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1.
JACC Cardiovasc Interv ; 13(4): 517-526, 2020 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-32081243

RESUMO

OBJECTIVES: The aim of this study was to examine the use of saphenous vein grafts (SVGs) for retrograde crossing during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: The use of SVGs for retrograde crossing during CTO PCI has received limited study. METHODS: A total of 1,615 retrograde CTO PCIs performed between 2012 and 2019 at 25 centers were examined. Clinical, angiographic, and technical characteristics and procedural outcomes were compared among retrograde cases via SVGs (SVG group) versus other collateral vessels (non-SVG group). RESULTS: Retrograde CTO PCI via SVGs was performed in 189 cases (12%). Patients in the SVG group were older (mean age 70 ± 9 years vs. 64 ± 10 years; p < 0.01) and had higher rates of prior myocardial infarction (62% vs. 51%; p < 0.01) and prior PCI (81% vs. 70%; p < 0.01). They were more likely to have moderate or severe calcification (81% vs. 65%; p < 0.01) and moderate or severe tortuosity (53% vs. 44%; p = 0.02) and had similar J-CTO (Multicenter CTO Registry in Japan) scores (3.2 ± 1.0 vs. 3.1 ± 1.1; p = 0.13) but higher PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores (4.7 ± 1.7 vs. 3.1 ± 1.1; p < 0.01). Technical (85% vs. 78%; p = 0.04) and procedural (81% vs. 74%; p = 0.04) success rates were higher in the SVG group, with no difference in in-hospital major adverse events (6.4% vs. 4.4%; p = 0.22). Contrast volume was lower in the SVG group (225 ml [173 to 325 ml] vs. 292 ml [202 to 400 ml]; p < 0.01). CONCLUSIONS: Use of SVGs for retrograde crossing is associated with higher rates of technical and procedural success and similar rates of in-hospital major adverse cardiac events compared with retrograde CTO PCI via other collateral vessels.

2.
Int J Cardiol ; 299: 75-80, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31301862

RESUMO

BACKGROUND: During chronic total occlusion (CTO) percutaneous coronary intervention (PCI), sometimes non-CTO lesions are also treated. METHODS: We compared the clinical and procedural characteristics and outcomes of CTO PCIs with and without concomitant treatment of a non-CTO lesion in a contemporary multicenter CTO registry. RESULTS: Of the 3598 CTO PCIs performed at 21 centers between 2012 and 2018, 814 (23%) also included PCI of at least one non-CTO lesion. Patients in whom non-CTO lesions were treated were older (65 ±â€¯10 vs. 64 ±â€¯10 years, p = 0.03), more likely to present with an acute coronary syndrome (32% vs. 23%, p < 0.01), and less likely to undergo PCI of a right coronary artery (RCA) CTO (46% vs. 58%, p < 0.01). The most common non-CTO lesion location was the left anterior descending artery (31%), followed by the circumflex (29%) and the RCA (25%).Combined non-CTO and CTO-PCI procedures had similar technical (88% vs. 87%, p = 0.33) and procedural (85% vs. 85%, p = 0.74) success and major in-hospital complication rates (3.4% vs. 2.7%, p = 0.23), but had longer procedure duration (131 [88, 201] vs. 117 [75, 179] minutes, p < 0.01), higher patient air kerma radiation dose (3.0 [1.9, 4.8] vs. 2.8 [1.5, 4.6] Gray, p < 0.01) and larger contrast volume (300 [220, 380] vs. 250 [180, 350] ml, p < 0.01). CONCLUSIONS: Combined CTO PCI with PCI of non-CTO lesions is associated with similar success and major in-hospital complication rates compared with cases in which only CTOs were treated, but requires longer procedure duration and higher radiation dose and contrast volume.

3.
Angiology ; 71(3): 274-280, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31845593

RESUMO

The impact of peripheral artery disease (PAD) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We reviewed 3999 CTO PCIs performed in 3914 patients between 2012 and 2018 at 25 centers, 14% of whom had a history of PAD. We compared the clinical and angiographic characteristics and procedural outcomes of patients with versus without history of PAD. Patients with PAD were older (67 ± 9 vs 64 ± 10 years, P < .001) and had a higher prevalence of cardiovascular risk factors. They also had more complex lesions as illustrated by higher Japanese CTO score (2.7 ± 1.2 vs 2.4 ± 1.3, P < .001). In patients with PAD, the final crossing technique was less often antegrade wire escalation (40% vs 51%, P < .001) and more often the retrograde approach (23 vs 20%, P < .001) and antegrade dissection/reentry (20% vs 16%, P < .001). Technical success was similar between the 2 study groups (84% vs 87%, P = .127), but procedural success was lower for patients with PAD (81% vs 85%, P = .015). The incidence of in-hospital major adverse cardiac events was higher among patients with PAD (3% vs 2%, P = .046). In conclusion, patients with PAD undergoing CTO PCI have more comorbidities, more complex lesions, and lower procedural success.


