Geographic diversity in chronic total occlusion percutaneous coronary intervention: insights from the PROGRESS-CTO registry.

BACKGROUND: There is variability in clinical and lesion characteristics as well as techniques in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We analyzed patient and lesion characteristics, techniques, and outcomes in 11 503 CTO-PCI procedures performed in North America (NA) and in the combined regions of Europe, Asia, and Africa from 2017 to 2023 as documented in the PROGRESS-CTO registry. RESULTS: Eight thousand four hundred seventy-nine (74%) procedures were performed in NA. Compared with non-NA patients, NA patients were older, with higher body mass index and higher prevalence of diabetes, hypertension, dyslipidemia, family history of coronary artery disease, prior history of PCI, coronary artery bypass graft surgery and heart failure, cerebrovascular disease, and peripheral arterial disease. Their CTOs were more complex, with higher J-CTO (2.56 ± 1.22 vs 1.81 ± 1.24; P less than .001) and PROGRESS-CTO (1.29 ± 1.01 vs 1.07 ± 0.95; P less than .001) scores, longer length, and higher prevalence of proximal cap ambiguity, blunt/no stump, moderate to severe calcification, and proximal tortuosity. Retrograde (31.0% vs 22.1%; P less than .001) and antegrade dissection and re-entry (ADR) (21.2% vs 9.2%; P less than .001) were more commonly used in NA centers, along with intravascular ultrasound (69.0% vs 10.1%; P less than .001). Procedure and fluoroscopy times were longer in NA, while contrast volume and radiation dose were lower. Technical (86.7% vs 86.8%; P > .90) and procedural (85.4% vs 85.8%; P = .70) success and in-hospital major adverse cardiovascular events (MACE) (1.9% vs 1.7%; P = .40) were similar in NA and non-NA centers. CONCLUSIONS: Compared with non-NA patients, NA patients undergoing CTO PCI have more comorbidities, higher CTO lesion complexity, are more likely to undergo treatment with retrograde and ADR, and have similar technical success and MACE.

Racial disparities in chronic total occlusion percutaneous coronary interventions: insights from the PROGRESS-CTO registry.

OBJECTIVES: There is limited data on race and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The authors sought to evaluate CTO PCI techniques and outcomes in different racial groups. METHODS: We examined the baseline characteristics and procedural outcomes of 11 806 CTO PCIs performed at 44 US and non-US centers between 2012 and March 2023. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, repeat target-vessel revascularization, pericardiocentesis, cardiac surgery, and stroke prior to discharge. RESULTS: The most common racial group was White (84.5%), followed by Black (5.7%), "Other" (3.9%), Hispanic (2.9%), Asian (2.4%), and Native American (0.7%). There were significant differences in the baseline characteristics between different racial groups. When compared with non-White patients, the retrograde approach and antegrade dissection re-entry were more likely to be the successful crossing strategies in White patients without any significant differences in technical success (86.4% vs 86.4%; P = .93), procedural success (84.8% vs 85.0%; P = .79), and in-hospital MACE (2.0% vs 1.5%; P = .15) between the 2 groups. The technical success rate was significantly higher in the "Other" racial group (91.0% vs 86.4% in White, 86.9% in Asian, 84.5% in Black, 84.5% in Hispanic, and 83.3% in Native American; P = .03) without any significant differences in procedural success or in-hospital MACE rates between the groups. CONCLUSIONS: Despite differences in baseline characteristics and procedural techniques, the procedural success and in-hospital MACE of CTO PCI were not significantly different between most racial groups.

Equipment entrapment/loss during chronic total occlusion percutaneous coronary intervention.

