Marfan Syndrome Associated With Acute Myocardial Infarction in the First Trimester of Pregnancy.

Marfan syndrome (MFS) is a rare hereditary connective tissue disorder with autosomal dominant inheritance associated with an increased risk of cardiovascular complications due to connective tissue fragility. Acute myocardial infarction during pregnancy is also a rare event associated with poor maternal and fetal outcomes. Herein, we report a case of a 30-year-old pregnant woman with a known history of MFS. The patient had been treated surgically for an ascending aorta aneurysm and mechanical prosthetic aortic valve repair. She presented at 12 weeks of gestation with severe chest pain, which proved to be acute myocardial infarction. This is believed to be the first case of this complex medical condition presented in the first trimester of pregnancy.

6-minute walking test: a useful tool in the management of heart failure patients.

Reduced functional ability and exercise tolerance in patients with heart failure (HF) are associated with poor quality of life and a worse prognosis. The 6-minute walking test (6MWT) is a widely available and well-tolerated test for the assessment of the functional capacity of patients with HF. Although the cardiopulmonary exercise test (a maximal exercise test) remains the gold standard for the evaluation of exercise capacity in patients with HF, the 6MWT (submaximal exercise test) may provide reliable information about the patient's daily activity. The current review summarizes the value of 6MWT in patients with HF and identifies its usefulness and limitations in everyday clinical practice in populations of HF. We aimed to investigate potential associations of 6MWD with other measures of functional status and determinants of 6MWD in patients with HF as well as to review its prognostic role and changes to various interventions in these patients.

The importance of characteristics of angina symptoms for the prediction of coronary artery disease in a cohort of stable patients in the modern era.

OBJECTIVE: Angina is an important clinical symptom indicating underlying coronary artery disease (CAD). Its characteristics are important for the diagnosis and risk stratification of patients with CAD. Currently, we aimed to investigate the association of chest pain characteristics with the presence of obstructive CAD in a contemporary cohort of patients undergoing coronary angiography for suspected stable CAD. METHODS: Consecutive patients undergoing coronary angiography for suspected stable CAD (n = 686) in a single university hospital cardiology department were enrolled. Chest pain was classified as typical angina, atypical angina, nonangina chest pain, and lack of symptoms. The presence of significant angiographic CAD was diagnosed by standard coronary angiography. RESULTS: Typical angina symptoms were associated with a higher prevalence of CAD (odds ratio [OR], 3.47, p < 0.001), whereas atypical angina symptoms were associated with a lower prevalence of CAD (OR, 0.49, p = 0.003) than the nonangina symptoms/or asymptomatic status. In multivariate analysis, typical angina symptoms remained an independent predictor of CAD (OR, 2.54, p < 0.001), with a greater predictive accuracy than other clinical risk factors (area under the curve [AUC], 0.715, p < 0.001) and similar to the accuracy of the high-sensitivity C-reactive protein (AUC, 0.712, p < 0.001). In a multivariate model, the combination of all studied factors further improved the predictive accuracy (AUC, 0.81, p < 0.001). CONCLUSION: In a contemporary cohort of patients referred for coronary angiography for stable CAD, the presence of typical angina symptoms was the most important independent predictor of obstructive CAD. The association of atypical angina symptoms with low CAD prevalence compared to nonangina chest pain or absence of significant symptoms probably reflects different management and referral strategies in these groups of patients.

"Subintimal external crush" technique for a "balloon uncrossable" chronic total occlusion.

Chronic total occlusion (CTO) revascularization is traditionally limited by the challenges related to lesion crossing. In a smaller number of cases, however, inability to advance the balloon catheter to the crossing site can account for recanalization failure ("balloon uncrossable" CTO). We describe a case of a "balloon uncrossable" CTO in which balloon crossing was achieved after subintimal dilation and "external crushing" of the CTO lesion resulting in significant modification of the CTO atheromatous plaque.

Optical coherence tomography findings after chronic total occlusion interventions: Insights from the "AngiographiC evaluation of the everolimus-eluting stent in chronic Total occlusions" (ACE-CTO) study (NCT01012869).

