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The treatment of chronic total coronary occlusions (CTO) carries the highest radiation exposure among percutaneous coronary interventions (PCI). In order to minimize radiation damage, we need to understand and optimize the contribution of all components of radiation exposure.A total of 1000 CTO procedures performed between 2011 and 2020 were compared according to implemented radiation modifications. Group 1 used the original set-up of the X-ray equipment (Artis Zee, Siemens). In group 2 a modified protocol aimed at reducing the fluoroscopy exposure, in group 3 further modifications aimed at reducing cineangiographic exposure.Despite an increased lesion complexity, Air Kerma (AK) was reduced from 2619 mGy (1653-4574) in group 1 to 2178 mGy (1332-3500; p0.001) in group 2 by mainly reducing fluoroscopic contribution by 54.1%, the cineangiographic contribution was lowered by only 6.6%. In group 3 AK dropped drastically to 746 mGy (480-1225; p0.001) mainly by reducing the cineangiographic contribution by 53.4%, still there was a further reduction of fluoroscopy contribution of 8.2%. This also led to a reduction of the skin entry dose from 1038 mGy (690-1589) in group 2 to 359 mGy (204-591; p0.001) in group 3. This was achieved both in normal weight and obese patients, and both in antegrade and retrograde procedures.The present study demonstrates that by modifying both the fluoroscopic and cineangiographic contribution to radiation exposure a drastic reduction of radiation risk can be achieved, even in obese patients. Currently accepted radiation thresholds may no longer be a limit for CTO PCI.

Gender-specific data addressing percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) in female patients are scarce and based on small sample size studies.We aimed to analyze gender-differences regarding in-hospital clinical outcomes after CTO-PCI.Data from 35,449 patients enrolled in the prospective European Registry of CTOs were analyzed. The primary outcome was the comparison of procedural success rate in the two cohorts (women vs. men), defined as a final residual stenosis less than 20%, with Thrombolysis In Myocardial Infarction grade flow = 3. In-hospital major adverse cardiac and cerebrovascular events (MACCEs) and procedural complications were deemed secondary outcomes.Women represented 15.2% of the entire study population. They were older and more likely to have hypertension, diabetes, and renal failure, with an overall lower J-CTO score. Women showed a higher procedural success rate (adjusted OR [aOR] = 1.115, confidence interval [CI]: 1.011-1.230, p = 0.030). Apart from previous myocardial infarction and surgical revascularization, no other significant gender differences were found among predictors of procedural success. Antegrade approach with true-to-true lumen techniques was more commonly used than retrograde approach in females. No gender differences were found regarding in-hospital MACCEs (0.9% vs. 0.9%, p = 0.766), although a higher rate of procedural complications was observed in women, such as coronary perforation (3.7% vs. 2.9%, p < 0.001) and vascular complications (1.0% vs. 0.6%, p < 0.001).Women are understudied in contemporary CTO-PCI practice. Female sex is associated with higher procedural success after CTO-PCI, yet no sex differences were found in terms of in-hospital MACCEs. Female sex was associated with a higher rate of procedural complications.