Assuntos
Angiografia Coronária , Oclusão Coronária/terapia , Intervenção Coronária Percutânea , Doença Arterial Periférica/cirurgia , Adulto , Idoso , Doença Crônica , Angiografia Coronária/métodos , Oclusão Coronária/complicações , Oclusão Coronária/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/métodos , Doença Arterial Periférica/complicações , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
4.
Artigo em Inglês | MEDLINE | ID: mdl-31797507

RESUMO

BACKGROUND: When crossing into the distal true lumen fails during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification (SPM) is often performed to restore antegrade flow and facilitate subsequent lesion recanalization. METHODS: Between January 2012 and May 4, 2019, 4,659 CTO PCIs were included in the PROGRESS-CTO registry, of which 935 (20%) had a prior unsuccessful attempt. Of those 935 patients, 119 (13%) had prior SPM. We analyzed the outcomes of the 58 SPM procedures for which data were available, as well as the outcomes of the 60 subsequent CTO PCI attempts. RESULTS: Mean patient age was 67 ± 9 years and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%) diabetes (48%), prior PCI (61%), and prior coronary artery bypass graft surgery (47%). The target CTO lesions often had proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J-CTO score (mean 3.2 ± 1.1). The technical and procedural success of subsequent CTO PCI were high (83% for both) with an acceptable rate of in-hospital major adverse cardiovascular events (3.3%). Technical and procedural success were higher for repeat attempts that were performed ≥60 days after the index CTO PCI (94% vs. 69%, p = .015). Median (interquartile range) subsequent procedure time was 147 (100, 215) min, contrast volume was 185 (150, 260) ml, and air kerma radiation dose was 2.5 (1.4, 4.2) Gray. CONCLUSION: Repeat CTO PCI attempts after SPM are associated with high likelihood for successful revascularization with acceptable risks.

6.
J Invasive Cardiol ; 31(7): E220-E225, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31257217

RESUMO

BACKGROUND: Left main coronary artery (LMCA) chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We reviewed 4436 CTO-PCIs performed in 4340 patients between 2012 and 2018 at 25 sites. LMCA-CTO-PCI was performed in 20 cases (0.45%). We examined the clinical and angiographic characteristics and procedural outcomes of these cases. RESULTS: Mean patient age was 68 ± 11 years and 65% were men. Most patients (85%) had undergone prior coronary artery bypass graft surgery and had a protected left main. Mean J-CTO score was 2.7 ± 1.3, mean PROGRESS-CTO score was 1.3 ± 1.1, and mean PROGRESS-CTO Complications score was 3.8 ± 1.9. Antegrade-wire escalation was the most common successful crossing strategy (50%), followed by retrograde crossing (30%) and antegrade dissection/re-entry (10%). Technical and procedural success rates were both 85%. One patient with failed LMCA-CTO-PCI had periprocedural myocardial infarction. Median procedure time was 178 minutes (interquartile range [IQR], 123-250 minutes), median contrast volume was 190 mL (IQR, 133-339 mL), and patient air kerma radiation dose was 2.6 Gray (IQR, 1.3-3.9 Gray). CONCLUSIONS: LMCA-CTO-PCI is infrequent, is performed mostly in patients with prior coronary artery bypass graft surgery, and is associated with good procedural outcomes.


Assuntos
Angiografia Coronária/métodos , Oclusão Coronária/cirurgia , Vasos Coronários/cirurgia , Intervenção Coronária Percutânea/métodos , Idoso , Oclusão Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Estudos Prospectivos , Resultado do Tratamento
7.
Circ Cardiovasc Interv ; 12(3): e007338, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30871357