BACKGROUND: There is limited information on optical coherence tomography (OCT) findings after percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). OCT allows high resolution imaging that can enhance understanding of the vascular response after stenting of chronically occluded vessels. METHODS: The Angiographic Evaluation of the Everolimus-Eluting Stent in Chronic Total Occlusions (ACE-CTO) study collected angiographic and clinical outcomes from 100 patients undergoing CTO PCI with the everolimus-eluting stent (EES). OCT was performed 8-months post stenting in 62 patients. Every third frame was analyzed throughout the course of the stented arterial segment. Lumen contours were semi-automatically traced and stent struts were manually delineated, with automatic measurement of the strut to lumen distance. Struts on the luminal side of the lumen contour were classified as malapposed if the distance to the lumen contour exceeded 0.108mm. RESULTS: A total of 44,450 struts in 6047 frames were analyzed, of which 4113 9.3%, 95% confidence intervals [CI] 9.0% to 9.5%) were malapposed and 1230 (2.8%, 95% CI 2.6% to 2.9%) were uncovered. Fifty-five of 62 patients (88.7%, 95% CI 78.5% to 98.4%) had at least one malapposed stent strut and 50 patients (80.7%, 95% CI 69.2% to 88.6%) had at least one uncovered stent strut. Mean strut-intimal thickness of the apposed and malapposed struts was 0.126±0.140mm and -0.491±0.440mm, respectively. CONCLUSION: High rates of stent strut malapposition and incomplete stent strut coverage were observed after CTO PCI using EES, highlighting unique challenges associated with stent implantation in CTOs.

Optimizing Radiation Safety in the Cardiac Catheterization Laboratory: A Practical Approach.

Reducing radiation exposure during cardiovascular catheterization is of paramount importance for both patient and staff safety. Over the years, advances in equipment and application of radiation safety protocols have significantly reduced patient dose and operator exposure. This review examines the current status of radiation protection in the cardiac and vascular catheterization laboratory and summarizes best practices for minimizing radiation exposure.

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.

Determinants of operator and patient radiation exposure during cardiac catheterization: Insights from the RadiCure (RADIation reduction during cardiac catheterization using real-timE monitoring) trial.

BACKGROUND: In the RadiCure study 505 catheterization procedures were 1:1 randomized to use or no use of real-time radiation monitoring. Use of the Bleeper Sv monitor resulted in a significant reduction in operator radiation exposure. METHODS: We examined the association between several baseline and procedural parameters with operator and patient radiation exposure using univariable and multivariable analysis in the 505 patients that were enrolled in RadiCure. All baseline demographic and procedure characteristics recorded were included in the univariable analysis. RESULTS: Median fluoroscopy time was 6.2 (2.5-12.5) minutes, median patient air kerma dose was 0.908 (0.602-1.636) Gray and median first operator exposure was 10 (5-22) µSv. For analysis purposes, the 505 procedures were dichotomized based on the median operator exposure (10 µSv) and median patient radiation dose (0.908 Gray). On multivariable analysis, factors associated with high (above median or >10 µSv) first operator radiation exposure included radial access (odds ratio [OR] 5.44, 95% Confidence Interval [CI] 2.88-10.76), chronic total occlusion (CTO) intervention (OR 12.78, 95% CI 4.42-43.60), real-time radiation monitoring (OR 0.42, 95% CI 0.26-0.66), and use of a radioabsorbent drape (OR 0.53, 95% CI 0.28-0.96). High patient radiation dose (above median or >0.908 Gray) was associated with body mass index>30 kg/m2 (OR 3.22, 95% CI 1.99-5.29), prior MI (OR 2.26, 95% CI 1.29-4.04), prior cerebrovascular disease (OR 0.34, 95% CI 0.15-0.75), hypertension (OR 2.40, 95% CI 1.05-5.82), prior coronary artery bypass graft surgery (OR 2.46, 95% CI 1.40-4.39) and CTO intervention (OR 12.93, 95% CI 3.28-87.31), but was not associated with real-time radiation monitoring and use of a radioabsorbent drape. CONCLUSIONS: Several clinical and procedural factors are associated with higher patient and operator radiation exposure. Real-time radiation monitoring and use of disposable radiation shields were associated with lower operator, but not patient, radiation dose. © 2015 Wiley Periodicals, Inc.

Effect of Extended-Release Niacin on Carotid Intima Media Thickness, Reactive Hyperemia, and Endothelial Progenitor Cell Mobilization: Insights From the Atherosclerosis Lesion Progression Intervention Using Niacin Extended Release in Saphenous Vein Grafts (ALPINE-SVG) Pilot Trial.