Background There is an increasing incidence of chronic total coronary occlusions (CTO). CTO are complex coronary lesions and known to represent a technical challenge for percutaneous recanalization procedures. However, the success rates of CTO- percutaneous coronary interventions (CTO-PCI) have increased tremendously with the continuous innovations in equipment and procedural techniques. Circular heavily calcified “Full Moon”- like plaques have been observed in CTO patients, however their frequency and relevance for CTO-PCI outcomes remain unclear, despite they can be straightforward identified by Coronary Computed Tomographic Angiography (CCTA) during CT-scans to select the CTO-PCI recanalization strategy. Purpose The aim of this study was to investigate the clinical value of CCTA – derived “Full Moon”-like plaques and to analyze its impact on percutaneous CTO recanalization. Methods and Results Out of the Charité CTO-PCI registry a total of 29 consecutive patients undergoing CTO-PCI and upstream CCTA-imaging for CTO planning were enrolled into the entire analysis. One patient was excluded due to stent artefacts with insufficient CCTA quality. Within the study cohort 17.9% (n=5) presented a “Full Moon”-like stenosis as CTO-causing target lesion. During CTO-PCI all these lesions (100%) required extensive debulking techniques as rotablation or ultrasound lithoplasty due to difficulties in device crossing compared to 13% (n=3) lesions in the non “Full Moon” group (p In detail, 40% of lesions in the “Full Moon” group had to be prepared by rotablation-therapy (compared to 0% in the non- “Full Moon” group; p Conclusions : “Full Moon”- like calcification derived by CCTA represents a frequently observed phenomenon in CTO and represents an important predictor for complexity during CTO-PCI. Coronary Computed Tomography can be used to identify such a marker of calcium complexity and therefore to plan the procedure in advance.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can improve patient symptoms, but it remains controversial whether it impacts subsequent clinical outcomes.In this systematic review and meta-analysis, we queried PubMed, ScienceDirect, Cochrane Library, Web of Science, and Embase databases (last search: September 15, 2021). We investigated the impact of CTO-PCI on clinical events including all-cause mortality, cardiovascular death, myocardial infarction (MI), major adverse cardiovascular event (MACE), stroke, subsequent coronary artery bypass surgery, target-vessel revascularization, and heart failure hospitalizations. Pooled analysis was performed using a random-effects model.A total of 58 publications with 54,540 patients were included in this analysis, of which 33 were observational studies of successful vs failed CTO-PCI, 19 were observational studies of CTO-PCI vs no CTO-PCI, and 6 were randomized controlled trials (RCTs). In observational studies, but not RCTs, CTO-PCI was associated with better clinical outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause mortality, MACE, and MI were 0.52 (95% CI, 0.42-0.64), 0.46 (95% CI, 0.37-0.58), 0.66 (95% CI, 0.50-0.86), respectively for successful vs failed CTO-PCI studies; 0.38 (95% CI, 0.31-0.45), 0.57 (95% CI, 0.42-0.78), 0.65 (95% CI, 0.42-0.99), respectively, for observational studies of CTO-PCI vs no CTO-PCI; 0.72 (95% CI, 0.39-1.32), 0.69 (95% CI, 0.38-1.25), and 1.04 (95% CI, 0.46-2.37), respectively for RCTs.CTO-PCI is associated with better subsequent clinical outcomes in observational studies but not in RCTs. Appropriately powered RCTs are needed to conclusively determine the impact of CTO-PCI on clinical outcomes.

Die perkutane Koronarintervention (PCI) von chronischen Koronarverschlussen (CTO-PCI) hat sich in der letzten Dekade stetig weiterentwickelt und geht mittlerweile mit Erfolgsraten von uber 85 % einher. Die Ausbildung zum selbststandigen CTO-Operateur dauert oft mehrere Jahre und Bedarf neben institutionellen Voraussetzungen eines hohen Eigenengagements zur standigen Weiterbildung. Randomisierte Daten konnten zwar eine symptomatische Verbesserung, aber bisher keine Mortalitatssenkung nach erfolgreicher Koronarintervention zeigen. Umso entscheidender ist die richtige Patientenauswahl verbunden mit einer niedrigen periinterventionellen Komplikationsrate. Um dies zu gewahrleisten, hat sich die Deutsche Gesellschaft fur Kardiologie (DKG) entschieden, ein Positionspapier fur alle in Praxen und Krankenhausern tatigen Kardiologen, insbesondere aber auch fur alle interventionellen Kardiologen zu verfassen. Zielfuhrend erscheint eine bundesweite Etablierung von spezialisierten CTO-Zentren. Nur dadurch konnen diese hochkomplexen Prozeduren dem Patienten gegenuber mit einem niedrigen und somit vertretbaren Risiko angeboten werden.

Antegrade wire crossing of a mid calcified left anterior descending (LAD) artery was achieved. However, the wire was seen deflecting in a different pathway than the angiographically anticipated course of the vessel. Therefore, the computed tomography images were reanalyzed and the wire was seen to be within the tented site of the left internal mammary artery to the LAD anastomosis and correctly positioned according to the vessel course.

