking techniques on long-term outcomes remains controversial. Methods: We performed a systematic review and meta-analysis of studies that compared EP vs intraplaque (IP) tracking in CTO PCI. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the Der-Simonian and Laird random-effects method. Results: Our meta-analysis included seven observational studies with 2,982 patients. Patients who underwent EP tracking had significantly more complex CTOs with higher J-CTO scores (2.9 ± 1.2 vs 1.6 ± 1.1, P \u3c 0.001), longer lesion length, more severe calcification, and significantly longer stented segments. During a median follow-up of 12 months (range 9-12 months), EP tracking was associated with a higher risk of major adverse cardiovascular events (MACE) (OR 1.50, 95% CI 1.10-2.06, P = 0.01) and target vessel revascularization (TVR) (OR 1.69, 95% CI 1.15-2.48, P = 0.01) compared with IP tracking. There was no difference in the incidence of all-cause death (OR 1.37, 95% CI 0.67-2.78, P = 0.39), myocardial infarction (MI) (OR 1.48, 95% CI 0.82-2.69, P = 0.20), or stent thrombosis (OR 2.09, 95% CI 0.69-6.33, P = 0.19) between EP and IP tracking. Conclusion: Compared with IP tracking, EP tracking was utilized in more complex and longer CTOs, required more stents, and was associated with a higher risk of MACE at 12 months, driven by a higher risk of TVR, but without an increased risk of death or MI. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

TCT-118 Comparative Analysis of Patients’ Characteristics in Chronic Total Occlusion Revascularization Studies: Trials Versus Real-World Registries

Background: The few randomized controlled trials (RCTs) on chronic total occlusion (CTO) percutaneous coronary interventions (PCI) are subject to selection bias. Methods: We performed a meta-analysis of national and dedicated CTO PCI registries and compared patient characteristics and outcomes with those of RCTs that randomized patients to CTO PCI vs medical therapy. Given the large sample size differences between RCTs and registries, we focused on the absolute numbers and their clinical significance. We considered a 5% relative difference between groups to be potentially clinically relevant. Results: From 2012 to 2022, 6 RCTs compared CTO PCI vs medical therapy (n = 1,047) and were compared with 15 registries (5 national and 10 dedicated CTO PCI registries). Compared with registry patients, RCT patients had fewer comorbidities, including diabetes, hypertension, previous myocardial infarction, and prior coronary artery bypass graft surgery. RCT patients had shorter CTO length (29.6 ± 19.7 vs 32.6 ± 23.0 mm, a relative difference of 9.2%) and lower J-CTO scores (2.0 ± 1.1 vs 2.3 ± 1.2, a relative difference of 13%) compared with those enrolled in dedicated CTO registries. Procedural success was similar between RCTs (84.5%) and dedicated CTO registries (81.4%) but was lower in national registries (63.9%). Conclusion: There is a paucity of randomized data on CTO PCI outcomes (6 RCTs, 1,047 patients). These patients have lower-risk profiles and less complex CTOs than those in real-world registries. Current evidence from RCTs may not be representative of real-world patients and should be interpreted within its limitation. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP

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-170 Development and Validation of a Scoring System for Predicting Clinical Coronary Artery Perforation During Percutaneous Coronary Interventions of Chronic Total Occlusions: The PROGRESS-CTO Perforation Score

Background: Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and often leads to serious adverse clinical events. Methods: We analyzed clinical and angiographic parameters from 9,618 CTO PCIs in the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention). Logistic regression prediction modeling was used to identify independently associated variables, and models were internally validated with bootstrapping. Clinical coronary artery perforation was defined as any perforation requiring treatment. Results: The incidence of clinical coronary perforation was 3.8% (n = 367). Five factors were independently associated with perforation and were included in the score: patient age ≥ 65 years, +1 point (OR: 1.79; 95% CI: 1.37-2.33); moderate or severe calcification, +1 point (OR: 1.85; 95% CI: 1.41-2.42); blunt or no stump, +1 point (OR: 1.45; 95% CI: 1.10-1.92); use of antegrade dissection and re-entry strategy, +1 point (OR: 2.43; 95% CI: 1.61-3.69); and use of the retrograde approach, +2 points (OR: 4.02; 95% CI: 2.95-5.46). The resulting score showed acceptable performance on receiver-operating characteristic curve (area under the curve: 0.741; 95% CI: 0.712-0.773). The Hosmer-Lemeshow test indicated good fitness (P = 0.991), and internal validation with bootstrapping demonstrated a good agreement with the model (observed area under the curve: 0.736; 95% bias-corrected CI: 0.706-0.767). Conclusions: The PROGRESS-CTO perforation score is a useful tool for prediction of clinical coronary perforation in CTO PCI. 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-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