Evaluation of Success and Complications Scores for Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the Latin American Registry.

Chronic total occlusion (CTO) percutaneous coronary intervention is a complex procedure and is associated with considerable risk of complications. Several success and complication scores have been developed; however, data regarding their external validation in other populations such as Latin America are scarce. This study aimed to evaluate the accuracy of the main predictors of success and complications in a broad cohort of procedures in the Latin American (LATAM) CTO registry. From April 2008 to December 2023, 3,706 consecutive procedures listed in the LATAM CTO registry were screened. Of these, 2,835 procedures had sufficient information to analyze the Multicenter CTO Registry in Japan (J-CTO); Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS); Ostial location, Rentrop grade, and Age (ORA); Clinical and Lesion-related Score (CL-score); and EuroCTO Score (CASTLE) success scores. The complication scores were PROGRESS (MACE, mortality, and pericardiocentesis) and Outcomes, Patient health status, and Efficiency iN Chronic Total Occlusion hybrid procedures (OPEN-CTO),OPEN-CLEAN. The J-CTO and CASTLE scores demonstrated the highest areas under the curve (AUC) of 0.718 and 0.703, respectively. The AUC value for the CL-score was 0.685, whereas the PROGRESS score had an AUC of 0.598 and the ORA AUC was 0.545. The level of agreement between scores was low; only 4% of the procedures were classified as difficult or very difficult by all scores and <1% were classified as easy by all 5 scores. Of the complication scores, PROGRESS mortality (AUC 0.651) and PROGRESS MACE (AUC 0.588) showed the best performance, identifying groups with >10% event rate. These results may improve the selection of revascularization techniques, especially for patient demographics that are historically underrepresented in CTO research.

Guide catheter extension use are associated with higher procedural success in chronic total occlusion percutaneous coronary interventions.

BACKGROUND: Guide catheter extensions (GCEs) increase support and facilitate equipment delivery, but aggressive instrumentation may be associated with a higher risk of complications. AIM: Our aim was to assess the impact of GCEs on procedural success and complications in patients submitted to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We analyzed data from the multicenter LATAM CTO Registry. Procedural success was defined as <30% residual stenosis and TIMI 3 distal flow. Major adverse cardiac and cerebrovascular events (MACCE) was defined as the composite of all-cause death, myocardial infarction, target vessel revascularization, and stroke. Propensity score matching (PSM) was used to compare outcomes with and without GCE use. RESULTS: From August 2010 to August 2021, 3049 patients were included. GCEs were used in 438 patients (14.5%). In unadjusted analysis, patients in the GCE group were older and had more comorbidities. The median J-CTO score and its components were higher in the GCE group. After PSM, procedural success was higher with GCE use (87.7% vs. 80.5%, p = 0.007). The incidence of coronary perforation (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 0.78-2.71, p = 0.230), bleeding (OR: 1.99, 95% CI: 0.41-2.41, p = 0.986), in-hospital death (OR: 1.39, 95% CI: 0.54-3.62, p = 0.495) and MACCE (OR: 1.07, 95% CI: 0.52-2.19, p = 0.850) were similar in both groups. CONCLUSION: In a contemporary, multicenter cohort of patients undergoing CTO PCI, GCEs were used in older patients, with more comorbidities and complex anatomy. After PSM, GCE use was associated with higher procedural success, and similar incidence of adverse outcomes.

DES Strut Thickness and Clinical Outcomes After CTO Recanalization: Insights From LATAM CTO Registry.

BACKGROUND: Ultra-thin strut drug-eluting stent (UTS-DES) may improve outcomes after percutaneous coronary intervention (PCI) but have received limited study in chronic total occlusion (CTO) PCI. AIMS: To compare of 1-year incidence of major adverse cardiac events (MACE) between patients who underwent CTO PCI with ultrathin (≤ 75 µm) versus thin (>75 µm) strut DES in the LATAM CTO registry. METHODS: Patients were considered for inclusion only if successful CTO PCI was performed and when only one type of stent strut thickness (ultrathin or thin) was used. A propensity score matching (PSM) was computed to produce similar groups in relation to clinical and procedural characteristics. RESULTS: Between January 2015 and January 2020, 2092 patients underwent CTO PCI, of whom 1466 were included in the present analysis (475 in the ultra-thin and 991 in the thin strut DES). In unadjusted analysis the UTS-DES group had lower rate of MACE (HR: 0.63 95 % CI 0.42 to 0.94, p = 0.04) and repeat revascularizations (HR: 0.50 95 % CI 0.31 to 0.81, p = 0.02) at 1-year follow-up. After adjustment for confounding factors in a Cox regression model there was no difference in 1-year incidence of MACE between groups (HR: 1.15 95 % CI 0.41 to 2.97, p = 0.85). On PSM of 686 patients (343 in each group) the 1-year incidence of MACE (HR 0.68 95 % CI 0.37-1.23; P = 0.22) and individual components of MACE did not differ between groups. CONCLUSIONS: One-year clinical outcomes after CTO PCI were similar with ultrathin and thin strut DES.

