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

Abi Rafeh, Nidal

Alaswad, Khaldoon

Benzuly, Keith

Brilakis, Emmanouil S

Burke, M. Nicholas

ElGuindy, Ahmed M

Flaherty, James D

Karacsonyi, Judit

Karmpaliotis, Dimitri

Nikolakopoulos, Ilias

Poommipanit, Paul

Schimmel, Daniel

Vemmou, Evangelia

English

Henry Ford Health System Scholarly Commons

Henry Ford Health Henry Ford Health Scholarly Commons Cardiology Articles Cardiology/Cardiovascular Research 3-3-2022 Percutaneous coronary intervention of chronic total occlusions involving a bifurcation: Insights from the PROGRESS-CTO registry Ilias Nikolakopoulos Evangelia Vemmou Judit Karacsonyi Khaldoon Alaswad Henry Ford Health, kalaswa1@hfhs.org Dimitri Karmpaliotis See next page for additional authors Follow this and additional works at: https://scholarlycommons.henryford.com/cardiology_articles Recommended Citation Nikolakopoulos I, Vemmou E, Karacsonyi J, Alaswad K, Karmpaliotis D, Rafeh NA, Schimmel D, Benzuly K, Flaherty JD, Poomipanit P, ElGuindy AM, Nicholas Burke M, and Brilakis ES. Percutaneous Coronary Intervention of Chronic Total Occlusions Involving a Bifurcation: Insights from the PROGRESS-CTO Registry. Hellenic J Cardiol 2022. This Article is brought to you for free and open access by the Cardiology/Cardiovascular Research at Henry Ford Health Scholarly Commons. It has been accepted for inclusion in Cardiology Articles by an authorized administrator of Henry Ford Health Scholarly Commons. Authors Ilias Nikolakopoulos, Evangelia Vemmou, Judit Karacsonyi, Khaldoon Alaswad, Dimitri Karmpaliotis, Nidal Abi Rafeh, Daniel Schimmel, Keith Benzuly, James D. Flaherty, Paul Poommipanit, Ahmed M. ElGuindy, M. Nicholas Burke, and Emmanouil S. Brilakis This article is available at Henry Ford Health Scholarly Commons: https://scholarlycommons.henryford.com/cardiology_articles/899 CorrespondencePercutaneous coronary intervention of chronic total occlusionsinvolving a bifurcation: Insights from the PROGRESS-CTO registryKeywords:chronic total occlusionpercutaneous coronary interventionbifurcationa b s t r a c tBackground: The impact of bifurcations at the proximal or distal cap on the outcomes of chronic totalocclusion (CTO) percutaneous coronary intervention (PCI) has received limited study.Methods: We analyzed the clinical, angiographic, and procedural data of 4,584 cases performed in pa-tients between 2012 and 2020 in a global CTO PCI registry. We compared 4 groups according to thebifurcation 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 ¼ 1451, 33%), distal cap(n ¼ 622, 14%), or both caps (n ¼ 954, 21%). “Proximal and distal cap” cases had higher J-CTO comparedwith “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 < 0.0001), and they were also associated with a lower technical success rate (79% vs 85% vs 85% vs 90%,P < 0.0001), higher pericardiocentesis rate (1% vs 1% vs 0.2% vs 0.3%, P ¼ 0.02), and higher emergencycoronary artery bypass graft surgery rate (0.3% vs 0% vs 0% vs 0%, P ¼ 0.01).Conclusion: More than two-thirds of CTO PCIs involve a bifurcation, which is associated with lowertechnical success and higher risk of complications.