RESUMO

BACKGROUND: We examined the procedural outcomes of chronic total occlusions (CTO) percutaneous coronary interventions in patients with prior coronary artery bypass graft surgery (CABG). METHODS AND RESULTS: We compared the clinical, angiographic characteristics and outcomes of 3486 CTO interventions performed in patients with (n=1101) and without (n=2317) prior CABG at 21 centers. Prior CABG patients (32% of total cohort) were older (67±9 versus 63±10 years; P<0.001) and had more comorbidities and lower left ventricular ejection fraction (50% [40-58] versus 55% [45-60]; P<0.001). The CTO target vessel in prior CABG patients was the right coronary artery (56%), circumflex (26%), and left anterior descending artery (17%). The mean J-CTO (2.9±1.2 versus 2.2±1.3; P<0.001) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; 1.5±1.1 versus 1.2±1.0; P<0.001) score was higher in prior CABG patients. Retrograde (53% versus 30%, P<0.001) and antegrade dissection reentry (35% versus 28%; P<0.001) techniques were used more frequently in prior CABG patients. Prior CABG patients had lower technical (84% versus 89%; P<0.001) and procedural (82% versus 87%, P<0.001) success, but similar incidence of in-hospital major complications (3.1% versus 2.5%; P=0.287). In-hospital mortality (1% versus 0.4%; P=0.016) and coronary perforation (7.1% versus 3.1%; P<0.001) occurred more frequently in prior CABG patients, however, CABG patients had a lower incidence of pericardial tamponade (0.1% versus 1.0%; P=0.002) and pericardiocentesis (0% versus 1.3%; P<0.001). CONCLUSIONS: In a large multicenter CTO percutaneous coronary interventions registry, prior CABG patients had lower success rate but similar overall risk for complications, although mortality was higher and the incidence of tamponade was lower. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02061436.

8.
JACC Cardiovasc Interv ; 12(4): 346-358, 2019 02 25.
Artigo em Inglês | MEDLINE | ID: mdl-30784639

RESUMO

OBJECTIVES: This study examined the frequency and outcomes of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: Radial access improves the safety of PCI, but its role in CTO PCI remains controversial. METHODS: We compared the clinical, angiographic, and procedural characteristics of 3,790 CTO interventions performed between 2012 and 2018 via radial-only access (RA) (n = 747) radial-femoral access (RFA) (n = 844) and femoral-only access (n = 2,199) access at 23 centers in the United States, Europe, and Russia. RESULTS: Patients' mean age was 65 ± 10 years, and 85% were men. Transradial access (RA and RFA) was used in 42% of CTO interventions and significantly increased over time from 11% in 2012 to 67% in 2018 (p < 0.001). RA patients were younger (age 62 ± 10 years vs. 64 ± 10 years and 65 ± 10 years; p < 0.001), less likely to have undergone prior coronary artery bypass graft surgery (18% vs. 39% and 35%; p < 0.001), and less likely to have undergone prior PCI (60% vs. 63% and 66%; p = 0.005) compared with those who underwent RFA and femoral-only access PCI. RA CTO PCI lesions had lower J-CTO (Multicenter CTO Registry in Japan) (2.1 ± 1.4 vs. 2.6 ± 1.3 and 2.5 ± 1.3; p < 0.001) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) complication (2.3 ± 1.9 vs. 3.2 ± 2.0 and 3.2 ± 1.9; p < 0.001) scores. The mean sheath size was significantly smaller in the RA group (6.6 ± 0.7 vs. 7.0 ± 0.6 and 7.3 ± 0.8; p < 0.0001), although it increased with lesion complexity. Antegrade dissection re-entry (20% vs. 33% and 32%; p < 0.001) was less commonly used with RA, whereas use of retrograde techniques was highest with RFA (47%). The overall rates of technical success (89% vs. 88% vs. 86%; p = 0.061), procedural success (86% vs. 85% vs. 85%; p = 0.528), and in-hospital major complication (2.47% vs. 3.40% vs. 2.18%; p = 0.830) were similar in all 3 groups, whereas major bleeding was lower in the RA group (0.55% vs. 1.94% and 0.88%; p = 0.013). CONCLUSIONS: Transradial access is increasingly being used for CTO PCI and is associated with similar technical and procedural success and lower major bleeding rates compared with femoral-only access interventions. (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO]; NCT02061436).

