Appropriateness of percutaneous revascularization of coronary chronic total occlusions: an overview.

Coronary chronic total occlusions (CTOs) are commonly encountered in patients undergoing coronary angiography. Several observational studies have demonstrated that successful CTO revascularization is associated with better cardiovascular outcomes and enhanced quality of life (QOL). However, in the absence of randomized trials, its prognostic benefit for patients remains debated. Over the past decade, the interest of the interventional community in CTO percutaneous coronary intervention (PCI) has exponentially grown due to important developments in dedicated equipment and techniques, resulting in high success and low complication rates. Both European and American guidelines have assigned a class IIa (level of evidence B) recommendation for CTO PCI. In the current review, we focus on the impact of CTO revascularization on clinical outcomes and QOL and on appropriate patient selection, and we provide a critical assessment of the current guidelines and recommendations on CTO PCI.

Management strategies in patients affected by chronic total occlusions: results from the Italian Registry of Chronic Total Occlusions.

BACKGROUND: Through contemporary literature, the optimal strategy to manage coronary chronic total occlusions (CTOs) remains under debate. OBJECTIVES: The aim of the Italian Registry of Chronic Total Occlusions (IRCTO) was to provide data on prevalence, characteristics, and outcome of CTO patients according to the management strategy. METHODS: The IRCTO is a prospective real world multicentre registry enrolling patients showing at least one CTO. Clinical and angiographic data were collected independently from the therapeutic strategy [optimal medical therapy (MT), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG)]; a comparative 1-year clinical follow-up was performed. RESULTS: A total of 1777 patients were enrolled for an overall CTO prevalence of 13.3%. The adopted therapeutic strategies were as follows: MT in 826 patients (46.5%), PCI in 776 patients (43.7%), and CABG in the remaining 175 patients (9.8%). At 1-year follow-up, patients undergoing PCI showed lower rate of major adverse cardiac and cerebrovascular events (MACCE) (2.6% vs. 8.2% and vs. 6.9%; P < 0.001 and P < 0.01) and cardiac death (1.4% vs. 4.7% and vs. 6.3%; P < 0.001 and P < 0.001) in comparison with those treated with MT and CABG, respectively. After propensity score-matching analysis, patients treated with PCI showed lower incidence of cardiac death (1.5 vs. 4.4%; P < 0.001), acute myocardial infarction (1.1 vs. 2.9%; P = 0.03), and re-hospitalization (2.3 vs. 4.4% P = 0.04) in comparison with those managed by MT. CONCLUSIONS: Our data showed how CTO PCI might significantly improve the survival and decrease MACCE occurrence at 1 year follow-up in comparison with MT and/or CABG.

Impact of renal function on clopidogrel-induced antiplatelet effects in coronary artery disease patients without diabetes mellitus.

Diabetes mellitus (DM) is the most important predictor of chronic kidney disease (CKD), and pharmacodynamic (PD) studies have shown that DM patients with impaired renal function are characterized by reduced clopidogrel response. However, post-hoc PD studies conducted in unselected cohorts, composed of both DM and non-DM patients, have reached controversial findings on the effects of CKD on clopidogrel response, likely attributed to patient heterogeneity. The impact of renal function on clopidogrel response in non-DM patients remains unexplored and represented the aim of this prospective investigation. We conducted a prospective PD investigation in non-DM patients with and without CKD defined as an estimated glomerular filtration rate (eGFR) below or above 60 mL/min, respectively. All patients had known coronary artery disease and were on maintenance aspirin therapy. PD assessments were assessed at baseline and 2 and 24 h after a 600 mg loading dose of clopidogrel. PD assays included light transmission aggregometry (LTA) using 5 and 20 µmol ADP with and without PGE1 and flow cytometric assessment of the phosphorylation status of the vasodilator-stimulated phosphoprotein (VASP) to determine the platelet reactivity index. A total of 60 patients were studied (n = 30 eGFR ≥60 mL/min; n = 30 eGFR <60 mL/min). At baseline there were no differences between groups. Following clopidogrel loading dose administration, levels of on-treatment platelet reactivity were similar between groups at 2 and 24 h as measured with LTA and VASP. Accordingly, there were no differences in rates of high on-treatment platelet reactivity between groups. In non-DM patients with CAD, the presence of impaired renal function is not associated with differences in clopidogrel-induced antiplatelet effects compared with patients with preserved renal function.