Assessment of collateral physiology in chronic total occlusions (CTO) currently requires dedicated devices, adds complexity, and increases the cost of the intervention. This study sought to derive collateral physiology from flow velocity changes (∆V) in donor arteries, calculated with artificial intelligence-aided angiography.Angiographies with successful percutaneous coronary intervention (PCI) in 2 centers were retrospectively analyzed. CTO collaterals were angiographically evaluated according to Rentrop and collateral connections (CC) classifications. Flow velocities in the primary and secondary collateral donor arteries (PCDA, SCDA) were automatically computed pre and post percutaneous coronary intervention (PCI), based on a novel deep-learning model to extract the length/time curve of the coronary filling in angiography. Parameters of collateral physiology, ∆collateral-flow (∆fcoll) and ∆collateral-flow-index (∆CFI), were derived from the ∆V pre-post.The analysis was feasible in 105 out of 130 patients. Flow velocity in the PCDA significantly decreased after CTO-PCI, proportionally to the angiographic collateral grading (Rentrop 1: 0.02 ± 0.01 m/s; Rentrop 2: 0.04 ± 0.01 m/s; Rentrop 3: 0.07 ± 0.02; p0.001; CC0: 0.01 ± 0.01 m/s; CC1: 0.04 ± 0.02 m/s; CC2: 0.06 ± 0.02 m/s; p0.001). ∆fcoll and ∆CFI paralleled ∆V. SCDA also showed a greater reduction in flow velocity if its collateral channels were CC1 vs. CC0 (0.03 ± 0.01 vs. 0.01 ± 0.01 m/s; p0.001). For each individual patient, ∆V was more pronounced in the PCDA than in the SCDA.Automatic assessment of collateral physiology in CTO is feasible, based on a deep-learning model analyzing the filling of the donor vessels in angiography. The changes in collateral flow with this novel method are quantitatively proportional to the angiographic grading of the collaterals.

Severe coronary calcification is a common cause for stent under-expansion, which is associated with an increased risk of stent thrombosis and restenosis. Presently the devices for treatment of under-expanded stent due to severe calcification are rotational atherectomy and high-pressure non-compliant balloons with the limitation of potential balloon rupture and perforation risk. We report on a series of seven successful treatments of chronically under-expanded stents due to severe calcification using shockwave coronary intravascular lithoplasty (IVL). Our report suggests that IVL is a feasible and safe tool for such chronically under-expanded stents.

The few randomized controlled trials (RCTs) on chronic total occlusion (CTO) percutaneous coronary intervention (PCI) are subject to selection bias.The purpose of this study was to evaluate the differences between real-world CTO patients and those enrolled in RCTs.This study performed a meta-analysis of national and dedicated CTO PCI registries and compared patient characteristics and outcomes with those of RCTs that randomized patients to CTO PCI versus medical therapy. Given the large sample size differences between RCTs and registries, the study focused on the absolute numbers and their clinical significance. The study considered a 5% relative difference between groups to be potentially clinically relevant.From 2012 to 2022, 6 RCTs compared CTO PCI versus medical therapy (n = 1,047) and were compared with 15 registries (5 national and 10 dedicated CTO PCI registries). Compared with registry patients, RCT patients had fewer comorbidities, including diabetes, hypertension, previous myocardial infarction, and prior coronary artery bypass graft surgery. RCT patients had shorter CTO length (29.6 ± 19.7 mm vs 32.6 ± 23.0 mm, a relative difference of 9.2%) and lower Japan-Chronic Total Occlusion Score scores (2.0 ± 1.1 vs 2.3 ± 1.2, a relative difference of 13%) compared with those enrolled in dedicated CTO registries. Procedural success was similar between RCTs (84.5%) and dedicated CTO registries (81.4%) but was lower in national registries (63.9%).There is a paucity of randomized data on CTO PCI outcomes (6 RCTs, n = 1,047). These patients have lower risk profiles and less complex CTOs than those in real-world registries. Current evidence from RCTs may not be representative of real-world patients and should be interpreted within its limitation.

