Long-term outcomes with first- vs. second-generation drug-eluting stents in saphenous vein graft lesions.

BACKGROUND: As compared with bare metal stents, first-generation drug-eluting stents (DES) improved post-procedural outcomes in aortocoronary saphenous vein graft (SVG) lesions, but there is limited information on outcomes after use of second-generation DES in SVGs. METHODS: We compared the outcomes of patients who received first- (n = 81) with those who received second-generation (n = 166) DES in SVG lesions at our institution between 2006 and 2013. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. RESULTS: Mean age was 66.0 ± 8.1 years and 97.6% of the patients were men. Mean SVG age was 11.1 ± 0.4 years. First-generation DES were sirolimus-eluting (n = 17) and paclitaxel-eluting (n = 64) stents. Second-generation DES were everolimus-eluting (n = 115) and zotarolimus-eluting (n = 51) stents. Median follow-up was 41 months. At 2-years post-procedure, patients with first- and second-generation DES had similar rates of death (20.91% vs. 20.27%, P = 0.916), target lesion revascularization (16.39% vs. 20.00%, P = 0.572), target vessel revascularization (20.97% vs. 23.16%, P = 0.747), myocardial infarction (26.15% vs. 23.00%, P = 0.644), and MACE (43.5% vs. 40.87%, P = 0.707), respectively. CONCLUSIONS: Outcomes with first- and second-generation DES in SVGs are similar. Novel stent designs are needed to further improve the clinical outcomes in this challenging patient and lesion subgroup. © 2015 Wiley Periodicals, Inc.

Transradial approach for coronary chronic total occlusion interventions: Insights from a contemporary multicenter registry.

OBJECTIVES: To examine the impact of transradial access on the procedural outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI). BACKGROUND: The efficacy and safety of transradial access in CTO PCI has received limited study. METHODS: We compared the technique and outcomes of transradial vs. transfemoral access among 650 CTO PCI cases performed between January 2012 and March 2014 at 6 US centers. RESULTS: Most patients were men (87%) with high frequency of diabetes mellitus (42%) and prior coronary artery bypass graft surgery (36%). The CTO target vessel was the right coronary (59%), left anterior descending (20%), or circumflex (17%) artery. TR access was used in 110 (17%) of the 650 cases, as follows: bilateral radial access (63%); bilateral radial access plus unilateral or bilateral femoral access (7%); unilateral radial access plus unilateral or bilateral femoral access (26%); and unilateral radial access (4%). Six and eight French guide catheters were used through the radial and femoral artery, respectively. Compared to transfemoral, transradial cases had similar technical (92.6% vs. 93.0%, P = 0.87) and procedural (91.1% vs. 90.0%, P = 0.95) success and major complication rates (1.7% vs 1.8%, P = 0.99). However, transradial access was associated with higher mean procedure (142 ± 83 vs. 120 ± 60 min, P = 0.008) and fluoroscopy (58 ± 40 vs. 49 ± 31 min, P <0.026) time, and number of crossing approach changes (0.7 ± 1.0 vs. 0.5 ± 0.7, P = 0.008). CONCLUSION: Transradial CTO PCI can be performed with similar success and complication rates with transfemoral CTO PCI, but is associated with longer procedural and fluoroscopy times. © 2015 Wiley Periodicals, Inc.

Current Perspectives and Practices on Chronic Total Occlusion Percutaneous Coronary Interventions.

OBJECTIVES: We sought to examine contemporary perspectives and practices on chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: The frequency and success of CTO-PCI have been increasing in recent years. METHODS: An online questionnaire was created and distributed to cardiologists within the United States and internationally. RESULTS: A total of 1149 responses were obtained. The United States (n = 845; 73.5%), Asia (n = 98; 8.5%), Europe (n = 88; 7.7%), South America (n = 42; 3.7%), and Canada (n = 33; 2.9%) accounted for most responses. Mean practice duration of the respondents was 16.4 ± 11.5 years and 66.9% were interventional cardiologists. Most respondents agreed that CTO-PCI results in an improvement of patient symptoms (90.7%), left ventricular function (79.3%), arrhythmia risk (69.2%), and overall survival (63.1%). Interventional cardiologists had a more favorable view of the benefits of CTO-PCI as compared with non-interventional cardiologists (P<.001). Most respondents estimated the procedural success rates of contemporary CTO-PCI to be between 51%-75% (34.2%) and 76%-85% (30.2%), with interventional cardiologists estimating higher success rates than non-interventionalists (P<.001). Perforation, mortality, and tamponade were the three most concerning complications. Time and procedure complexity were reported to be the most significant barriers to the development of a CTO-PCI program. CONCLUSIONS: Most cardiologists believe that CTO-PCI can provide significant clinical benefits and can be accomplished with moderate to high success rates. Interventional cardiologists have a more favorable view of CTO-PCI as compared with non-invasive cardiologists.

Prevalence and treatment of "balloon-uncrossable" coronary chronic total occlusions.