Effects of cangrelor in coronary artery disease patients with and without diabetes mellitus: an in vitro pharmacodynamic investigation.

Platelets from patients with diabetes mellitus (DM) are hyper-reactive and whether cangrelor, a potent intravenous P2Y(12) receptor blocker, has differential pharmacodynamic (PD) effects according DM status is unknown. The aim of this investigation was to evaluate the in vitro PD effects of cangrelor in coronary artery disease (CAD) patients with and without DM. This prospective study enrolled 120 clopidogrel-naïve patients with CAD on aspirin therapy. PD assessments using cangrelor (500 nmol/l) in vitro included vasodilator-stimulated phosphoprotein assay to obtain the P2Y(12) reactivity index (PRI), and multiple electrode aggregometry (MEA). In a 20 patients subgroup, dose-dependent response was assessed following exposure to escalating concentrations (baseline, 5, 50, 500 and 5,000 nmol/l); thrombin generation processes were evaluated by thromboelastography (TEG). PD data were evaluable in 103 patients. No differences in baseline PD parameters were observed in DM (n = 48) and non-DM (n = 45) subjects. Cangrelor reduced PRI values irrespective of DM status (p < 0.0001), yielding no difference in patients with and without DM (16.1 ± 12.3 vs. 16.8 ± 11.3; p = 0.346). All MEA values were significantly reduced, although this was of greater magnitude with purinergic compared to non-purinergic agonists. A trend analysis showed a dose-dependent effect on platelet inhibition, with no interaction due to DM status, whereas no significant dose-dependent effect was observed for TEG-derived parameters. Therefore, in vitro cangrelor provides potent and dose-dependent blockade of the platelet P2Y(12) receptor, with no differential effect in DM and non-DM patients. In addition, in vitro cangrelor exerts moderate inhibitory effects on non-purinergic platelet signaling pathways, without modulating platelet-derived thrombin generation processes.

Prasugrel.

Prasugrel is a third-generation thienopyridine which selectively inhibits the platelet P2Y(12) receptor more rapidly, more potently, and with less interindividual response variability compared with the second-generation thienopyridine clopidogrel. Large-scale phase III clinical testing showed that in high-to moderate-risk acute coronary syndrome patients undergoing percutaneous coronary intervention, prasugrel translates into a greater reduction in ischemic events, including stent thrombosis, in the short and long term compared to clopidogrel. Prasugrel, however, is associated with an increased risk of major bleeding, which is more pronounced in certain patient subgroups. The ideal patient population for prasugrel use are those patients without prior transient ischemic attack/stroke, <75 years of age and >60 kg in whom the greatest ischemic benefit is achieved without a significant increase in major bleeding risk. Dose modifications in specific populations or at given time-points may represent an avenue to minimize bleeding risk and therefore maximize the clinical benefit of prasugrel. Ongoing clinical studies with prasugrel will better define the safety and efficacy profiles of this agent and potentially set the basis for new indications for use.

Long-term clinical and angiographic results of Sirolimus-Eluting Stent in Complex Coronary Chronic Total Occlusion Revascularization: the SECTOR registry.