To evaluate the feasibility of a new acquisition protocol to reduce radiation exposure.Percutaneous coronary interventions (PCI) for chronic total coronary occlusions (CTO) are characterized by the highest radiation exposure among PCI procedures.We analyzed 552 consecutive CTO procedures between January 2018 and October 2019. After 366 procedures (Group 1) a modified radiation acquisition protocol was implemented for the subsequent 186 procedures (Group 2). Besides a low fluoroscopy frame rate of 6/s and cine frame rate of 7.5/s for both groups, additional modifications consisted of increased copper filtering with lower entry dose in combination with a modified image postprocessing. Radiation exposure was assessed as air kerma (AK; mGy), and dose-area product (DAP; cGy*cmThere was no significant difference in lesion or procedural complexity between the study groups with 46 and 43% of the procedures done via the retrograde approach. While fluoroscopy time remained similar (median: 32.7 vs. 34.3 min), the protocol modifications resulted in a drastic reduction of AK by 68% from 2,040 (1,321-3,339) mGy to 655 (415-1,113) mGy (p .001) without affecting the procedural success rate. DAP was equally decreased by 71%. These considerable reductions were observed even in obese patients of BMI 30. In Group 2, not a single procedure exceeded the 5 Gy threshold as compared to 10.4% in Group 1.Radiation exposure decreased considerably with a new acquisition protocol without affecting procedure duration and success. These modifications were applicable also to patients with a high BMI.

Aims: We sought to compare the efficiency of the novel EuroCTO (CASTLE) score with the commonly used Multicentre CTO registry in Japan (J-CTO) score in predicting procedural success of percutaneous recanalization (PCI) for coronary chronic total occlusions (CTOs). Methods and results: We evaluated 660 consecutive CTO PCIs (mean age: 66±11 years, 84% male). The mean J-CTO and EuroCTO (CASTLE) scores were 1.86 ± 1.2 and 1.74 ± 1.2, respectively. Antegrade wire escalation, antegrade dissection re-entry and retrograde approach were used in 82%, 14% and 37% of cases, respectively. Receiver-operator characteristic analysis demonstrated equal overall discriminatory capacity between the two scores (AUC: 0.698, 95%CI: 0.653-0.742 p

Background Recent improvement in clinical skills, technology and hardware has resulted in improved success rates with chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We performed a study level pooled analysis from the five largest registries of percutaneous coronary intervention (PCI) of CTO. Research design and methods We conducted pooled analysis of 9500 patients in registries and data on procedural characteristics, technical success, and MACCE was collected. Results A total of 9500 patients were included in the analysis. Mean age was 65.4 years with previous CABG in 24.8%, reattempt procedure in 24.8% and mean JCTO score was 2.2. Final wiring strategy in hybrid algorithm-based registries was AWE in 40.8-58%, Retrograde in 24-35%, ADR in 16-25% and in Expert JCTO and EURO CTO was AWE in 72-75% and retrograde in 25-28%. Technical success was achieved in 87.8%. In hospital MACCE was 2.5 % (95% CI: 1.8 to 3.4%), mortality 0.44% (95% CI: 0.23 to 0.84%), stroke 0.2% (95% CI: 0.1 to 0.3%); myocardial infraction 1.6% (95% CI: 1.1 to 2.2%); and cardiac tamponade 0.8% (95% CI: 0.5 to 1.3 %). Conclusion CTO PCI is currently performed with high technical success rates and low complication rates in experienced hands utilizing various techniques.