Chronic Total Occlusion Recanalization Concurrent to Culprit Primary Percutaneous Coronary Intervention via Distal Transradial Access: Maximizing Revascularization Through Minimalist Approach.

For ST-segment elevation myocardial infarction (STEMI) patients with multi-vessel coronary disease, complete revascularization is superior to culprit-only percutaneous coronary intervention (PCI). Chronic total occlusion represents the most challenging setting for PCI. Distal transradial access (dTRA) has advantages such as faster hemostasis and risk of proximal radial artery occlusion. We report a case of nonculprit coronary total occlusion recanalization concurrent to culprit primary PCI via dTRA in the setting of STEMI.

Associação entre os Níveis Séricos de Elabela e Oclusão Total Crônica em Pacientes com Angina Pectoris Estável / Association Between Serum Elabela Levels and Chronic Totally Occlusion in Patients with Stable Angina Pectoris

Resumo Fundamento: Os efeitos benéficos do elabela no sistema cardiovascular foram demonstrados em estudos. Objetivo: Comparar os níveis séricos de elabela de pacientes com oclusão total crônica (OTC) com pacientes controle com artérias coronárias normais e investigar se há correlação com o desenvolvimento colateral. Métodos: Estudo transversal e prospectivo. O estudo incluiu cinquenta pacientes (28,0% mulheres, idade média 61,6±7,3 anos) com OTC em pelo menos um vaso coronário e 50 pacientes (38% mulheres, idade média 60,7±6,38 anos) com artérias coronárias normais. Os pacientes do grupo OTC foram divididos em dois grupos: Rentrop 0-1, composto por pacientes com fraco desenvolvimento colateral e Rentrop 2-3, composto por pacientes com bom desenvolvimento colateral. Além da idade, sexo, características demográficas e exames laboratoriais de rotina dos pacientes, foram medidos os níveis de elabela. Resultados: As características demográficas e os valores laboratoriais mostraram-se semelhantes em ambos os grupos. Ao passo que o nível médio de NT-proBNP e troponina estava maior no grupo OTC, o nível médio de elabela estava menor (p<0,05 para todos). Na análise de regressão multivariada, os níveis de NT-proBNP e elabela foram considerados preditores independentes para OTC. Além disso, o nível de elabela apresentou-se estatisticamente maior em pacientes do grupo Rentrop 2-3 em comparação com os pacientes do grupo Rentrop 0-1 (p<0,05). Conclusões: Em nosso estudo, mostramos que o nível médio de elabela estava baixo em pacientes com OTC em comparação com pacientes normais. Além disso, constatamos que o nível de elabela é inferior em pacientes com desenvolvimento colateral fraco em comparação com pacientes com bom desenvolvimento colateral. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Abstract Background: The beneficial effects of Elabela on the cardiovascular system have been shown in studies. Objective: To compare serum Elabela levels of chronic total occlusion (CTO) patients with control patients with normal coronary arteries, and to investigate whether there is a correlation with collateral development. Methods: The study was planned cross-sectionally and prospectively. Fifty patients (28.0% female, mean age 61.6±7.3years) with CTO in at least one coronary vessel and 50 patients (38% female, mean age 60,7±6.38 years) with normal coronary arteries were included in the study. Patients in the CTO group were divided into two groups as Rentrop 0-1, those with weak collateral development, and Rentrop 2-3 with good collateral development. In addition to the age, sex, demographic characteristics and routine laboratory tests of the patients, Elabela levels were measured. Results: Demographic characteristics and laboratory values were similar in both groups. While the mean NT-proBNP and troponin were higher in the CTO group, the Elabela mean was lower (p <0.05 for all). In the multivariate regression analysis, NT-proBNP and Elabela levels were found to be independent predictors for CTO. Also, Elabela level was found to be statistically higher in Rentrop class 2-3 patients compared to Rentrop class 0-1 patients (p<0.05). Conclusion: In our study, we showed that the average Elabela level was low in CTO patients compared to normal patients. In addition, we found the level of Elabela to be lower in patients with weak collateral development compared to patients with good collateral development. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Chronic Total Occlusion of the Left Main Coronary Artery in an HIV-Infected Patient.