© 2022 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access articleunder the CC BY license (http://creativecommons.org/licenses/by/4.0/).The impact of a side branch in the proximal or distal cap on thesuccess and complication rates of chronic total occlusion percuta-neous coronary intervention (CTO PCI) has received limited study.We analyzed clinical, angiographic, and procedural data of 4,584CTO PCIs performed in 4,479 patients between 2012 and 2020 in aglobal CTO PCI registry (NCT02061436). We compared 4 groups ac-cording to the bifurcation location: “proximal and distal,” “proximalcap,” “distal cap,” and “no bifurcation.” The study was approved bythe Institutional Review Board of each center.Bifurcations were defined by the presence of a side branch ofdiameter >2 mm within 5 mm of the proximal or distal cap ofthe CTO lesion. The presence of a bifurcation was visually assessedby the operator after dual injection and before any attempt to cross.A procedure was defined as retrograde if an attempt was made tocross the lesion through a collateral vessel or bypass graft supplyingthe target vessel distal to the lesion; if not, the procedure was clas-sified as antegrade-only. Technical success was defined as success-ful CTO revascularization (main vessel only) with an achievementof <30% residual diameter stenosis and Thrombolysis in MyocardialInfarction (TIMI) 3 antegrade flow. In-hospital major adverse car-diovascular events (MACE) include death, myocardial infarction,recurrent angina requiring urgent repeat target vessel or targetlesion revascularization (with PCI or coronary artery bypass graftsurgery), stroke, and tamponade requiring pericardiocentesis.Myocardial infarction was defined as per the Third Universal Defi-nition of Myocardial Infarction Type 41.Categorical variables are presented as percentages and werecompared with the chi-square test. Continuous variables are sum-marized by mean ± standard deviation or median [interquartilerange] and compared with the t-test, analysis of variance, or Wil-coxon rank-sum test. All P-values refer to overall significancetesting between the four groups, unless reported otherwise.The CTO involved a bifurcation in 67% of all cases, as follows:proximal cap (n ¼ 1451, 32%), distal cap (n ¼ 622, 14%), or bothproximal and distal caps (n ¼ 954, 21%). “Proximal and distal cap”patients were more likely to have had myocardial infarctioncompared with “proximal cap,” “distal cap,” and “no bifurcation”patients and also had a higher J-CTO score, greater use of the retro-grade approach (Table), and lower technical success (Fig.). In-hospital MACE rates differed significantly between the groups,driven by difference in rates of emergency Coronary Artery BypassGrafting (CABG) and pericardiocentesis (Table). Two of the threeemergency CABG surgeries happened in cases with perforationthat required pericardiocentesis. Perforation rates, especially Ellisclass 2 and cavity spilling, were higher in the “proximal” and “prox-imal and distal cap” groups (Table). The mechanism of perforationdid not differ according to the location of the bifurcation (Table).We performed logistic regression analysis adjusting for lesioncharacteristics (blunt/no stump, lesion length>20 mm, moderate/severe proximal tortuosity, and moderate/severe calcification), thepresence of the bifurcation, and intravascular ultrasound (IVUS)use. After adjustment, presence of a bifurcation was significantlyPeer review under responsibility of Hellenic Society of Cardiology.Contents lists available at ScienceDirectHellenic Journal of Cardiologyjournal homepage: http: / /www.journals .e lsevier .com/hel lenic- journal -of -cardiology/Hellenic Journal of Cardiology xxx (xxxx) xxxhttps://doi.org/10.1016/j.hjc.2022.02.0051109-9666/© 2022 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).Please cite this article as: I. Nikolakopoulos, E. Vemmou, J. Karacsonyi et al., Percutaneous coronary intervention of chronic total occlusionsinvolving a bifurcation: Insights from the PROGRESS-CTO