The aim of this study was to identify independent predictors of procedural success after retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI).Retrograde CTO PCI is an established technique, but predictors of success remain poorly understood.A multivariable logistic regression model was used to analyze potentially important demographic, clinical, anatomical, and technical aspects of retrograde CTO PCI cases uploaded to the multicenter European CTO (ERCTO) Club Registry.In calendar years 2018 and 2019, 2,364 retrograde CTO PCI cases constituted the primary analysis cohort. A primary retrograde strategy was used in 1,953 cases (82.6%), and an initial antegrade approach was converted to retrograde in 411 cases (17.4%). Procedural success was achieved in 1,820 cases (77.0%) and was more likely to occur after a primary retrograde attempt versus conversion from an initial antegrade approach (80.9% vs 58.4%; P 0.0001). After multivariable analysis, an absence of lesion calcification (OR: 1.86; 95% CI: 1.37-2.51; P 0.0001), a higher degree of distal vessel opacification (OR: 2.47; 95% CI: 1.72-3.55; P 0.0001), little or no proximal target vessel tortuosity (OR: 1.84; 95% CI: 1.28-2.64; P = 0.001), Werner collateral connection CC1 (OR: 4.87; 95% CI: 2.90-8.19; P 0.0001) or CC2 (OR: 5.33; 95% CI: 3.02-9.42; P 0.0001), and the top tertile of operator volume (120 cases over 2 years) (OR: 1.88; 95% CI: 1.26-2.79; P = 0.002) were associated with the greatest chance of achieving angiographic success.Less calcification with good distal vessel opacification, little or absent proximal vessel tortuosity, and visible collateral connections, along with high-volume operator status, were all independently predictive of angiographically successful retrograde CTO PCI.

Purpose This analysis of a consecutive series of bioresorbable vascular scaffolds (BVS) implanted for complex chronic total occlusions (CTOs) was done to evaluate the potential of this device to avoid a permanent full metal jacket with drug-eluting stents. Patients We analyzed 52 young patients (50.8 ± 8.3 years) for the BVS group, and additionally we followed a subgroup of 17 patients where DES were combined with BVS mainly because severe calcification at the lesion site (hybrid group). Results BVS were successfully implanted in 69 of 70 patients. An average of 3.17 BVS were used per lesion in the BVS group, with a CTO length of 28 ± 20 mm, and a reference diameter of 2.92 ± 0.34 mm, 69% were J-CTO ≥ 2. The retrograde approach was used in 38%. The device length was 79 ± 25 mm with 3.65 ± 0.34 mm final balloon diameter. In the hybrid group BVS was used to cover the distal segment beyond the actual occlusion predominantly in LAD lesions. Patients were discharged with dual antiplatelet therapy prescribed for 12 months. At 12 months, no patient had died or experienced an acute myocardial infarction. Angiography or MSCT follow-up available in 67% showed no reocclusion within 12 months. The target revascularization was 7% at 12 months. Two patients experienced a late non-acute reocclusion at 17 and 19 months. Conclusions The implantation of BVS for long complex CTOs was feasible with no stent thrombosis despite the high complexity of lesions and multiple BVS implanted. The lack of mechanical strength may lead to the need for focal reintervention, but still the long-term burden of full metal jacketed vessels could be avoided.

Objectives The aim was to establish a contemporary scoring system to predict the outcome of chronic total occlusion coronary angioplasty. Background Interventional treatment of chronic total coronary occlusions (CTOs) is a developing subspecialty. Predictors of technical success or failure have been derived from datasets of modest size. A robust scoring tool could facilitate case selection and inform decision making. Methods The study analyzed data from the EuroCTO registry. This prospective database was set up in 2008 and includes >20,000 cases submitted by CTO expert operators (>50 cases/year). Derivation (n = 14,882) and validation (n = 5,745) datasets were created to develop a risk score for predicting technical failure. Results There were 14,882 patients in the derivation dataset (with 2,356 [15.5%] failures) and 5,745 in the validation dataset (with 703 [12.2%] failures). A total of 20.2% of cases were done retrogradely, and dissection re-entry was performed in 9.3% of cases. We identified 6 predictors of technical failure, collectively forming the CASTLE score (Coronary artery bypass graft history, Age (≥70 years), Stump anatomy [blunt or invisible], Tortuosity degree [severe or unseen], Length of occlusion [≥20 mm], and Extent of calcification [severe]). When each parameter was assigned a value of 1, technical failure was seen to increase from 8% with a CASTLE score of 0 to 1, to 35% with a score ≥4. The area under the curve (AUC) was similar in both the derivation (AUC: 0.66) and validation (AUC: 0.68) datasets. Conclusions The EuroCTO (CASTLE) score is derived from the largest database of CTO cases to date and offers a useful tool for predicting procedural outcome.