BACKGROUND: Drug-eluting stents showed a better angiographic and clinical outcome in comparison with bare metal stent in chronic total occlusions (CTOs) percutaneous revascularization, however, great concerns still remain regarding the rate of restenosis and reocclusion in comparison with nonocclusive lesions. AIM: To evaluate angiographic and clinical outcomes after sirolimus-eluting stent (SES) implantation in the setting of a "real world" series of complex CTOs. METHODS AND RESULTS: From January 2006 to December 2008, 172 consecutive patients with 179 CTO lesions were enrolled into registry. Among these, successful recanalization was obtained in 144 lesions (80.4%) with exclusive SES implantation in 104 lesions. The 9-12 months angiographic follow-up was executed in 85.5% of lesions with evidence of angiographic binary restenosis in 16.8% of lesions. Total stent length and number of stent implanted were recognized as independent predictors of restenosis (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.28-107.09, P = 0.02) and (OR 5.8, 95% CI 1.39-23.55, P = 0.01), respectively.The 2-year clinical follow-up showed rates of target lesion revascularization, non-Q wave myocardial infarction, and total major adverse cardiovascular events (MACEs) of 11.1%, 2%, and 13.1%, respectively. Cox proportional-hazard analysis showed diabetes as independent predictor of MACEs (hazard ratio [HR] 4.832; 95% CI, 0.730-0.861; P = 0.028). CONCLUSIONS: Data from this registry demonstrate the long-term efficacy and safety of SES implantation after complex CTOs recanalization.

Does occlusion duration influence procedural and clinical outcome of patients who underwent percutaneous coronary intervention for chronic total occlusion?

BACKGROUND: Previous studies have reported that the indeterminable aging and long-duration occlusion are associated with procedural failure and adverse long-term outcome. We aimed to investigate the clinical impact of occlusion duration in a consecutive series of patients who underwent percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. METHODS AND RESULTS: From October 2005 to June 2009, a total of 303 patients with 328 CTO lesions were consecutively treated achieving a success rate of 86.3%. The average of occlusion duration estimated in 62.5% of cases (known occlusion duration [KOD] patients, n = 188) was 29.8 ± 41.3 months. In the remaining 37.5% of cases, the occlusion duration was indeterminate (indetermination of occlusion duration [IOD] patients, n = 115). No influence of duration in procedural outcome was observed. Moreover, no differences of 1-year major adverse cardiac events (MACE) were observed between KOD and IOD patients. The multivariate COX regression analysis identified diabetes mellitus and multivessel coronary disease as independent predictors of 12-month MACE (HR 5.023; 95% CI 0.164-9.653; P = 0.025 and HR 0.801; 95% CI 0.109-0.909, P = 0.033). The analysis did not show any influence of IOD and long occlusion duration in the occurrence of MACE. Predictors of angiographic failure recognized with multivariate binary logistic were vessel diameter <2.5 mm (OR 5.3; 95% CI 1.19-8.91; P = 0.02), CTO length >20 mm (OR 6.3; 95% CI 1.22-9.54; P = 0.02), and severe calcification (OR 3.2; 95% CI 1.62-5.51; P = 0.03). CONCLUSION: IOD and long duration of CTO do not affect procedural and clinical outcome of patients who underwent CTO PCI. This marks the importance of considering PCI treatment, a reliable strategy in cases of IOD or long occlusion duration.

Antiplatelet therapy: thrombin receptor antagonists.

Activated platelets stimulate thrombus formation in response to rupture of an atherosclerotic plaque or endothelial cell erosion, promoting atherothrombotic disease. Multiple pathways contribute to platelet activation. Aspirin, an irreversible inhibitor of thromboxane A2 synthesis, in combination with clopidogrel, an inhibitor of P2Y(12) adenosine diphosphate platelet receptors, represent the current standard-of-care of antiplatelet therapy for patients with acute coronary syndrome and for those undergoing percutaneous coronary intervention. Although these agents have demonstrated significant clinical benefit, the increased risk of bleeding and the recurrence of thrombotic events represent substantial limitations. Thrombin is one of the most important platelet activators. The inhibition of protease-activated receptor 1 showed a good safety profile in preclinical studies. In fact, phase II studies with vorapaxar (SCH530348) and atopaxar (E5555) showed no increase of bleeding events in addition to the current standard-of-care of antiplatelet therapy. Although the results of phase III trials for both drugs are awaited, this family is a promising new addition to the current clinical practice for patients with atherothrombotic disease, not only as an alternative, but also as additional therapy.