registry, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2022.02.005associated with a lower technical success when compared withabsence of any bifurcation (odds ratio [OR] for the proximal cap:0.63; 95% confidence intervals [CI]: 0.44 to 0.89; P-value ¼ 0.009,OR for the distal cap: 0.59; 95% CI: 0.39 to 0.89; P-value ¼ 0.01, ORfor proximal and distal caps: 0.54; 95% CI: 0.37 to 0.77; P-value <0.001). A first-order interaction term of intravascular ultrasound(IVUS) use and bifurcation presencewas not significantly associatedwith a technical success (OR for the proximal cap: 1.81; 95% CI: 0.78to 4.26; P-value ¼ 0.17, OR for the distal cap: 1.57; 95% CI: 0.55 to4.48; P-value ¼ 0.39, OR for proximal and distal caps: 1; 95% CI:0.44 to 2.25; P-value ¼ 0.99).We performed the same analysis for the endpoint of perforation.After adjustment, presence of a proximal and distal cap bifurcationwas significantly associated with higher perforation rates whencompared with absence of any bifurcation (OR for the proximalcap: 2.16; 95% CI: 0.97 to 4.81; P-value ¼ 0.06, OR for the distalcap: 2.29; 95% CI: 0.89 to 5.87; P-value ¼ 0.08, OR for proximaland distal caps: 2.38; 95% CI: 1.05 to 5.43; P-value¼ 0.04). An inter-action term of IVUS use and bifurcation presence was not associ-ated with perforation rates (OR for the proximal cap: 0.48; 95%CI: 0.16 to 1.47; P-value ¼ 0.19, OR for the distal cap: 0.38; 95% CI:0.09 to 1.58; P-value ¼ 0.18, OR for proximal and distal caps:0.29; 95% CI: 0.08 to 1; P-value ¼ 0.05).Bifurcations involving the CTO were more common in our studycompared with previous CTO PCI series that used the visual inspec-tion of the angiogram and the same definition2,3. Our study did notassess for side branches within the CTO segment, as performed inprevious studies. In addition, we included any side branch presentwithin 5 mm of the proximal or distal cap, irrespective of the de-gree of stenosis.CTO lesions involving a bifurcation had lower technical successrates. As reported in previous studies, CTOs involving a bifurcationalso had a higher risk of complications, namely emergency CABG2,3and perforation. In contrast to previous studies4, the rate ofTableClinical technical and procedural characteristics and outcomes according to the presence of a bifurcation at the proximal or distal cap or both.VARIABLE No bifurcationn ¼ 1,557Proximal capn ¼ 1,451DistalCap n ¼ 622Proximal and distalcaps n ¼ 954P-valueAge, years, mean ± SD 67 ± 10 67 ± 10 65 ± 10 64 ± 10 0.4Previous MI, % 40 41 35 47 <.0001Target vessel,% <.0001 RCA 53 45 56 55 LAD 26 35 16 23 LCX 19 18 25 21 Other 2 2 3 1J-CTO score, mean ± SD 2 ± 1.2 2.5 ± 1.1 2.4 ± 1.2 2.9 ± 1 <.0001Crossing strategies used, % AWE 89 90 87 85 <.0001 ADR 22 24 24 26 0.06 Retrograde 17 27 35 43 <.0001First crossing strategy, % AWE 86 86 81 85 <.0001 ADR 6 4 6 3 Retrograde 6 9 11 17Successful crossing strategy, % AWE 65 56 50 41 <.0001 ADR 17 16 13 15 Retrograde 9 14 22 22MCS use, % 3.6 2.4 1.9 2.4 0.08 Prophylactic 2.3 1.9 1.1 1.4 0.2 Urgent 0.5 0.3 0.5 0.7 0.45Technical success, % 91 85 85 78 <.0001Procedure time, min, median [IQR] 101 [67,150] 113 [74,166] 120 [85,173] 133 [91,190] <.0001Contrast volume, mL, median [IQR] 209 [150,300] 220 [155,300] 220 [155,300] 240 [170,300] <.0001AK radiation dose, Gy, median [IQR] 2.3 [1.2,3.5] 2 [1.1,3.4] 2.3 [1.3,3.8] 2.5 [1.5,4.1] <.0001Perforation, %Class1.93 3.8 3 4.6 0.0009 Ellis 1 33 24 44 23 0.08 Ellis 2 22 40 37 51 Ellis 3 41 27 19 13 Cavity-spilling 3.7 9 0 13Mechanism Wire 38 51 26 51 0.18 Microcatheter 3 9 0 12 0.18 Balloon 7 11 11 12 0.92 Stent 10 7 11 2 0.44In-hospital MACE, % 1 2 1 2.4 0.04 Death 