Background Contrast-associated acute kidney injury (CA-AKI) is a potential risk associated with the percutaneous coronary interventions (PCI) for chronic total coronary occlusions (CTO). This study should evaluate the incidence of CA-AKI in an era of advanced strategies of recanalization techniques and identify modifiable determinants. Methods We analysed 1924 consecutive CTO procedures in 1815 patients between 2012 and 2019. All patients were carefully monitored at least up to 48 h after a CTO procedure for changes in renal function. Results The incidence of CA-AKI was 5.6%, but there was no relation to the technical approach such as frequency of the retrograde technique, intravascular ultrasound or radial access. Procedures with CA-AKI had longer fluoroscopy times (37.6 vs 46.1 min; p = 0.005). The major determinants of CA-AKI were age, presence of diabetes and reduced ejection fraction, as well as chronic kidney disease stage ≥2, serum haemoglobin, and fluoroscopy time. Contrast volume or contrast volume/GFR ratio were not independent determinants of CA-AKI. Periprocedural perforations were more frequent in CA-AKI patients (11.3 vs 2.3%; p Conclusions CA-AKI was associated with the risk of in-hospital adverse events. Established patient-related risk factors for CA-AKI (age, diabetes, preexisting chronic kidney disease, low ejection fraction) were confirmed in this study. In addition, the length of the procedure, coronary perforations and low preprocedural serum haemoglobin were risk factors that might be preventable in patients at high risk for CA-AKI.

© 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC By-NC-ND License (http://creativecommons.org/licenses/by-nc-nd/4), The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.

Dual lumen microcatheters (DLMC) have become indispensable tools in the setting of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Other than allowing preservation and treatment of bifurcated coronary branches within or in the proximity of the CTO-body, they enable the use of modified parallel wiring, antegrade dissection and re-entry, collateral selection and retrograde negotiation of the distal CTO-cap. This Euro-CTO consensus document describes current DLMCs and suggests a practical guide to anatomies and techniques in which these devices are applicable.

Background Development of different strategies and devices improved CTO revascularization. However, technical and procedural success might be influenced by several factors including geographical expertise. Methods A total of 4412 CTO coronary treated lesions (Japan 1531 Europe 2881) (mean age 64.5±10.7, male 85.2%, JCTO score 2.09±1.24) were analyzed in European and Japanese registries during the year 2016. The primary endpoint was to assess technical success rate of CTO-PCI cases and procedural outcomes. Results Primary Antegrade approach and success rate were 71.5% and 90.8% respectively in Japan while 77.0% and 94.1%, respectively in Europe, (p20mm. Conclusions Technical success rate was similar between Japan and Europe, but more retrograde approach was common in Japan. Unsuccessful retrograde crossing channel, severe lesion calcification and occlusion length>20mm were independent predictors of failed procedures for both countries. Procedural complications were higher in Japan probably because of longer procedural time and higher frequency of retrograde approach. Funding Acknowledgement Type of funding source: None

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.

The improved success rate of recanalization of occluded coronary arteries is partly due to the development of the retrograde approach via collateral pathways. The proper application of this technique requires a thorough knowledge of the anatomy of the coronary collateral system, and its functional capacity. Furthermore, proper angiographic technique is required to highlight the collateral pathways and understand the challenges when trying to pass wires through these channels.

Aims The aim of this study was to investigate the effect of contact-to-balloon time on mortality in ST-segment elevation myocardial infarction (STEMI) patients with and without haemodynamic instability. Methods and results Using data from the prospective, multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial, we assessed the prognostic relevance of first medical contact-to-balloon time in n = 12 675 STEMI patients who used emergency medical service transportation and were treated with primary percutaneous coronary intervention (PCI). Patients were stratified by cardiogenic shock (CS) and out-of-hospital cardiac arrest (OHCA). For patients treated within 60 to 180 min from the first medical contact, we found a nearly linear relationship between contact-to-balloon times and mortality in all four STEMI groups. In CS patients with no OHCA, every 10-min treatment delay resulted in 3.31 additional deaths in 100 PCI-treated patients. This treatment delay-related increase in mortality was significantly higher as compared to the two groups of OHCA patients with shock (2.09) and without shock (1.34), as well as to haemodynamically stable patients (0.34, P