Coronary artery disease (CAD) is amongst the leading causes of death in human immunodeficiency virus (HIV)-infected persons. Severe left main disease (LMD) occurs in approximately five percent of HIV-infected patients, with chronic total occlusion (CTO) of this vessel being an even rarer phenomenon. We describe a non-adherent HIV-infected patient with a left main coronary artery (LMCA) CTO that presented with heart failure with mildly reduced ejection fraction (HFrEF) and ventricular tachycardia (VT).

Seguimiento a un año de la revascularización percutánea de oclusiones coronarias crónicas en el Hospital México / One-year follow-up of percutaneous revascularization of chronic coronary occlusions at Hospital México

Resumen La prevalencia de la enfermedad arterial coronaria compleja en la población mundial es alta. Las oclusiones coronarias crónicas totales (OCT) generan gran morbilidad en la población y significan un reto terapéutico por su alta complejidad. En años recientes con el desarrollo de nuevas tecnologías se ha visto a nivel mundial un beneficio en la calidad de vida, síntomas y función sistólica del ventrículo izquierdo al realizar intervención coronaria percutánea (ICP) de las OCT con una alta tasa de éxito y pocas complicaciones. En este trabajo se describen los resultados clínicos cardiovasculares a un año de realizar ICP en pacientes con OCT intervenidos en el Hospital México en Costa Rica durante 2016-2017. Se registraron 54 pacientes con seguimiento de 1 año posterior a ICP de OCT. Se analizaron variables sociodemográficas y clínicas, cuantificando síntomas según la escala funcional de la Asociación de Corazón de Nueva York (NYHA) y la Sociedad Canadiense de Cardiología (CCS) de angina, así como valoración de la fracción de eyección (FE) por ecocardiografía en forma basal y posterior a la ICP, y las complicaciones asociadas De los 54 pacientes sometidos a ICP de OCT, la mayoría fueron hombres con edad promedio de 64 años y nivel académico básico. No hubo diferencia significativa en la FE previo y posterior al procedimiento (p=0.68), con una tendencia a la mejoría en los pacientes con disfunción sistólica severa con tejido viable. Sí hubo diferencias significativas en mejoría de síntomas basados en la escala funcional NYHA (p<0,01) y la escala de angina CCS (p<0,01). Se alcanzó un éxito en el procedimiento en el 96.3% de los casos sin diferencia significativa según el acceso vascular ni la escala J-CTO con una tasa de complicaciones baja. Concluimos que hay un beneficio clínico significativo en cuanto a los síntomas, al revascularizar a pacientes con oclusiones coronarias crónicas totales, con una alta tasa de éxito en el procedimiento y pocas complicaciones.

Abstract There is a high prevalence of complex coronary artery disease worldwide, in this group chronic total occlusions (CTO) generate a great burden of disease in the population and are a difficult therapeutic challenge. In recent years and with the development of new technologies, the world have seen a benefit in quality of life, symptoms and systolic function of the left ventricle when performing a percutaneous coronary intervention (PCI) of CTO with high success rate and low rate of complications. In this study we describe the cardiovascular clinical results one year after performing PCI in patients with CTOs in Hospital Mexico in Costa Rica during 2016-2017. Methods: We registry 54 patients completing one year follow up after PCI of CTO. We measure sociodemographic and clinical variables quantifying symptoms using NYHA and CCS scales, ejection fraction (EF) using echocardiography previous and after PCI, and the complications developed. We identified 54 patients who underwent PCI of CTO, most were men with an average age of 64 years and a basic academic level. There was no significant difference in the pre-and-post-procedure EF (p=0.68), with a trend to improvement in patients with severe left ventricle systolic dysfunction and viable myocardium. There were significant differences in symp- tom improvement based on the NYHA functional status score (p<0.01) and the CCS angina score (p<0.01). A successful procedure was achieved in 96.3% of cases with no significant difference depending on vascular access or the J-CTO scale with low complication rate. Conclusions: There is a significant clinical benefit based on symptoms of performing PCI in patients with CTO with a high success rate in the procedure and a few associated complications.

Chronic total occlusion percutaneous coronary intervention in Latin America.