9.
Am J Cardiol ; 123(9): 1422-1428, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30798947

RESUMO

There is limited data on the use of atherectomy during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We compared the clinical and procedural characteristics and outcomes of CTO PCIs performed with or without atherectomy in a contemporary multicenter CTO PCI registry. Between 2012 and 2018, 3,607 CTO PCIs were performed at 21 participating centers. Atherectomy was used in 117 (3.2%) cases: rotational atherectomy in 105 cases, orbital atherectomy in 8, and both in 4 cases. Patients in whom atherectomy was used, were older (68 ± 8 vs 64 ± 10 years, p <0.0001) and had higher Japan-chronic total occlusion score (3.0 ± 1.2 vs 2.4 ± 1.3, p <0.0001). CTO PCI cases in which atherectomy was used had similar technical (91% vs 87%, p = 0.240) and procedural (90% vs 85%, p = 0.159) success and in-hospital major adverse cardiac event (4% vs 3%, p = 0.382) rates. However, atherectomy cases were associated with higher rates of donor vessel injury (4% vs 1%, p = 0.031), tamponade requiring pericardiocentesis (2.6% vs 0.4%, p = 0.012) and more often required use of a left ventricular assist device (9% vs 5%, p = 0.031). Atherectomy cases were associated with longer procedural duration (196 [141, 247] vs 119 [76, 180] minutes, p <0.0001), and higher patient air kerma radiation dose (3.6 [2.5, 5.6] vs 2.8 [1.6, 4.7] Gray, p = 0.001). In conclusion, atherectomy is currently performed in approximately 3% of CTO PCI cases and is associated with similar technical and procedural success and overall major adverse cardiac event rates, but higher risk for donor vessel injury and tamponade.


Assuntos
Aterectomia/métodos , Oclusão Coronária/cirurgia , Vasos Coronários/cirurgia , Sistema de Registros , Idoso , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
10.
J Invasive Cardiol ; 31(5): 133-139, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30643040

RESUMO

BACKGROUND: For patients needing coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI), a planned, staged intervention has been recommended by experts. Ad hoc CTO-PCI, however, occurs in practice. METHODS: Observational, contemporary, multicenter, international registry. Our goals were to determine the frequency, characteristics, procedural techniques, and outcomes of patients who underwent ad hoc vs planned CTO-PCI. RESULTS: Among 2282 patients who underwent CTO-PCI between 2012 and 2017, 318 (14%) were ad hoc. Patients undergoing ad hoc CTO-PCI had lower J-CTO, PROGRESS CTO, and PROGRESS Complications scores. Antegrade-wire escalation was used more often in ad hoc PCI (96% vs 81%; P<.001), whereas antegrade-dissection re-entry (22% vs 32%) and retrograde approaches (14% vs 38%) were more common in planned PCI (P<.001). There was no difference in ad hoc vs planned PCI in technical (85% vs 86%) and procedural success (84% vs 84%). In-hospital major adverse cardiac events (MACE) were more common in patients who underwent planned procedures (0.6% vs 2.9%; P=.02). Multivariable analyses showed that ad hoc CTO-PCI was not associated with technical success or MACE. CONCLUSIONS: Ad hoc CTO-PCI occurs more commonly in less complex lesions and is associated with similarly high success rates as planned CTO-PCI in lower J-CTO score lesions, suggesting that ad hoc CTO-PCI may be an acceptable option for experienced hybrid operators in carefully selected cases. Complex cases, as quantified by the J-CTO score, have a higher in-hospital MACE rate and should preferably be performed following proper planning and preparation.


Assuntos
Oclusão Coronária , Serviços Médicos de Emergência , Planejamento de Assistência ao Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea , Idoso , Angiografia Coronária/métodos , Oclusão Coronária/diagnóstico , Oclusão Coronária/fisiopatologia , Oclusão Coronária/cirurgia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Sistema de Registros , Risco Ajustado/métodos , Medição de Risco/métodos , Índice de Gravidade de Doença , Tempo para o Tratamento
11.
J Invasive Cardiol ; 31(1): 27-34, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30418166

RESUMO

OBJECTIVES: The most common re-entry technique during retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is reverse controlled antegrade and retrograde tracking (rCART). The use of guide-catheter extensions can facilitate rCART, but has received limited study. METHODS: We compared the clinical and procedural characteristics and outcomes of traditional rCART vs guide-catheter extension rCART vs cases in which both techniques were used (combined rCART) in patients with successful retrograde CTO crossing in a contemporary multicenter CTO-PCI registry. RESULTS: Between 2012 and 2018, rCART was used in 467 of 1336 retrograde CTO-PCI cases. Guide-catheter extension rCART was used in 60/467 cases (13%; use increased from 0% in 2012 to 26% in 2017). The traditional rCART group, guide-catheter extension rCART group, and combined rCART group had similar target lesion J-CTO scores (3.3 ± 1.1 vs 3.2 ± 1.2 vs 3.6 ± 0.8, respectively; P=.28), technical success rates (99% vs 100% vs 96.4%, respectively; P=.36), procedural success rates (93.2% vs 93.8% vs 96.3%, respectively; P=.82), and major in-hospital adverse cardiac event (MACE) rates (6.4% vs 9.4% vs 3.6%, respectively; P=.66). Total procedural time was longer in the combined rCART group (196 min [IQR, 146-256 min] vs 200 min [IQR, 164-293 min] vs 255 min [IQR, 195-280 min], respectively; P<.01), with a trend for lower patient air kerma radiation dose in the guide-catheter extension groups (4.11 Gray [IQR, 2.49-5.77 Gray] vs 3.19 Gray [IQR, 1.29-4.74 Gray] vs 3.47 Gray [IQR, 2.89-5.56 Gray]; P=.07). CONCLUSIONS: Guide-catheter extension rCART is increasingly being used for retrograde CTO crossing and is associated with similar success and MACE rates as traditional rCART.