BACKGROUND: Thirty-eight patients with intermediate (30%-60% diameter stenosis) saphenous vein graft lesions were randomized to extended-release niacin (ER-niacin) or placebo for 12 months. We sought to evaluate the impact of ER-niacin on carotid intima media thickness (CIMT), endothelial function, and endothelial progenitor cell (EPC) mobilization. METHODS: Carotid B-mode ultrasound was used to image the common and internal carotid arteries, at baseline and at 12 months after enrollment. Reactive hyperemia peripheral arterial tonometry, as assessed with EndoPAT 2000 (Itamar Medical, Inc) and EPC mobilization assessed with flow cytometry, were measured at enrollment, and at 1 and 12 months. RESULTS: The baseline clinical characteristics were similar in the two study groups. High-density lipoprotein cholesterol levels tended to increase more in the ER-niacin group (5.9 ± 8.7 mg/dL vs 1.4 ± 7.1 mg/dL; P=.14). Between baseline and 12 months, right common carotid artery (0.96 ± 0.44 mm vs 0.70 ± 0.24 mm; P=.04), and left common carotid artery (0.80 ± 0.30 mm vs 0.70 ± 0.20 mm; P=.08) CIMT tended to decrease in the ER-niacin group, compared with no change in the placebo group. The change in logarithmic reactive hyperemia index between 1 month and 12 months was similar in patients receiving ER-niacin vs placebo (0.003 ± 0.12 vs -0.058 ± 0.12; P=.39), whereas EPC mobilization increased in the ER-niacin group and decreased in the placebo group (8.65 ± 28.41 vs -5.87 ± 30.23 EPC colony forming units/mL of peripheral blood; P=.02). CONCLUSIONS: ER-niacin did not have a significant impact on CIMT or endothelial function, but increased EPC mobilization.

Effect of Extended-Release Niacin on Saphenous Vein Graft Atherosclerosis: Insights from the Atherosclerosis Lesion Progression Intervention Using Niacin Extended Release in Saphenous Vein Grafts (ALPINE-SVG) Pilot Trial.

BACKGROUND: Intermediate saphenous vein graft (SVG) lesions have high rates of progression. The purpose of this study was to examine the impact of extended-release niacin (ER-niacin) vs placebo on intermediate SVG lesions. METHODS: Patients with intermediate (30%-60% diameter stenosis) SVG lesions were randomized to ER-niacin vs placebo for 12 months. Quantitative coronary angiography (QCA), intravascular ultrasonography (IVUS), and optical coherence tomography (OCT) were performed at baseline and at 12 months. The primary endpoint was change in percent atheroma volume (ΔPAV). Enrollment was planned for 138 patients for 90% power to detect ≥2.5% difference in the primary endpoint of ΔPAV, but stopped early after publication of two negative outcome trials of ER-niacin, with enrolled patients completing the 12-month trial protocol. RESULTS: Thirty-eight patients were randomized to niacin (n = 19) or placebo (n = 19), yielding power of 47% to detect the primary planned treatment effect of 2.5 ± 4.0% difference in ΔPAV. Between baseline and 12-month follow-up, no significant difference was found between study groups in ΔPAV (-1.31 ± 6.05% vs 1.05 ± 17.8%; P=.60). By OCT, the ER-niacin vs placebo group had less plaque rupture within the intermediate SVG lesion (0.0% vs 36.0%; P=.01). CONCLUSION: Administration of ER-niacin did not significantly impact intermediate SVG disease, with the notable limitation of compromised statistical power due to early termination of enrollment.

The Hybrid Approach to Intervention of Chronic Total Occlusions

The "hybrid" approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) was developed to provide guidance on optimal crossing strategy selection. Dual angiography remains the cornerstone of clinical decision making in CTO PCI. Four angiographic parameters are assessed: (a) morphology of the proximal cap (clear-cut or ambiguous); (b) occlusion length; (c) distal vessel size and presence of bifurcations beyond the distal cap; and (d) location and suitability of location and suitability of a retrograde conduit (collateral channels or bypass grafts) for retrograde access. Antegrade wire escalation is favored for short (<20 mm) occlusions, usually escalating rapidly from a soft tapered-tip polymer-jacketed guidewire to a stiff polymer-jacketed or tapered-tip guidewire. Antegrade dissection/re-entry is favored in long (≥20 mm long) occlusions, trying to minimize the dissection length by re-entering into the distal true lumen immediately after the occlusion. Primary retrograde approach is preferred for lesions with an ambiguous proximal cap, poor distal target, good interventional collaterals, and heavy calcification,as well as chronic kidney disease. The "hybrid" approach advocates early change between strategies to enable CTO crossing in the most efficacious, efficient, and safe way. Several early studies are demonstrating high success and low complication rates with use of the "hybrid" approach, supporting its expanding use in CTO PCI.

The AngiographiC Evaluation of the Everolimus-Eluting Stent in Chronic Total Occlusion (ACE-CTO) Study.