BACKGROUND: There is limited data on equipment loss or entrapment during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We analyzed the baseline clinical and angiographic characteristics and outcomes of equipment loss/entrapment at 43 US and non-US centers between 2017 and 2023. RESULTS: Equipment loss/entrapment was reported in 40 (0.4%) of 10 719 cases during the study period. These included guidewire entrapment/fracture (n = 21), microcatheter entrapment/fracture (n = 11), stent loss (n = 8) and balloon entrapment/fracture/rupture (n = 5). The equipment loss/entrapment cases were more likely to have moderate to severe calcification, longer lesion length, higher J-CTO and PROGRESS-CTO complications scores, and use of the retrograde approach compared with the remaining cases. Retrieval was attempted in 71.4% of the guidewire, 90.9% of the microcatheter, 100% of the stent loss, and 100% of the balloon cases, and was successful in 26.7%, 30.0%, 50%, and 40% of the cases, respectively. Procedures complicated by equipment loss/entrapment had higher procedure and fluoroscopy time, contrast volume and patient air kerma radiation dose, lower procedural (60.0% vs 85.6%, P less than .001) and technical (75.0% vs 86.8%, P = .05) success, and higher incidence of major adverse cardiac events (MACE) (17.5% vs 1.8%, P less than .001), acute MI (7.5% vs 0.4%, P less than .001), emergency coronary artery bypass graft (CABG) (2.5% vs 0.1%, P = .03), perforation (20.0% vs 4.9%, P less than .001), and death (7.5% vs 0.4%, P less than .001). CONCLUSIONS: Equipment loss is a rare complication of CTO PCI; it is more common in complex CTOs and is associated with lower technical success and higher MACE.

The Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Interventions: Technical Analysis and Procedural Outcomes.

BACKGROUND: Retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with lower success and higher complication rates when compared with the antegrade approach. OBJECTIVES: This study sought to assess contemporary techniques and outcomes of retrograde CTO PCI. METHODS: We examined the baseline characteristics, procedural techniques and outcomes of 4,058 retrograde CTO PCIs performed at 44 centers between 2012 and 2023. Major adverse cardiac events (MACE) included any of the following in-hospital events: death, myocardial infarction, repeat target vessel revascularization, pericardiocentesis, cardiac surgery, and stroke. RESULTS: The average J-CTO (Multicenter CTO Registry in Japan) score was 3.1 ± 1.1. Retrograde crossing was successful in 60.5% and lesion crossing in 81.6% of cases. The collaterals pathways successfully used were septals in 62.0%, saphenous vein grafts in 17.4%, and epicardials in 19.1%. The technical and procedural success rates were 78.7% and 76.6%, respectively. When retrograde crossing failed, technical success was achieved in 50.3% of cases using the antegrade approach. In-hospital MACE was 3.5%. The clinical coronary perforation rate was 5.8%. The incidence of in-hospital MACE with retrograde true lumen crossing, just marker antegrade crossing, conventional reverse controlled antegrade and retrograde tracking (CART), contemporary reverse CART, extended reverse CART, guide-extension reverse CART, and CART was 2.1%, 0.8%, 5.5%, 3.0%, 2.1%, 3.2%, and 4.1%, respectively; P = 0.01). CONCLUSIONS: Retrograde CTO PCI is utilized in highly complex cases and yields moderate success rates with 5.8% perforation and 3.5% periprocedural MACE rates. Among retrograde crossing strategies, retrograde true lumen puncture was the safest. There is need for improvement of the efficacy and safety of retrograde CTO PCI.

Use of the Carlino Technique in Chronic Total Occlusion Percutaneous Coronary Intervention.

We examined the outcomes of the Carlino technique in chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). We analyzed the baseline clinical and angiographic characteristics and outcomes of 128 CTO PCIs that included the Carlino technique at 22 US and no-US centers between 2016 and 2023. The Carlino technique was used in 128 (2.8%) of 4,508 cases that used anterograde dissection and reentry (78.9%) or the retrograde approach (21.1%) during the study period, and it increased steadily over time (from 0.0% in 2016 to 8.3% in 2023). The mean patient age was 65.6 ± 9.7 years, and 88.7% of the patients were men with high prevalence of hypertension (89.1%) and dyslipidemia (80.2%). The Carlino technique was more commonly used in cases with moderate to severe calcification (77.2% vs 55.5%, p <0.001) with higher J-CTO (3.3 ± 0.9 vs 3.0 ± 1.1, p = 0.007), Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) (1.7 ± 1.0 vs 1.4 ± 1.0, p = 0.001), PROGRESS-CTO Mortality (2.6 ± 0.9 vs 2.0 ± 0.9, p = 0.013) and PROGRESS-CTO Perforation (3.7 ± 1.1 vs 3.5 ± 1.0, p = 0.029) scores. Carlino cases had longer procedure and fluoroscopy time, and higher contrast volume and radiation dose. Carlino cases had lower technical (65.6% vs 78.5%, p <0.001) and procedural (63.3% vs 76.3%, p <0.001) success, similar major adverse cardiac events (6.2% vs 3.2%, p = 0.101) and higher incidence of pericardiocentesis (3.9% vs 1.3%, p = 0.042), perforation (18.0% vs 8.9%, p = 0.001) and contrast-induced acute kidney injury (2.3% vs 0.4%, p = 0.012). The Carlino technique was associated with higher procedural success when used for retrograde crossing (81.5% vs 58.4%, p = 0.047). The Carlino technique is increasingly being used in CTO PCI especially for higher complexity lesions.