Assuntos
Angioplastia Coronária com Balão/métodos , Cateteres Cardíacos , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/terapia , Segurança do Paciente , Sistema de Registros , Idoso , Cateterismo Cardíaco/métodos , Doença Crônica , Estudos de Coortes , Angiografia Coronária/métodos , Feminino , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
12.
Can J Cardiol ; 34(10): 1264-1274, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30269827

RESUMO

BACKGROUND: Ostial chronic total occlusions (CTOs) can be challenging to recanalize. METHODS: We sought to examine the prevalence, angiographic presentation, and procedural outcomes of ostial (side-branch ostial and aorto-ostial) CTOs among 1000 CTO percutaneous coronary interventions (PCIs) performed in 971 patients between 2015 and 2017 at 14 centres in the US, Europe, and Russia. RESULTS: Ostial CTOs represented 16.9% of all CTO PCIs: 9.6% were aorto-ostial, and 7.3% were side-branch ostial occlusions. Compared with nonostial CTOs, ostial CTOs were longer (44 ± 33 vs 29 ± 19 mm, P < 0.001) and more likely to have proximal-cap ambiguity (55% vs 33%, P < 0.001), moderate/severe calcification (67% vs 45%, P < 0.001), a diffusely diseased distal vessel (41% vs 26%, P < 0.001), interventional collaterals (64% vs 53%, P = 0.012), and previous coronary artery bypass graft surgery (CABG) (51% vs 27%, P < 0.001). The retrograde approach was used more often in ostial CTOs (54% vs 29%, P < 0.001) and was more often the final successful crossing strategy (30% vs 18%, P = 0.003). Technical (81% vs 84%, P = 0.280), and procedural (77% vs 83%, P = 0.112) success rates and the incidence of in-hospital major complication were similar (4.8% vs 2.2%, P = 0.108), yet in-hospital mortality (3.0% vs 0.5%, P = 0.010) and stroke (1.2% vs 0.0%, P = 0.030) were higher in the ostial CTO PCI group. In multivariable analysis, ostial CTO location was not independently associated with higher risk for in-hospital major complications (adjusted odds ratio 1.27, 95% confidence intervals 0.37 to 4.51, P = 0.694). CONCLUSIONS: Ostial CTOs can be recanalized with similar rates of success as nonostial CTOs but are more complex, more likely to require retrograde crossing and may be associated with numerically higher risk for major in-hospital complications.


Assuntos
Oclusão Coronária/cirurgia , Intervenção Coronária Percutânea/estatística & dados numéricos , Sistema de Registros , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico , Oclusão Coronária/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Prevalência , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
13.
Am J Cardiol ; 122(3): 381-387, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-30201106

RESUMO

The frequency and outcomes of patients who underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of more than one CTO during the same procedure have received limited study. We compared the clinical and angiographic characteristics and procedural outcomes of patients who underwent treatment of single versus >1 CTOs during the same procedure in 20 centers from the United States, Europe, and Russia. A total of 2,955 patients were included: mean age was 65 ± 10 years and 85% were men with high prevalence of previous myocardial infarction (46%), and previous coronary artery bypass graft surgery (33%). More than one CTO lesions were attempted during the same procedure in 58 patients (2.0%) and 70% of them were located in different major epicardial arteries. Compared with patients who underwent PCI of a single CTO, those who underwent PCI of >1 CTOs during the same procedure had similar J-CTO (2.4 ± 1.3 vs 2.5 ± 1.3, p = 0.579) and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (1.5 ± 1.2 vs 1.3 ± 1.0 p = 0.147) scores. The multi-CTO PCI group had similar technical success (86% vs 87%, p = 0.633), but higher risk of in-hospital major complications (10.3% vs 2.7%, p = 0.005), and consequently numerically lower procedural success (79% vs 85%, p = 0.197). The multi-CTO PCI group had higher in-hospital mortality (5.2% vs 0.5%, p = 0.005) and stroke (5.2%vs 0.2%, p <0.001), longer procedure duration (162 [117 to 242] vs 122 [80 to 186] minutes, p <0.001) and higher radiation dose (3.6 [2.1 to 6.4] vs 2.9 [1.7 to 4.7] Gray, p = 0.033). In conclusion, staged revascularization may be the preferred approach in patients with >1 CTO lesions requiring revascularization, as treatment during a single procedure was associated with higher risk for periprocedural complications.