BACKGROUND: There are limited data on outcomes after implantation of second-generation drug-eluting stents in coronary chronic total occlusions (CTOs). We aimed to evaluate the frequency of angiographic restenosis and clinical outcomes after implantation of the everolimus-eluting stent (EES) in coronary CTOs. METHODS: One hundred patients undergoing successful CTO percutaneous coronary intervention using EES at our institution between 2009 and 2012 were enrolled. The primary study endpoint was binary in-segment restenosis at 8-month follow-up quantitative coronary angiography. Secondary endpoints included death, myocardial infarction, target-lesion and target-vessel revascularization, and symptom improvement. RESULTS: Mean age was 64 ± 7 years and 99% of the patients were men. The successful crossing technique was antegrade wiring in 51 patients, antegrade dissection/reentry in 24 patients, and retrograde in 25 patients. Binary angiographic restenosis occurred in 46% of the patients (95% confidence interval [CI], 35%-57%). The pattern of restenosis was focal, proliferative, and total occlusion in 19 lesions (46%), 14 lesions (34%), and 8 lesions (20%), respectively. At 12 months, the incidences of death, myocardial infarction, target-lesion revascularization, and target-vessel revascularization were 2%, 2%, 37%, and 39%, respectively. At 12 months, symptoms were improved, unchanged, or worse compared with baseline in 89 patients, 8 patients, and 1 patient, respectively (2 patients died before the 12-month follow-up). On multivariable analysis, smaller stent diameter was associated with higher risk for binary angiographic restenosis. CONCLUSION: High rates of angiographic restenosis and repeat revascularization were observed among patients receiving EES in coronary CTOs, but most had significant symptom improvement.

The Double-Blind Stick-and-Swap Technique for True Lumen Reentry After Subintimal Crossing of Coronary Chronic Total Occlusions.

Subintimal dissection and reentry techniques are widely used in chronic total occlusion (CTO) interventions; however, inability to reenter into the distal true lumen is a common cause of failure. In some patients, subintimal hematoma may develop, compressing the lumen and hindering reentry. We describe 3 CTO cases in which the distal vessel could not be visualized after subintimal crossing, in spite of attempts to decompress the subintimal hematoma. Bidirectional "blind" puncture was performed with the Stingray wire through both ports of the Stingray balloon, followed by exchange of the Stingray wire for a Pilot 200 guidewire (the "double-blind stick-and-swap" technique) achieving distal true lumen reentry.

Comparison of Iodixanol and Ioxaglate for Coronary Optical Coherence Tomography Imaging.

BACKGROUND: The impact of contrast type on coronary imaging using optical coherence tomography (OCT) has received limited study. We compared OCT imaging obtained using the non-ionic, iso-osmolar iodixanol with the ionic, low-osmolar ioxaglate. METHODS: Twenty-two vessels in 20 patients were imaged twice using manual injection of iodixanol and ioxaglate in random order. OCT images were analyzed at 1 mm intervals to determine lumen area, artifact diameter and area, as well as stent strut coverage and malapposition in OCT pullbacks that included stents. RESULTS: There were no complications related to OCT imaging or to contrast administration. A total of 2184 cross-sections (1092 with iodixanol and 1092 with ioxaglate) were analyzed. Compared with iodixanol, imaging using ioxaglate provided similar mean lumen area (6.21 ± 2.83 mm2 vs 6.27 ± 2.83 mm2; Spearman's rho, 0.982), mean minimum lumen diameter (2.47 ± 0.59 mm vs 2.50 ± 0.58 mm; Spearman's rho, 0.939), and mean maximum lumen diameter (2.99 ± 0.71 mm vs 3.01 ± 0.70 mm; Spearman's rho, 0.964), but lower mean artifact area per cross-section (0.099 ± 0.325 mm2 vs 0.068 ± 0.329 mm2; P<.001). Analyses of 3303 stent struts in 388 cross-sections (194 with iodixanol and 194 with ioxaglate) demonstrated similar strut malapposition rates (11.82% vs 13.90%; P=.10) and strut coverage (41.92% vs 40.33%; P=.35). CONCLUSIONS: Compared with iodixanol, OCT imaging using ioxaglate provided similar lumen and diameter measurements and stent strut characterization, but smaller area of artifact.

Impact of a Disposable Sterile Radiation Shield on Operator Radiation Exposure During Percutaneous Coronary Intervention of Chronic Total Occlusions.