A novel 3-d reconstruction system for the assessment of bifurcation lesions treated by the mini-crush technique.

BACKGROUND: Conventional two-dimensional angiography lacks the ability to properly image the true bifurcation geometry, and its percutaneous coronary intervention-induced changes in the clinical setting. METHODS AND RESULTS: A novel three-dimensional reconstruction system was investigated by retrospectively analyzing 39 lesions in 35 consecutive patients with coronary bifurcation disease treated with the mini-crush technique. At baseline, significant correlations were proved between two- and three-dimensional systems in terms of either reference vessel diameter (R(2)= 0.68 and 0.29 for main and side branches, respectively), minimum lumen diameter (R(2)= 0.73 and 0.36), stenosis diameter (R(2)= 0.69 and 0.29), and lesion length (R(2)= 0.48 and 0.58). These results were consistent with those observed after the procedure and at 8-month follow-up. Lesion length was significantly longer with the three-dimensional compared to the two-dimensional system for both main and side branches (P < 0.001, and P = 0.007, respectively). CONCLUSIONS: The three-dimensional quantitative reconstruction system may provide accurate evaluation of the complex curvilinear structure of bifurcation lesions when using a double stent technique.

Recanalization of complex coronary chronic total occlusions using high-frequency vibrational energy CROSSER catheter as first-line therapy: a single center experience.

BACKGROUND: Several studies have illustrated the safety and the procedural outcome of high-frequency vibrational energy in guidewire refractory chronic total occlusions (CTOs). AIM: To evaluate the advantage of high-frequency vibrational energy device (CROSSER Catheter) use in coronary complex CTO revascularization as primary strategy. METHODS: CROSSER was used as a primary approach if four or more unfavorable angiographic features were observed in the CTO lesions. RESULTS: From May 2007 to February 2009, a CTO percutaneous intervention attempt was performed in 178 lesions of 171 patients (60.1 +/- 8.9 age with 49.4 +/- 7.2% in ejection fraction). Among these, the CROSSER was used in 46 complex CTO lesions of 45 patients (25.8% of cases) and in the remaining cases, typical CTO percutaneous coronary intervention techniques were employed. Clinical success was 84.8% in CROSSER group. Moreover, in the CROSSER group, no periprocedural myocardial infarction, perforation, or 30 days MACE was observed. In addition, the use of CROSSER was associated with lower time of procedure, time of fluoroscopy, and contrast load administration as compared with conventional techniques [88 +/- 27 minutes vs 109 +/- 38 minutes (P = 0.045), 39 +/- 12 minutes vs 50 +/- 27 minutes (P = 0.032), and 334 +/- 122cc vs 408 +/- 198cc (P = 0.05), respectively]. CONCLUSION: In the present study, the CROSSER System was safe and obtained a high rate of success in complex CTO similar to conventional dedicated guidewire techniques for noncomplex CTO; however, the CROSSER Catheter obtained CTO recanalization with lower contrast load administration, less time of procedure, and lower fluoroscopy exposure.

Prognostic value of exercise myocardial scintigraphy in patients with coronary chronic total occlusions.