Impact of calcium on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention.

BACKGROUND: Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We examined the impact of calcium on procedural outcomes of 13,079 CTO PCIs performed in 12,799 patients at 46 US and non-US centers between 2012 and 2023. RESULTS: Moderate or severe calcification was present in 46.6% of CTO lesions. Patients whose lesions were calcified were older and more likely to have had prior coronary artery bypass graft surgery. Calcified lesions were more complex with higher J-CTO score (3.0 ± 1.1 vs. 1.9 ± 1.2; p < 0.001) and lower technical (83.0% vs. 89.9%; p < 0.001) and procedural (81.0% vs. 89.1%; p < 0.001) success rates compared with mildly calcified or non-calcified CTO lesions. The retrograde approach was more commonly used among cases with moderate/severe calcification (40.3% vs. 23.5%; p < 0.001). Balloon angioplasty (76.6%) was the most common lesion preparation technique for calcified lesions, followed by rotational atherectomy (7.3%), laser atherectomy (3.4%) and, intravascular lithotripsy (3.4%). The incidence of major adverse cardiovascular events (MACE) was higher in cases with moderate or severe calcification (3.0% vs. 1.2%; p < 0.001), as was the incidence of perforation (6.5% vs. 3.4%; p < 0.001). On multivariable analysis, the presence of moderate/severe calcification was independently associated with lower technical success (odds ratio, OR = 0.73, 95% CI: 0.63-0.84) and higher MACE (OR = 2.33, 95% CI: 1.66-3.27). CONCLUSIONS: Moderate/severe calcification was present in nearly half of CTO lesions, and was associated with higher utilization of the retrograde approach, lower technical and procedural success rates, and higher incidence of in-hospital MACE.

Impella percutaneous left ventricular assist device for severe acute ischaemic mitral regurgitation as a bridge to surgery.

Ischaemic papillary muscle rupture causing acute severe mitral regurgitation (MR) has a dramatic presentation and a very high mortality. Emergent surgical repair improves outcomes, which necessitates robust preoperative stabilisation. Here we discuss a patient with cardiogenic shock with an acute severe MR that was deemed very high risk for emergent valve replacement due to haemodynamic instability and respiratory failure. A percutaneous left ventricular assist device Impella 2.5 (Abiomed, Danvers, MA) drastically improved clinical status, and the patient underwent a successful surgical mitral valve replacement soon after placement of the temporary assist device. Our case highlights that percutaneous ventricular assist devices may help to stabilise patients with severe acute ischaemic MR, and it can serve as a bridge to surgery in high risk patients.

Thyroid Lymphoma as a Cause of Dysphagia and Dyspnea in a Patient without Palpable Nodules or Goiter.

Tumors originating in the neck are well-known causes of progressive dysphagia and dyspnea (including stridor), and thyroid lymphoma is an uncommon example. Physical examination provides an important first step in the evaluation of such complaints, as tumors large enough to produce such symptoms are typically considered to be palpable, if not able to be seen grossly. In this case presentation, the authors describe a nonsubsternal thyroid lymphoma measuring 3 x 4 cm at its largest diameter, producing dysphagia and leading to respiratory emergency, that was entirely nonpalpable to physical exam even after confirmation of its presence by computed tomography.