OBJECTIVES: To report clinical, angiographic characteristics, outcomes, and predictors of unsuccessful procedures in patients who underwent chronic total occlusion (CTO) percutaneous coronary interventions (PCI) in Latin America. BACKGROUND: CTO PCI has been increasingly performed worldwide, but there is a lack of information in this region. METHODS: An international multicenter registry was developed to collect data on CTO PCI performed in centers in Latin America. Patient, angiographic, procedural and outcome data were evaluated. Predictors of unsuccessful procedures were assessed by multivariable analysis. RESULTS: We have included data related to 1,040 CTO PCIs performed in seven countries in Latin America (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, and Puerto Rico). The mean age was 64 ± 10 years, and CTO PCI was performed mainly for angina control (81%) or treatment of a large ischemic area (30%). Overall technical success rate was 82.5%, and it was achieved with antegrade wire escalation in 81%, antegrade dissection/re-entry in 8% and with retrograde techniques in 11% of the successful procedures. Multivariable analysis identified moderate/severe calcification, a blunt proximal cap and a previous attempt as independent predictors of unsuccessful procedures. In-hospital major adverse cardiovascular events (MACE) occurred in 3.1% of the cases, death in 1% and cardiac tamponade in 0.9% CONCLUSIONS: CTO PCI in Latin America has been performed mainly for ischemia relief. Procedures were associated with a success rate above 80% and low incidence of MACE. Predictors of unsuccessful procedures were similar to those previously reported in the literature.

Marcadores angiográficos negativos en la intervención coronaria percutánea de las oclusiones totales crónicas / Negative angiographic markers in percutaneous coronary intervention of chronic total occlusions

Resumen Objetivos: El objetivo de este estudio es evaluar variables angiográficas predictivas negativas y la presencia de la rama lateral en la proximidad de la capa distal de la oclusión en el resultado de la intervención coronaria percutánea de las oclusiones totales crónicas. Método: Las variables angiográficas potencialmente negativas fueron evaluadas retrospectivamente en 156 oclusiones totales crónicas sometidas a intervención coronaria percutánea. Se utilizó regresión logística binaria con una finalidad predictiva para identificar un modelo de variables que en su conjunto puedan predecir satisfactoriamente el resultado negativo de la intervención. Resultados: Las variables asociadas de forma independiente al fracaso de procedimiento fueron la enfermedad multivaso (odds ratio = 5,12; intervalo de confianza del 95%, 1,94-13,5; P = 0.001), la presencia de muñón ambiguo (odds ratio = 5,08; IC intervalo de confianza del 95%, 2,22- 11,63; P < 0.001), longitud de la oclusión ≥20 mm (odds ratio = 3,7; IC intervalo de confianza del 95%, 1,37-9,97; P = 0.01) y la localización ostial de la oclusión (odds ratio = 6,53; intervalo de confianza del 95%, 1,67-25,63; P = 0.007). La rama lateral en la proximidad de la capa distal no permaneció en el modelo predictivo. Conclusión: La enfermedad multivaso, muñón ambiguo, una longitud ≥20 mm y la localización ostial son factores independientes y predictivos de un resultado desfavorable de la angioplastia. La rama lateral en la capa distal de la oclusión no se asoció al fracaso de la intervención. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Abstract Objective: The purpose of this study is to identify negative angiographic predictive variables and the presence of a side branch close to the distal cap of the occlusion in the chronic total occlusion percutaneous coronary intervention outcome. Methods: Potential negative angiographic variables were retrospectively evaluated in 156 chronic total occlusions that had undergone a percutaneous coronary intervention. Binary logistic regression with predictive purpose was used to identify a model of variables which, all in all, could successfully predict a negative intervention result. Results: Variables independently associated with the procedural failure were multivessel disease (odds ratio = 5.12; 95% confidence interval (CI); 1.94-13.5; P = .001), ambiguous stump presence (odds ratio = 5.08; 95% CI; 2.22-11.63 P < .001), occlusion length ≥20 mm (odds ratio = 3.7; 95% CI; 1.37-9.97 P = .01), and ostial location (odds ratio = 6.53; 95% CI; 1.67-25.63; P = .007). Side branch at distal cap proximity did not remain in the predictive model. Conclusions: Multivessel disease, ambiguous stump, a length ≥20 mm, and an ostial location of a chronic total occlusion are independent predictive factors of an unfavourable angioplasty result. A side branch at occlusion distal cap was not associated with the procedural failure. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Precise Retrograde Supera Stenting of the Ostium (PRESTO) of the Superficial Femoral Artery for Complex Femoropopliteal Occlusions: The PRESTO Technique.