OBJECTIVES: To evaluate the prognostic value of exercise myocardial scintigraphy in patients undergoing incomplete revascularization by means of percutaneous coronary intervention (PCI) with at least a residual chronic total occlusion (CTO) left untreated. METHODS: Of 569 consecutive patients with multivessel disease undergoing myocardial scintigraphy after incomplete revascularization by PCI between March 1997 and December 2004, 126 (79% male, 64+/-10 years) with >or= 1 residual CTO fulfilled the eligibility criteria and entered in the study. Hard events defined as cardiac death and myocardial infarction, soft events defined as incidence of unstable angina and PCI procedures, and their composite were assessed at a median follow-up period of 44 months. RESULTS: Hard events were observed in six patients (4.8%). All of them had severely abnormal perfusion defects detected by myocardial scintigraphy. Soft events occurred in 0 (0%), 10 (7.9%), and 15 (11.9%) patients with normal, mildly abnormal, and severely abnormal perfusion, respectively. In the Kaplan-Meier analysis, the log-rank test was statistically significant across patients stratified by summed stress score either in terms of hard, soft and hard, or soft events. Univariate and multivariate Cox proportional-hazards showed an incremental significant information when the scintigraphic variables were added to clinical, angiographic, left ventricular ejection fraction, and Duke treadmill score, for prediction of the composite of hard and soft cardiac events (P < 0.006). CONCLUSIONS: Among patients with a residual CTO left untreated after PCI, myocardial perfusion imaging provides significant independent information concerning the subsequent risk of cardiac events.

Clinical features of transient left ventricular apical ballooning.

This report describes the clinical characteristics of 8 consecutive patients with transient left ventricular apical ballooning identified among 389 patients (2%) admitted to a tertiary referral hospital with suspected acute coronary syndromes over a 1-year period. Among these patients, 2 cases appeared to be caused by acute myocarditis and 1 case by head trauma with intracranial bleeding. In the remaining 5 cases, no apparent cause was found. All patients but 1 were postmenopausal women (mean age 60 +/- 13.5 years). Preceding strong emotional or physical stress was present in 6 patients. The presenting symptom in 7 patients was chest pain. Four patients had significant ST-segment elevation, and the remaining 4 had T-wave inversions on their admission electrocardiograms. Mean peak troponin I was moderately elevated (3.7 +/- 4.5 ng/dl). The mean echocardiographic left ventricular ejection fraction was 40 +/- 10% on admission and increased significantly to 63 +/- 4% at 1-month follow-up (p <0.0001). All patients but 1 had abnormal corrected Thrombolysis In Myocardial Infarction frame counts (>27 frames) in >or=1 major epicardial coronary artery. All patients were alive and without major adverse cardiac events at 6-month follow-up. In conclusion, transient left ventricular apical ballooning should be considered in the differential diagnosis of patients presenting with suspected acute coronary syndromes, because it may account for approximately 2% of hospital admissions.

Fatal derecruitment of occluded left anterior descending collaterals after left circumflex revascularization.

Coronary arteries are not definitely functionally terminal arteries, as previously thought; indeed, they are linked and interconnected by a rich network of collaterals. Chronic total occlusions (CTOs) represent a subset of frequent lesions encountered in everyday catheterization laboratory practice, generally associated with a developed system of collateral connections. These latter have the capacity to prevent myocardial necrosis and may even uphold metabolic supply to the ischemic territory to maintain its contractile capacity. Authors have reported a rapid and progressive reduction of collateral function and their decline after antegrade flow restoration, resulting in higher myocardial susceptibility to ischemia in the CTO territory. Here, we report the case of a fatal derecruitment of collaterals for a left anterior descending CTO not reopened, after left circumflex subocclusion revascularization.

Percutaneous Coronary Revascularization for Chronic Total Occlusions: A Novel Predictive Score of Technical Failure Using Advanced Technologies.