BACKGROUND: The frequency and outcomes of "balloon-uncrossable" coronary chronic total occlusions (CTOs) have received limited study. METHODS: We retrospectively examined 373 consecutive CTO percutaneous coronary interventions (PCIs) performed at our institution between 2005 and 2013 to determine the frequency and treatment of balloon-uncrossable CTOs. RESULTS: Mean age was 63.7 ± 8.3 years and 98.9% of the patients were men. Twenty-four patients (6.4%, 95% confidence intervals 4.2% to 9.4%) were found to have a balloon-uncrossable CTO. Compared to the other CTO PCI patients, those with balloon-uncrossable CTOs had similar clinical and angiographic characteristics. Successful crossing of the balloon-uncrossable CTO was achieved in 22 of 24 patients (91.7%) using a variety of techniques, such as successive balloon inflations (43.5%), microcatheter advancement (21.7%), laser (8.7%), techniques that increase guide catheter support (13.0%), and subintimal lesion crossing (13.0%). Patients with balloon-uncrossable CTOs had longer procedure time (184.5 ± 77.9 vs 134.0 ± 69.0 min, P<.01), fluoroscopy time (55.2 ± 24.9 vs 37.9 ± 20.8 min, P<.01), and received high contrast volume (404.4 ± 137.9 vs 351.7 ± 138.5 mL, P=.08), but had similar incidence of major complications (8.3% vs 3.2%, P=.25) as compared with patients who did not have balloon-uncrossable CTOs. CONCLUSION: Balloon-uncrossable CTOs are encountered in 6.4% of contemporary CTO PCIs and can be successfully treated in most patients using a variety of techniques.

Application and outcomes of a hybrid approach to chronic total occlusion percutaneous coronary intervention in a contemporary multicenter US registry.

BACKGROUND: A hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) prioritizing and combining all available crossing techniques was developed to optimize procedural efficacy, efficiency, and safety, but there is limited published data on its outcomes. METHODS: We examined the procedural techniques and outcomes of 1036 consecutive CTO PCIs performed using a hybrid approach between 2012 and 2015 at 11 US centers. RESULTS: Mean age was 65 ± 10 years and 86% of the patients were men, with a high prevalence of diabetes mellitus (43%) and prior coronary artery bypass graft surgery (34%). Most target CTOs were located in the right coronary artery (59%), followed by the left anterior descending artery (23%) and the circumflex (19%). Dual injection was used in 71%. Technical success was achieved in 91% and a major procedural complication occurred in 1.7% of cases. The final successful crossing technique was antegrade wire escalation in 46%, antegrade dissection/re-entry in 26%, and retrograde in 28%. The initial crossing strategy was successful in 58% of the lesions, whereas 39% required an additional approach. Overall, antegrade wire escalation was used in 71%, antegrade dissection/re-entry in 36%, and the retrograde approach in 42% of procedures. Median contrast volume, fluoroscopy time, and air kerma radiation dose were 260 (200-360) ml, 44 (27-72) min, and 3.4 (2.0-5.4) Gray, respectively. CONCLUSION: Application of a hybrid approach to CTO crossing resulted in high success and low complication rates across a varied group of operators and hospital practice structures, supporting its expanding use in CTO PCI.

The efficacy and safety of the "hybrid" approach to coronary chronic total occlusions: insights from a contemporary multicenter US registry and comparison with prior studies.

BACKGROUND: Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is challenging and has been associated with low success rates. However, recent advancements in equipment and the flexibility to switch between multiple technical approaches during the same procedure ("hybrid" percutaneous algorithm) have dramatically increased the success of CTO-PCI. We sought to compare the contemporary procedural outcomes of hybrid CTO-PCI with previously published CTO-PCI studies. METHODS: The procedural outcomes of 497 consecutive CTO-PCIs performed between January 2012 and August 2013 at five high-volume centers in the United States were compared with the pooled success and complication rates reported in 39 prior CTO-PCI series that included ≥100 patients and were published after 2000. RESULTS: The baseline clinical and angiographic characteristics of the study patients were comparable to those of previous studies. Technical and procedural success was achieved in 455 cases (91.5%) and 451 cases (90.7%), respectively, and were significantly higher than the pooled technical and procedural success rates from prior studies (76.5%, P<.001 and 75.2%, P<.001, respectively). Major procedural complications occurred in 9/497 patients (1.8%) overall and included death (2 patients), acute myocardial infarction (5 patients), repeat target vessel PCI (1 patient), and tamponade requiring pericardiocentesis (2 patients). The incidence of major complications was similar to that of prior studies (pooled rate 2.0%; P=.72). CONCLUSION: Use of the hybrid approach to CTO-PCI is associated with higher success and similar complication rates compared to prior studies, supporting its expanded use for treating these challenging lesions.

Application of the "hybrid approach" to chronic total occlusions in patients with previous coronary artery bypass graft surgery (from a Contemporary Multicenter US registry).

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been traditionally associated with lower success rates in patients with previous coronary artery bypass graft surgery (CABG). We sought to examine the success and complication rates of CTO PCI using the "hybrid" crossing algorithm among patients with a history of previous CABG. The procedural outcomes of 496 consecutive CTO PCIs performed at 5 high-volume PCI centers in the United States from January 2012 to August 2013 were assessed. The outcomes of patients with previous CABG were compared with those of patients without previous CABG. Compared with patients without previous CABG (n = 320), patients with previous CABG (n = 176, 35%) were older, had more coronary artery disease risk factors, and had less favorable baseline angiographic CTO characteristics. Technical and procedural success was slightly lower among patients with previous CABG (88.1% vs 93.4%, p = 0.044 and 87.5 vs 92.5%, p = 0.07, respectively). Patients with previous CABG more commonly underwent CTO PCI using the retrograde approach (39% vs 24%, respectively, p <0.001) and received higher air kerma radiation exposure (4.8 [interquartile range 3.0 to 6.4] vs 3.1 [1.9 to 5.3] Gray, p <0.001) and fluoroscopy time (59 [38 to 77] vs 34 [21 to 55] minutes, p <0.001). Major procedural complications were similar in the 2 groups: 2 of 176 (1.1%) patients with previous CABG versus 7 of 320 (2.1%) patients without previous CABG (p = 0.40). In conclusion, with application of the "hybrid" approach to CTO PCI, success was slightly lower, and complication rates were similar between patients with and without previous CABG.