0.4 0.3 0.2 0.2 0.78 MI 0.3 0.5 0.7 1 0.21 Re-PCI 0.1 0.1 0 0 0.79 Re-CABG 0 0 0 0.3 0.01 Stroke 0.1 0.2 0.2 0.2 0.94 Pericardiocentesis 0.3 1 0.2 1 0.02CTO, chronic total occlusion; PCI, percutaneous coronary intervention; MI, myocardial infarction; CABG, coronary artery bypass graft; RCA, right coronary artery; LAD, leftanterior descending; LCX, left circumflex; J-CTO, Japanese multicenter chronic total occlusion registry; MCS, mechanical circulatory support; AK, air kerma; Gy, gray;MACE, major adverse cardiovascular events; SD, standard deviation; IQR, interquartile range.I. Nikolakopoulos, E. Vemmou, J. Karacsonyi et al. Hellenic Journal of Cardiology xxx (xxxx) xxxPlease cite this article as: I. Nikolakopoulos, E. Vemmou, J. Karacsonyi et al., Percutaneous coronary intervention of chronic total occlusionsinvolving a bifurcation: Insights from the PROGRESS-CTO registry, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2022.02.005periprocedural MI was not higher in lesions involving a bifurcation,possibly because systematic biomarker measurements were notperformed in our study.Our study does not assess the incidence and impact of sidebranch occlusion or use of specific bifurcation wiring and stentingtechniques.5 In addition, we cannot determine which technique(antegrade wiring, dissection/re-entry, or retrograde) caused eachperforation. Finally, bifurcations were operator-reported and notbased on core laboratory adjudication.In conclusion, two-thirds of CTO lesions involve a bifurcation,most commonly at the proximal cap. The presence of a bifurcationis associated with a lower technical success and higher risk of com-plications, especially when there is a bifurcation in both the prox-imal and the distal cap.FundingThe authors are grateful for the generosity of our many philan-thropy partners, including our anonymous donors, Drs. Mary Annand Donald A. Sens, Ms. Dianne and Dr. Cline Hickok, Ms. Charlotteand Mr. Jerry Golinvaux Family Fund, the Roehl Family Foundation,and the Joseph Durda Foundation, Ms.Wilma andMr. Dale Johnson,for making this work possible at the Minneapolis Heart InstituteFoundation's Science Center for Coronary Artery Disease (CCAD).DisclosuresDr. Nikolakopoulos: nothing to disclose; Dr. Vemmou: nothingto disclose; Dr. Karacsonyi: nothing to disclose; Dr. Alaswad:consulting fees from Terumo and Boston Scientific; consultant, nofinancial, Abbott Laboratories; Dr. Karmpaliotis: speaker honoraria:Abbott Vascular, Boston Scientific, Medtronic, Vascular Solutions.Dr. Poomimanit: proctordAsahi Intecc, Inc, proctordAbbottVascular, and facultydMedtronic National Fellows Course; Dr. AbiRafeh: proctor and speaker honoraria from Boston Scientific andAbbott Vascula; Dr.ElGuindy: proctorship fees from Boston Scienti-fic; Dr. Burke: shareholder in Egg Medical and MHI Ventures; Dr.Brilakis: consulting/speaker honoraria from Abbott Vascular, Amer-ican Heart Association (associate editor Circulation), Amgen, AsahiIntecc, Biotronik, Boston Scientific, Cardiovascular InnovationsFoundation (Board of Directors), CSI, Elsevier, GE Healthcare,IMDS, Medicure, Medtronic, Siemens, and Teleflex; researchsupport: Boston Scientific, GE Healthcare; owner, HippocratesLLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical.AcknowledgementsStudy data were collected and managed using Research Elec-tronic Data Capture (REDCap) electronic data capture tools hostedat theMinneapolis Heart Institute Foundation (MHIF), Minneapolis,Minnesota. REDCap is a secure, web-based application designed tosupport data capture for research studies, providing: (1) an intui-tive interface for validated data entry; (2) audit trails for trackingdata manipulation and export procedures; (3) automated exportprocedures for seamless data downloads to common statisticalpackages; and (4) procedures for importing data from externalsources.References1. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. ThirdUniversal Definition of Myocardial Infarction. Circulation. 2012;126(16):2020e2035.2. Ojeda S, Pan M, Gutierrez A, et al. Bifurcation lesions involved in the recanaliza-tion process of coronary chronic total occlusions: Incidence, treatment and clin-ical implications. Int J Cardiol. 2017;230:432e438.3. Galassi AR, Boukhris M, Tomasello SD, et al. Incidence, treatment, and in-hospitaloutcome of bifurcation lesions in patients undergoing percutaneous coronary in-terventions for chronic total occlusions. Coron Artery Dis. 2015;26(2):142e149.4. Paizis I, Manginas A, Voudris V, Pavlides G, Spargias K, Cokkinos DV. Percuta-neous coronary intervention for chronic total occlusions: the role of side-branch obstruction. EuroIntervention: J EuroPCR Collab Work Group Intervent Car-diol Euro Soc Cardiol. 2009;4(5):600e606.5. Nguyen-Trong P, Rangan BV, Karatasakis A, et al. Predictors and outcomes ofside-branch occlusion in coronary chronic total occlusion interventions. J Inva-sive Cardiol. 2016;28(4):168e173.Ilias Nikolakopoulos, Evangelia Vemmou, Judit KaracsonyiMinneapolis Heart Institute Foundation and Minneapolis HeartInstitute, Abbott Northwestern Hospital, Minneapolis, MN, USAKhaldoon AlaswadHenry Ford Hospital, Detroit, MI, USADimitri KarmpaliotisColumbia University, New York, NY, USANidal Abi RafehSt. George Hospital University Medical Center, Beirut, LebanonFigure. In-hospital outcomes after chronic total occlusion percutaneous coronary intervention according to the presence of a bifurcation at the proximal or distal cap or both. MACE,major adverse cardiovascular events; CABG, coronary artery bypass graft.I. Nikolakopoulos, E. Vemmou, J. Karacsonyi et al. Hellenic Journal of Cardiology xxx (xxxx) xxxPlease cite this article as: I. Nikolakopoulos, E. Vemmou, J. Karacsonyi et al., Percutaneous coronary intervention of chronic total occlusionsinvolving a bifurcation: Insights from the PROGRESS-CTO registry, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2022.02.005Daniel Schimmel, Keith Benzuly, James D. FlahertyDivision of Cardiology (V.S.J., D.R.S.), Feinberg School of Medicine,Northwestern University, Chicago, IL, USAPaul PoommipanitHarrington Heart and Vascular Institute, University Hospitals-ParmaMedical Center, Parma, OH, USAAhmed M. ElGuindyAswan Heart Centre, Magdi Yacoub Foundation, EgyptM. Nicholas Burke, Emmanouil S. Brilakis*Minneapolis Heart Institute Foundation and Minneapolis HeartInstitute, Abbott Northwestern Hospital, Minneapolis, MN, USA* Corresponding author. Emmanouil S. Brilakis, MD, PhD,Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis,MN, 55407, USA. Tel.: þ1 612 863 3900, Fax: þ612 863 6441.E-mail address: esbrilakis@gmail.com (E.S. Brilakis).12 May 2021Available online xxxI. Nikolakopoulos, E. Vemmou, J. Karacsonyi et al. Hellenic Journal of Cardiology xxx (xxxx) xxxPlease cite this article as: I. Nikolakopoulos, E. Vemmou, J. Karacsonyi et al., Percutaneous coronary intervention of chronic total occlusionsinvolving a bifurcation: Insights from the PROGRESS-CTO registry, Hellenic Journal of Cardiology, https://doi.org/10.1016/j.hjc.2022.02.005

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

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

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