OBJECTIVES: The aims of this study were to describe the 10-year experience of a single operator dedicated to chronic total occlusion (CTO) and to establish a model for predicting technical failure. BACKGROUND: During the last decade, the interest in percutaneous coronary interventions (PCIs) of chronic total occlusions (CTOs) has increased, allowing the improvement of success rate. METHODS: One thousand nineteen patients with CTO underwent 1,073 CTO procedures performed by a single CTO-dedicated operator. The study population was subdivided into 2 groups by time period: period 1 (January 2005 to December 2009, n = 378) and period 2 (January 2010 to December 2014, n = 641). Observations were randomly assigned to a derivation set and a validation set (in a 2:1 ratio). A prediction score was established by assigning points for each independent predictor of technical failure in the derivation set according to the beta coefficient and summing all points accrued. RESULTS: Lesions attempted in period 2 were more complex in comparison with those in period 1. Compared with period 1, both technical and clinical success rates significantly improved (from 87.8% to 94.4% [p = 0.001] and from 77.6% to 89.9% [p < 0.001], respectively). A prediction score for technical failure including age ≥75 years (1 point), ostial location (1 point), and collateral filling Rentrop grade <2 (2 points) was established, stratifying procedures into 4 difficulty groups: easy (0), intermediate (1), difficult (2), and very difficult (3 or 4), with decreasing technical success rates. In derivation and validation sets, areas under the curve were comparable (0.728 and 0.772, respectively). CONCLUSIONS: With growing expertise, the success rate has increased despite increasing complexity of attempted lesions. The established model predicted the probability of technical failure and thus might be applied to grading the difficulty of CTO procedures.

Impact of left ventricular remodeling and renal function on 24h-ECG recordings and cardiovascular outcome in elderly hypertensive patients.

BACKGROUND: The prognostic role of left ventricular remodeling and renal function in elderly hypertensive patients has been so far scarcely investigated. AIMS: We assessed the impact of left ventricular geometry and renal function on 24h-Holter electrocardiogram (ECG) recordings and outcome in elderly hypertensive patients. METHODS: We enrolled 251 asymptomatic hypertensive elderly patients (>65year-old). Left ventricular remodeling was evaluated by 2-D echocardiogram. Lown's class, mean QTc and standard deviation of all normal R-R intervals (SDNN) were assessed by 24-h Holter-ECG recordings. Data on all-cause and cardiovascular mortality were collected for 2years. RESULTS: Mean age was 76.2±11.4years. High Lown's classes were more frequently observed in the presence of left ventricular hypertrophy (LVH) (57.3% vs. 23.7%; p<0.001). Mean QTc was 444.8±34.8ms and resulted directly correlated with indexed left ventricular mass (r=0.228; p=0.001). Patients with Chronic Kidney Disease (CKD) showed lower SDNN as compared with those with preserved renal function (92.02±36.11ms vs. 103.84±33.96ms, respectively; p=0.017). At 2years, all-cause and cardiovascular mortality rates were 38.0% and 21.1%, respectively. Diabetes mellitus (HR: 2.40; 95% C.I.1.16 to 4.99; p=0.019), CKD (HR: 2.22; 95% C.I.1.10 to 4.52; p=0.028), prolonged QTc (HR: 2.18; 95% C.I.1.07 to 4.41; p=0.030) and SDNN<96ms (HR: 1.98; 95% C.I.1.03 to 4.13; p=0.048) were independent predictors of cardiovascular death at 2year follow-up. CONCLUSIONS: CKD and left ventricular remodeling predicted altered ventricular batmotropism. Diabetes, CKD, heart rate variability and QTc are important predictors of cardiovascular death in elderly hypertensive patients.

Incidence, treatment, and in-hospital outcome of bifurcation lesions in patients undergoing percutaneous coronary interventions for chronic total occlusions.

BACKGROUND: Bifurcation lesions represent a distinct lesion subset associated with an increased risk of procedural complications. Data on the incidence, treatment, and outcome of bifurcation lesions associated with chronic total occlusions are limited. METHODS: Among chronic total occlusion procedures performed by a single experienced operator, patients with a bifurcation lesion within the chronic total occlusion vessel and a side branch reference diameter greater than or equal to 2.0 mm were enrolled. RESULTS: A total of 905 patients (mean age 61.1±9.5 years, men 89.4%) were treated for 922 chronic total occlusion lesions. Among these, 244 bifurcation lesions were observed (26.5%). The procedural time was significantly longer in bifurcation lesions (139±67 vs. 124±68 min; P=0.003), with greater use of contrast load (470±193 vs. 436±227 ml; P=0.04) and higher number of stents (3.1±1.5 vs. 2.9±1.4; P=0.035). Overall, an angiographic success was achieved in 91.1% of cases with a higher rate in nonbifurcation lesions (92.5 vs. 87.3%; P=0.04). Coronary perforations were more often observed in bifurcation lesions (4.9 vs. 1.7%; P<0.001), resulting in more tamponades (2.4 vs. 0.2%; P<0.001). True bifurcations were encountered in the majority of cases (86.8%) and required more two-stent techniques than false bifurcations (50 vs. 18.8%; P=0.001). CONCLUSION: The incidence of bifurcation lesions in chronic total occlusions is higher than that reported in continuous lesions. The presence of a bifurcation lesion increases the complexity of the procedure and may lead to less angiographic success and more periprocedural complications.