In der interventionellen Kardiologie ist eine stetig zunehmende Zahl an Patienten zu verzeichnen, die aufgrund ihres Alters und ihrer Komorbiditäten trotz eindeutiger prognoserelevanter Koronarstenosen nicht einer leitliniengerechten operativen Myokardrevaskularisation zugeführt werden können. Insbesondere Patienten mit relevanter, ischämisch bedingter Einschränkung der linksventrikulären Pumpfunktion profitieren von einer interventionellen Revaskularisation. Gefürchtete Komplikationen bei diesen Patienten sind die Kreislaufdepression bei prolongierter Koronarischämie, z. B. aufgrund länger andauernder Ballondilatationen, die akute Nierenschädigung aufgrund einer passageren Kreislaufdepression, Ischämie-getriggerte Herzrhythmusstörungen und inkomplette Revaskularisierung aufgrund einer Kreislaufinstabilität während der zumeist komplexen Prozeduren. Im Beitrag werden die Rationale, die Indikationen, die Datenlage, das praktische Vorgehen und die potenziellen Komplikationen dargestellt, die dem Konzept der geschützten Hochrisiko-Koronarintervention („protected percutaneous coronary intervention“, „protected PCI“) zugrunde liegen. A correction to this article is available online at https://doi.org/10.1007/s12181-017-0213-6

Covered stents are indicated for coronary perforations, but they may seal off major side branches in that process. We report the successful sealing of an ostial left main perforation, induced by a guide catheter in the course of a retrograde approach to treat a chronic total occlusion (CTO) of the right coronary artery (RCA) in a 76year old woman with prior CABG. The implanted Papyrus covered stent, however, overlapped the left main bifurcation and occluded the non-grafted circumflex artery (CX) resulting in acute ischemia. Through a double lumen catheter advanced over the wire located in the left anterior descending coronary artery (LAD) territory, a stiff recanalization wire could be advanced from the side-port to penetrate the stent membrane towards the CX. This was successfully achieved, and after subsequent dilatation, a drug-eluting stent was implanted in Culotte-fashion from the CX to the left main with subsequent kissing-balloon dilatation. The clinical symptoms subsided immediately, and the RCA was finally recanalized in antegrade parallel wire technique. No periprocedural infarct was observed during 48h of follow-up before discharge. At clinical follow-up of 6months the patient is symptom-free.

Background The increasing complexity of percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTO) leads to a significant increase of radiation exposure for both patient and operator. Objective To study the potential of modified settings of the X-ray equipment combined with operator protocols to reduce radiation dose despite increasing procedural complexity. Patients and Methods We analyzed a consecutive cohort of 984 PCIs for CTOs in 863 patients between January 2010 and July 2015. During that period, the X-ray equipment was changed from an analog to a digital detector system, and a subsequent filter and imaging modification was implemented. The fluoroscopy settings were reduced from 15 pulses/s to 7.5, and then to 6. The cine framerate was reduced from 15 to 7.5/s. For the last time period, with optimized settings, procedural, and lesion related factors influencing the radiation exposure were analyzed. Results The lesion complexity increased from a J-CTO score of 1.64 to 2.33 with an increase of retrograde procedures from 21.6 to 50.4%. With a similar fluoroscopy time, the dose area product was reduced from period 1 to 2 by 20%, and further by 7% to period 3. There was a significant reduction of Air Kerma from period 2 to 3 from 3.5 to 2.7 Gy. The operator exposure was reduced by more than half. The patient's weight and the complexity of the procedure were the main determinants of radiation exposure. Conclusions The radiation exposure for patient and operator was decreased considerably during the three observation periods despite an increase in lesion and procedural complexity. Rigorous implementation of radiation device settings did reduce radiation exposure without impeding procedural success. © 2017 Wiley Periodicals, Inc.