BACKGROUND: Daily radiation exposure over many years can adversely impact the health of medical professionals. METHODS: Operator radiation exposure was recorded for 124 percutaneous coronary interventions (PCIs) performed at our institution between August 2011 and May 2013: 69 were chronic total occlusion (CTO)-PCIs and 55 were non-CTO PCIs. A disposable radiation protection sterile drape (Radpad; Worldwide Innovations & Technologies, Inc) was used in all CTO-PCI cases vs none of the non-CTO PCI cases. Operator radiation exposure was compared between CTO and non-CTO PCIs. RESULTS: Mean age was 64.6 ± 6.2 years and 99.2% of the patients were men. Compared with non-CTO PCI, patients undergoing CTO-PCI were more likely to have congestive heart failure, to be current smokers, and to have longer lesions, and less likely to have prior PCI and a saphenous vein graft target lesion. CTO-PCI cases had longer procedural time (median: 123 minutes [IQR, 85-192 minutes] vs 27 minutes [IQR, 20-44 minutes]; P<.001), fluoroscopy time (35 minutes [IQR, 19-54 minutes] vs 8 minutes [IQR, 5-16 minutes]; P<.001), number of stents placed (2.4 ± 1.5 vs 1.7 ± 0.9; P<.001), and patient air kerma radiation exposure (3.92 Gray [IQR, 2.48-5.86 Gray] vs 1.22 Gray [IQR, 0.74-1.90 Gray]; P<.001), as well as dose area product (267 Gray•cm² [IQR, 163-4.25 Gray•cm²] vs 84 Gray•cm² [IQR, 48-138 Gray•cm²]; P<.001). In spite of higher patient radiation exposure, operator radiation exposure was similar between the two groups (20 µSv [IQR, 9.5-31 µSv] vs 15 µSv [IQR, 7-23 µSv]; P=.07). CONCLUSIONS: Operator radiation exposure during CTO-PCI can be reduced to levels similar to less complicated cases with the use of a disposable sterile radiation protection shield.

Systematic Review of the BridgePoint System for Crossing Coronary and Peripheral Chronic Total Occlusions.

BACKGROUND: The BridgePoint system consists of the CrossBoss coronary catheter and Stingray CTO system (Boston Scientific) for coronary chronic total occlusions (CTOs), and the Viance crossing catheter and Enteer re-entry system (Covidien) for peripheral CTOs. METHODS: We performed a systematic review of the literature on the BridgePoint system published between October 2008 and August 2014, in accordance with the standards set forth in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: We identified a total of 20 studies: 12 studies on coronary CTOs (10 retrospective with 2 prospective case series) and 8 studies on peripheral CTOs (all retrospective). Among 320 patients undergoing coronary CTO intervention, pooled technical success and major adverse cardiac event rates were 77.1% and 3.8%, respectively. Among 175 patients undergoing peripheral CTO intervention, pooled technical success and major adverse events were 82.2% and 4.6%, respectively. Only 1 study reported long-term outcomes after use of the coronary BridgePoint system, demonstrating similar incidence of major adverse cardiac events between BridgePoint-treated and non-BridgePoint treated patients; however, the study had low power. CONCLUSIONS: The BridgePoint system is associated with high procedural success rates and low complication rates when used for crossing both coronary and peripheral CTOs.

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.

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.

Procedural failure of chronic total occlusion percutaneous coronary intervention: Insights from a multicenter US registry.

BACKGROUND: The hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly increased procedural success rates, yet some cases still fail. We sought to evaluate the causes of failure in a contemporary CTO PCI registry. METHODS: We examined 380 consecutive patients who underwent CTO-PCI at 4 high volume CTO PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, complication, and efficiency outcomes were compared between successful and failed cases. Failed cases were individually reviewed by an independent reviewer to determine the cause of failure. RESULTS: Procedural success was 91.3%. Compared with patients in whom CTO PCI was successful, those in whom CTO PCI failed had similar baseline clinical characteristics, but were more likely to have longer occlusion length, more tortuosity, more proximal cap ambiguity and blunt stump, and higher mean J-CTO scores (2.8 ± 1.1 vs. 3.5 ± 1.0, P < 0.001), and less likely to have collaterals suitable for the retrograde approach (66% vs. 45%, P = 0.021). Failure was due to a complication in 10 cases (30%). In the remaining 23 cases (70%) failure was due to inability to wire the lesion (n = 21, 4 of which were CTOs due to in-stent restenosis), or poor antegrade flow after PCI (n = 5). CONCLUSIONS: Compared with successful cases, failed CTO-PCI cases are more likely to have higher J-CTO scores, longer occlusion length, ambiguous proximal cap and no appropriate collaterals for retrograde crossing. Development of novel CTO crossing techniques is needed to further increase CTO PCI success rates.