Percutaneous Coronary Interventions for Chronic Total Occlusions: More Benefit for the Patient or for the Interventionist's Ego?

Chronic total occlusions (CTOs) represent a common lesion subset observed in patients who undergo coronary angiography. During the past decade, the interest of the interventionist community in CTOs has exponentially grown with fast advancement in dedicated equipment and techniques, which has resulted in high rates of procedural success and low rates of complications. Although different observational studies have shown that CTO revascularization was associated with good clinical outcome, its real benefit for patients remains to be determined, particularly in the absence of randomized trials. In addition, compared with non-CTO lesions, the American and European guidelines downgraded percutaneous coronary intervention in the setting of CTOs. In this viewpoint, we try to identify patients who would benefit from CTO recanalization, and discuss the issues that might improve the appropriateness of CTO percutaneous coronary intervention.

Retrograde Recanalization of Chronic Total Occlusions in Europe: Procedural, In-Hospital, and Long-Term Outcomes From the Multicenter ERCTO Registry.

BACKGROUND: A retrograde approach improves the success rate of percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). OBJECTIVES: The authors describe the European experience with and outcomes of retrograde PCI revascularization for coronary CTOs. METHODS: Follow-up data were collected from 1,395 patients with 1,582 CTO lesions enrolled between January 2008 and December 2012 for retrograde CTO PCI at 44 European centers. Major adverse cardiac and cerebrovascular events were defined as the composite of cardiac death, myocardial infarction, stroke, and further revascularization. RESULTS: The mean patient age was 62.0 ± 10.4 years; 88.5% were men. Procedural and clinical success rates were 75.3% and 71.2%, respectively. The mean clinical follow-up duration was 24.7 ± 15.0 months. Compared with patients with failed retrograde PCI, successfully revascularized patients showed lower rates of cardiac death (0.6% vs. 4.3%, respectively; p < 0.001), myocardial infarction (2.3% vs. 5.4%, respectively; p = 0.001), further revascularization (8.6% vs. 23.6%, respectively; p < 0.001), and major adverse cardiac and cerebrovascular events (8.7% vs. 23.9%, respectively; p < 0.001). Female sex (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.33 to 3.18; p = 0.001), prior PCI (HR: 1.73; 95% CI: 1.16 to 2.60; p = 0.011), low left ventricular ejection fraction (HR: 2.43; 95% CI: 1.22 to 4.83; p = 0.011), J-CTO (Multicenter CTO Registry in Japan) score ≥3 (HR: 2.08; 95% CI: 1.32 to 3.27; p = 0.002), and procedural failure (HR: 2.48; 95% CI: 1.72 to 3.57; p < 0.001) were independent predictors of major adverse cardiac and cerebrovascular events at long-term follow-up. CONCLUSIONS: The number of retrograde procedures in Europe has increased, with high percents of success, low rates of major complications, and good long-term outcomes.

Coronary vasomotion dysfunction after everolimus-eluting stent implantation.

First generation drug-eluting stent can cause a paradoxical "in-segment" coronary vasoconstriction. This phenomenon was seen with sirolimus, paclitaxel, and, more recently, also with zotarolimus-eluting stent. For the first time, we describe a case of coronary-induced vasoconstriction by everolimus-eluting stents (EES).