PURPOSE: To describe a novel technique designed to safely and precisely deploy the Supera stent accurately at the ostium of the proximal superficial femoral artery (SFA) without compromising the profunda and common femoral arteries. TECHNIQUE: After antegrade crossing of the chronic total occlusion (CTO) at the SFA ostium and accurate predilation of the entire SFA lesion, a retrograde arterial access is obtained. The Supera stent is navigated in retrograde fashion to position the first crown to be released just at the SFA ostium. Antegrade dilation is performed across the retrograde access site to obtain adequate hemostasis. The technique has been applied successfully in 21 patients (mean age 78.1±8.2 years; 13 men) with critical limb ischemia using retrograde Supera stenting from the proximal anterior tibial artery (n=6), the posterior tibial artery (n=2), retrograde stent puncture in the mid to distal SFA (n=2), the native distal SFA/proximal popliteal segment (n=6), and the distal anterior tibial artery (n=5). No complications were observed. CONCLUSION: Distal retrograde Supera stent passage and reverse deployment allow precise and safe Supera stenting at the SFA ostium.

[Negative angiographic markers in percutaneous coronary intervention of chronic total occlusions]. / Marcadores angiográficos negativos en la intervención coronaria percutánea de las oclusiones totales crónicas.

OBJECTIVE: The purpose of this study is to identify negative angiographic predictive variables and the presence of a side branch close to the distal cap of the occlusion in the chronic total occlusion percutaneous coronary intervention outcome. METHODS: Potential negative angiographic variables were retrospectively evaluated in 156 chronic total occlusions that had undergone a percutaneous coronary intervention. Binary logistic regression with predictive purpose was used to identify a model of variables which, all in all, could successfully predict a negative intervention result. RESULTS: Variables independently associated with the procedural failure were multivessel disease (odds ratio=5.12; 95% confidence interval (CI); 1.94-13.5; P=.001), ambiguous stump presence (odds ratio=5.08; 95% CI; 2.22-11.63 P<.001), occlusion length ≥20mm (odds ratio=3.7; 95% CI; 1.37-9.97 P=.01), and ostial location (odds ratio=6.53; 95% CI; 1.67-25.63; P=.007). Side branch at distal cap proximity did not remain in the predictive model. CONCLUSIONS: Multivessel disease, ambiguous stump, a length ≥20mm, and an ostial location of a chronic total occlusion are independent predictive factors of an unfavourable angioplasty result. A side branch at occlusion distal cap was not associated with the procedural failure.

Noninvasive Cardiac Imaging in Patients with Known and Suspected Coronary Artery Disease: What is in it for the Interventional Cardiologist?

The long-standing coronary artery disease (CAD) paradigm simplified by the discrimination between patients with or without CAD warrants to be revisited by the insightful information provided by noninvasive cardiac imaging, leading to a comprehensive physiopathological assessment rather than a mainly anatomical approach. This review will address (1) the role of non-invasive cardiac imaging for the appropriate selection of stable patients referred to invasive coronary angiography (ICA), and the evolving concept and prognostic implications of myocardial ischemia; (2) the usefulness of computed tomography coronary angiography for the guidance of percutaneous coronary interventions; and (3) the role and potential clinical impact of novel anatomical and functional non-invasive prognostic markers.

Recanalization of femoropopliteal chronic total occlusion susing the ENABLER-P balloon catheter system

Purpose: To evaluate the safety and effectiveness of a new system to facilitate intraluminaladvancement of conventional guidewires through chronic total occlusions (CTO) of thesuperficial femoral artery (SFA) and popliteal artery.Methods: The ENABLER-P Balloon Catheter System uses a unique balloon-anchoringmechanism and an automated balloon inflation device for steady, controlled advancementof a standard non-hydrophilic guidewire. The system was evaluated in 37 patients (22 men;mean age 67 years (range 41–87) with femoropopliteal CTOs averaging 86 mm in length(range 10–340). The device was used in a variety of occlusions, including heavily calcified,long, and fibrotic lesions. After successful guidewire recanalization facilitated by thesystem, occluded arterial segments were treated conventionally with balloon angioplasty,atherectomy, and stents as appropriate.Results: The primary endpoint of successful crossing was achieved in 86% (32/37) of theoverall study population. The average activation time for successful crossing was5.3 minutes (range 0.4–22). Of the 32 cases successfully crossed with the ENABLER-PSystem, all but 1 was successfully recanalized. One (3%) device-related complicationoccurred when the wire was advanced into a side branch when treating a 300-mm-longflush ostial SFA occlusion; the resulting perforation was managed with a covered stentwithout further sequelae.Conclusion: This novel system, which provides enhanced force to a standard guidewire tipfor controlled intraluminal advancement, is a promising device for the treatment ofperipheral CTOs.