Assuntos
Angiografia Coronária/métodos , Oclusão Coronária/cirurgia , Intervenção Coronária Percutânea/métodos , Sistema de Registros , Idoso , Doença Crônica , Oclusão Coronária/diagnóstico , Oclusão Coronária/mortalidade , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Federação Russa/epidemiologia , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
14.
J Invasive Cardiol ; 30(11): E113-E121, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30218557

RESUMO

OBJECTIVES: The effect of chronic kidney disease (CKD) on in-hospital outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We evaluated the prevalence of CKD and its impact on CTO-PCI outcomes in 1979 patients who underwent 2040 procedures between 2012 and 2017 at 18 centers. CKD was defined as preprocedural estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². RESULTS: Compared with patients without CKD (n = 1444; 73%), patients with CKD (n = 535; 27%) had more comorbidities (hypertension, diabetes mellitus, heart failure, peripheral arterial disease, prior myocardial infarction, PCI, coronary artery bypass graft surgery, and stroke), and more severe calcification and proximal vessel tortuosity. Patients with and without CKD had similar technical success rates (84% vs 86%; P=.49) and procedural success rates (83% vs 84%; P=.44). Patients with CKD had higher in-hospital mortality rate (1.9% vs 0.3%; P<.001) and in-hospital major adverse cardiovascular event (MACE) rate (4.3% vs 2.2%; P<.01). In-hospital mortality and MACE rates increased with decreasing eGFR levels (P=.03). In multivariate analysis, an independent association was observed between CKD and in-hospital mortality (adjusted odd ratio, 4.4; 95% confidence interval, 1.2-16.0; P=.02), but not overall MACE (adjusted odds ratio, 1.4; 95% confidence interval, 0.8-2.7; P=.28). CONCLUSIONS: CKD is common among patients undergoing CTO-PCI. High success rates can be achieved in patients with decreased glomerular filtration rate, but CKD may be associated with higher in-hospital mortality.


Assuntos
Oclusão Coronária/cirurgia , Vasos Coronários/diagnóstico por imagem , Pacientes Internados , Intervenção Coronária Percutânea , Sistema de Registros , Insuficiência Renal Crônica/complicações , Idoso , Angiografia Coronária , Oclusão Coronária/complicações , Oclusão Coronária/mortalidade , Europa (Continente)/epidemiologia , Feminino , Taxa de Filtração Glomerular , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Insuficiência Renal Crônica/epidemiologia , Federação Russa/epidemiologia , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
15.
JACC Cardiovasc Interv ; 11(14): 1325-1335, 2018 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-29706508

RESUMO

OBJECTIVES: The aim of this study was to determine the techniques and outcomes of hybrid chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a diverse group of patients and operators on 2 continents. BACKGROUND: CTO PCI has been evolving with constant improvement of equipment and techniques. METHODS: Contemporary outcomes of CTO PCI were examined by analyzing the clinical, angiographic, and procedural characteristics of 3,122 CTO interventions performed in 3,055 patients at 20 centers in the United States, Europe, and Russia. RESULTS: The mean age was 65 ± 10 years, and 85% of the patients were men, with high prevalence of diabetes (43%), prior myocardial infarction (46%), prior coronary artery bypass graft surgery (33%), and prior PCI (65%). The CTO target vessels were the right coronary artery (55%), left anterior descending coronary artery (24%), and left circumflex coronary artery (20%). The mean J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores were 2.4 ± 1.3 and 1.3 ± 1.0, respectively. The overall technical and procedural success rate was 87% and 85%, respectively, and the rate of in-hospital major complications was 3.0%. The final successful crossing strategy was antegrade wire escalation in 52.0%, retrograde in 27.1%, and antegrade dissection re-entry in 20.9%; >1 crossing strategy was required in 40.9%. Median contrast volume, air kerma radiation dose, and procedure and fluoroscopy time were 270 ml (interquartile range: 200 to 360 ml), 2.9 Gy (interquartile range: 1.7 to 4.7 Gy), 123 min (interquartile range: 81 to 188 min) and 47 min (interquartile range: 29 to 77 min), respectively. CONCLUSIONS: CTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the United States, Europe, and Russia. (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO]; NCT02061436).