OBJECTIVES The aim of the study was to evaluate the outcomes of retrograde versus antegrade approach in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND The retrograde approach has increased the success rate of CTO PCI but has been associated with a higher risk for complications. METHODS We conducted a meta-analysis of studies published between 2000 and August 2019 comparing the in-hospital and long-term outcomes with retrograde versus antegrade CTO PCI. RESULTS Twelve observational studies (10,240 patients) met our inclusion criteria (retrograde approach 2,789 patients, antegrade approach 7,451 patients). Lesions treated with the retrograde approach had higher J-CTO score (2.8 vs. 1.9, p

Introduction: Whether duration of chronic total occlusion (CTO) affects lesion and procedural characteristics remains largely unknown. Aim: To investigate whether CTO duration influences lesion characteristics and revascularization success. Material and methods: EuroCTO Registry data on patients who had CTO percutaneous coronary intervention between January 2015 and April 2017 were analyzed. Three groups were created based on occlusion age: 3 to 6 months (n = 1415), 7 to 12 months (n = 973), > 12 months (n = 1656). Results: Patients with greater CTO duration were older (63.0 (56.0–70.0); 63.0 (56.0–71.0); 66.0 (59.0–73.0) years respectively; p < 0.001), had more 3-vessel disease (32.2%; 30.9%; 46.1% respectively; p < 0.001) and more frequent prior coronary artery bypass grafting (8.2%; 9.9%; 29.4% respectively; p < 0.001). In multivariate analysis, occlusion duration was associated with moderate/ severe calcification (OR = 1.52; 95% CI: 1.28–1.80; p < 0.001), lesion length > 20 mm (OR 1.77; 95% CI 1.49–2.10; p < 0.001), and collateral circulation Werner type 2 (OR = 1.20; 95% CI: 1.01–1.43; p = 0.041). The CTO duration was associated with lower procedural success (OR for success 0.60; 95% CI: 0.46–0.79; p < 0.001). In multivariate analysis in-hospital adverse events did not differ according to duration of CTO. Conclusions: Coronary artery CTO duration is associated with greater extent of calcification, lesion length, development of collateral circulation and, most importantly, with lower procedural success.

© American Heart Association, Inc., Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Background The aim of this study was to evaluate the functional result of chronic total occlusion percutaneous coronary intervention (PCI) measured by fractional flow reserve (FFR) immediately post the index procedure and at short-term follow-up. Methods and Results This was a prospective single-center observational study. Consecutive patients with right coronary artery chronic total occlusion scheduled for elective PCI were included. FFR measurements were performed immediately after successful PCI and at 4 months follow-up. Twenty-six patients completed baseline and follow-up measurements. Mean age was 61.2±9.7 years, 88.5% of the patients were male, and 19.2% were diabetic. The mean FFR immediately after successful chronic total occlusion PCI was 0.82±0.10 and significantly increased to 0.89±0.07 at 4 months ( P P =0.03). At 4 months, FFR ≤0.80 was found only in 2 patients with subintimal recanalization. At follow-up, 42.7% of the patients continued to have an FFR Conclusions Post chronic total occlusion PCI, FFR increased significantly at short-term follow-up compared with measurements post index procedure. Because FFR remained

Aims Despite advances in understanding the physiological role of collaterals in coronary chronic total occlusions (CTOs), collateral anatomy remains poorly defined. Our aim was to define the anatomy and interventional utility of collaterals within a large population of patients with CTOs. Methods and results We studied the coronary angiograms of 481 patients with 519 CTOs at six centres in the U.K. over four years. Detailed angiographic analysis was performed by interventional cardiologists specialising in CTO percutaneous coronary intervention (PCI). All visible collaterals with a collateral connection (CC) grade ≥1 were recorded. A subgroup of CTOs (n=277) was assessed for interventional capability, defined as whether the collateral supply was able to facilitate retrograde access. We described 45 different collateral patterns: 20 in right coronary artery (RCA), 13 in left anterior descending (LAD), and 12 in circumflex artery CTOs. Septal collaterals from the LAD to the right posterior descending artery (RPDA), and from the posterior descending artery to the LAD were most common, and most often considered as having "interventional capability". Conclusions This is the largest analysis of collateral circulation anatomy in a population of patients with CTOs. We anticipate that these data will be of significant benefit in angiographic analysis and procedure planning for CTO PCI.