Assuntos
Oclusão Coronária/terapia , Intervenção Coronária Percutânea/métodos , Idoso , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Prevalência , Radiografia Intervencionista , Sistema de Registros , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
16.
Catheter Cardiovasc Interv ; 91(4): 657-666, 2018 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-29359452

RESUMO

BACKGROUND: The prevalence, treatment and outcomes of balloon undilatable chronic total occlusions (CTOs) have received limited study. METHODS: We examined the prevalence, clinical and angiographic characteristics, and procedural outcomes of percutaneous coronary interventions (PCIs) for balloon undilatable CTOs in a contemporary multicenter US registry. RESULTS: Between 2012 and 2017 data on balloon undilatable lesions were available for 425 consecutive CTO PCIs in 415 patients in whom guidewire crossing was successful: 52 of 425 CTOs were balloon undilatable (12%). Mean patient age was 65 ± 10 years and most patients were men (84%). Patients with balloon undilatable CTOs were more likely to be diabetic (67 vs. 41%, P < 0.001) and have heart failure (44 vs. 28%, P = 0.027). Balloon undilatable CTOs were longer (40 mm [interquartile range, IQR 20-50] vs. 30 [IQR 15-40], P = 0.016), more likely to have moderate/severe calcification (87 vs. 54%, P < 0.001), and had higher J-CTO score (3.2 ± 1.1 vs. 2.5 ± 1.3, P < 0.001) and PROGRESS-CTO complications score (3.9 ± 1.7 vs. 3.1 ± 2.0, P < 0.005). They were associated with lower technical and procedural success (92 vs. 98%, P = 0.024; and 88 vs. 96%, P = 0.034, respectively) and higher risk for in-hospital major adverse events (8 vs. 2%, P = 0.008) due to higher perforation rates. The most frequent treatments for balloon undilatable CTOs were high pressure balloon inflations (64%), rotational atherectomy (31%), laser (21%), and cutting balloons (15%). CONCLUSIONS: Balloon undilatable CTOs are common and are associated with lower success and higher complication rates.


Assuntos
Angioplastia Coronária com Balão , Oclusão Coronária/cirurgia , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Sistema de Registros , Fatores de Risco , Tomografia de Coerência Óptica , Falha de Tratamento , Estados Unidos/epidemiologia
17.
J Invasive Cardiol ; 30(3): 89-96, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29138364

RESUMO

BACKGROUND: Retrograde percutaneous coronary intervention (PCI) of native coronary artery chronic total occlusion (CTO) via left internal mammary artery (LIMA) graft has received limited study. METHODS AND RESULTS: We compared the clinical and procedural characteristics and outcomes of retrograde CTO-PCI through LIMA grafts vs other conduits in a contemporary multicenter CTO registry. The LIMA was used as the collateral channel in 20 of 990 retrograde CTO-PCIs (2.02%) performed at 18 United States centers. The mean age of the study patients was 69 ± 7 years and 95% were men. The most common CTO target vessel was the right coronary artery (55%). The mean J-CTO score in the LIMA group was high (3.45 ± 0.76). The technical success rates were 70% for retrograde PCI via LIMA graft vs 81.05% for retrograde via other conduits (P=.25), while procedural success rates were 70% for retrograde PCI via LIMA graft and 78.19% for retrograde via other conduits (P=.41). The incidence of major in-hospital complications was also similar between the LIMA and non-LIMA retrograde groups (5% vs 6%; P>.99). Use of guide-catheter extensions (40% vs 28%; P=.22), intravascular ultrasound (45% vs 31%; P=.20), and left ventricular assist devices (24% vs 10%; P=.08) was numerically higher in retrograde CTO-PCIs via LIMA grafts. CONCLUSIONS: Retrograde CTO-PCI is infrequently performed via LIMA grafts and is associated with similar success and major in-hospital complication rates as retrograde CTO-PCI performed via other conduits.


Assuntos
Vasos Coronários/cirurgia , Artéria Torácica Interna/cirurgia , Intervenção Coronária Percutânea , Idoso , Doença Crônica , Angiografia Coronária/métodos , Oclusão Coronária/diagnóstico , Oclusão Coronária/epidemiologia , Oclusão Coronária/fisiopatologia , Oclusão Coronária/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Sistema de Registros/estatística & dados numéricos , Índice de Gravidade de Doença , Estados Unidos/epidemiologia
18.
Catheter Cardiovasc Interv ; 91(2): 175-179, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29193753

RESUMO

OBJECTIVES: The aim of the Hybrid Video Registry (HVR) is to assess the acute safety and efficacy of the Hybrid Approach in comparison to other contemporary methods of CTO-PCI. BACKGROUND: Recently, multiple techniques in Percutaneous Coronary Intervention (PCI) for coronary Chronic Total Occlusions (CTO) have been synthesized into a method referred to as the "Hybrid Approach". METHODS: About 194 video-taped timed live cases from CTO-PCI training workshops were analyzed by independent data abstractors and compared to three contemporary CTO-PCI registries stratified by case complexity based on the J-CTO score. RESULTS: Overall procedural success was 95% of all cases attempted with an excellent safety profile. In the most complex lesion subset, which made up 45% of all HVR cases, success was 92.8%, which was significantly higher than either the Royal Bromptom (78.9%), or Japanese-CTO (73.3%) registries, P = 0.04 Hybrid vs. Royal Brompton, P = 0.006 Hybrid vs. Japanese-CTO). The Hybrid Approach was also associated with shorter procedure times and lower contrast utilization. CONCLUSIONS: In a real world angiographic registry of complex CTOs, the Hybrid Approach to CTO-PCI is safe, and may be superior to other contemporary approaches to CTO intervention with respect to procedural success and efficiency among a diverse group of operators and lesion complexity. © 2017 Wiley Periodicals, Inc.


Assuntos
Oclusão Coronária/cirurgia , Intervenção Coronária Percutânea/métodos , Gravação em Vídeo , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/fisiopatologia , Humanos , Japão , Duração da Cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/etiologia , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Reino Unido , Estados Unidos
19.
Am J Cardiol ; 120(8): 1285-1292, 2017 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-28826896

RESUMO

Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.


Assuntos
Oclusão Coronária/cirurgia , Vasos Coronários/lesões , Complicações Intraoperatórias , Intervenção Coronária Percutânea/efeitos adversos , Sistema de Registros , Lesões do Sistema Vascular/epidemiologia , Idoso , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Feminino , Humanos , Incidência , Japão/epidemiologia , Masculino , Razão de Chances , Fatores de Risco , Ruptura , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/terapia
20.
Can J Cardiol ; 33(4): 478-484, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28169091

RESUMO

BACKGROUND: High patient radiation dose during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) might lead to procedural failure and radiation skin injury. METHODS: We examined the association between several clinical and angiographic variables on patient air kerma (AK) radiation dose among 748 consecutive CTO PCIs performed at 9 experienced US centres between May 2012 and May 2015. RESULTS: The mean age was 65 ± 10 years, 87% of patients were men, and 35% had previous coronary artery bypass graft surgery (CABG). Technical and procedural success was 92% and 90%, respectively. The median patient AK dose was 3.40 (interquartile range, 2.00-5.40) Gy and 34% of the patients received > 4.8 Gy (high radiation exposure). In univariable analysis male sex (P = 0.016), high body mass index (P < 0.001), history of hyperlipidemia (P = 0.023), previous CABG (P < 0.001), moderate or severe calcification (P < 0.001), tortuosity (P < 0.001), proximal cap ambiguity (P = 0.001), distal cap at a bifurcation (P = 0.006), longer CTO occlusion length (P < 0.001), blunt/no blunt stump (P < 0.001), and centre (P < 0.001) were associated with higher patient AK dose. In multivariable analysis high body mass index (P < 0.001), previous CABG (P = 0.005), moderate or severe calcification (P = 0.005), longer CTO occlusion length (P < 0.001), and centre (P < 0.001) were independently associated with higher patient AK dose. CONCLUSIONS: Approximately 1 in 3 patients who undergo CTO PCI receive high AK radiation dose (> 4.8 Gy). Several baseline clinical and angiographic characteristics can help predict the likelihood of high radiation dose and assist with intensifying efforts to reduce radiation exposure for the patient and the operator.


Assuntos
Angiografia Coronária/efeitos adversos , Oclusão Coronária/cirurgia , Intervenção Coronária Percutânea/métodos , Exposição à Radiação/efeitos adversos , Lesões por Radiação/diagnóstico , Sistema de Registros , Idoso , Doença Crônica , Oclusão Coronária/diagnóstico , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Lesões por Radiação/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
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