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Background: Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and often leads to serious adverse clinical events. Aims: We sought to develop a risk score to predict clinical coronary artery perforation in patients undergoing CTO PCI. Methods: We analysed clinical and angiographic parameters from 9,618 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO). Logistic regression prediction modelling was used to identify variables independently associated with clinical perforation, and the model was internally validated with bootstrapping. Clinical coronary artery perforation was defined as any perforation requiring treatment. Results: The incidence of clinical coronary perforation was 3.8% (n=367). Five factors were independently associated with perforation and were included in the score: patient age ≥65 years +1 point (odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.37-2.33), moderate/severe calcification +1 point (OR 1.85, 95% CI: 1.41-2.42), blunt/no stump +1 point (OR 1.45, 95% CI: 1.10-1.92), use of antegrade dissection and re-entry +1 point (OR 2.43, 95% CI: 1.61-3.69), and use of the retrograde approach +2 points (OR 4.02, 95% CI: 2.95-5.46). The resulting score showed acceptable performance on receiver operating characteristic (ROC) curve (area under the curve [AUC]: 0.741, 95% CI: 0.712-0.773). The Hosmer-Lemeshow test indicated a good fit (p=0.991), and internal validation with bootstrapping demonstrated good agreement with the model with observed AUC: 0.736 (95% bias-corrected CI: 0.706-0.767). Conclusions: The PROGRESS-CTO perforation score may be a useful tool for predicting clinical coronary perforation during CTO PCI.

BackgroundPercutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) has been performed for the improvement of symptoms and quality of life in patients with stable angina. The ORBITA study demonstrated the role of the placebo effect in contemporary PCI in non-CTO chronic coronary syndromes. However, the benefit of CTO PCI beyond that of a placebo has not been demonstrated.AimsThe ORBITA-CTO pilot study will be a double-blind, placebo-controlled study of CTO PCI randomising patients who have: (1) been accepted by a CTO operator for PCI; (2) experienced symptoms due to a CTO; (3) evidence of ischaemia; (4) evidence of viability within the CTO territory; and (5) a J-CTO score ≤3.MethodsPatients will undergo medication optimisation that will ensure they are on at least a minimum amount of anti-anginals and complete questionnaires. Patients will record their symptoms on an app daily throughout the study. Patients will undergo randomisation procedures, including an overnight stay, and be discharged the following day. All anti-anginals will be stopped after randomisation and re-initiated on a patient-led basis during the 6-month follow-up period. At follow-up, patients will undergo repeat questionnaires and unblinding, with a further 2-week unblinded follow-up.ResultsThe co-primary outcomes are feasibility (blinding) in this cohort and angina symptom score using an ordinal clinical outcome scale for angina. Secondary outcomes include changes in quality-of-life measures, Seattle Angina Questionnaire (SAQ), peak VO2, and anaerobic threshold on the cardiopulmonary exercise test.ConclusionThe feasibility of a placebo-controlled CTO PCI study will lead to future studies assessing efficacy. The impact of CTO PCI on angina measured using a novel daily symptom app may provide improved fidelity in assessing symptoms in patients with CTO's.

Percutaneous transcatheter interventions have evolved as standard therapies for a variety of cardiovascular diseases, from revascularization for atherosclerotic vascular lesions to the treatment of structural cardiac diseases. Concomitant technological innovations, procedural advancements, and operator experience have contributed to effective therapies with low complication rates, making early hospital discharge safe and common. Same-day discharge presents numerous potential benefits for patients, providers, and health care systems. There are several key elements that are shared across the spectrum of interventional cardiology procedures to create a successful same-day discharge pathway. These include appropriate patient and procedure selection, close postprocedural observation, predischarge assessments specific for each type of procedure, and the existence of a patient support system beyond hospital discharge. This review provides the rationale, available data, and a framework for same-day discharge across the spectrum of coronary, peripheral, and structural cardiovascular interventions.

There are limited data on the association of operator volume with the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).We analyzed the association between operator volume and procedural outcomes of 7035 CTO-PCIs performed between 2012 and February 2021 at 30 centers.The study population was divided into 3 groups based on annual operator CTO-PCI volume: low-volume operators (LVO:lt;30 cases/year; 39.7% of the cases); medium-volume operators (MVO: 30-60 cases/year; 25.7% of the cases); and high-volume operators (HVO:gt;60 cases/ year; 34.6% of the cases). Mean patient age was 64.4 ± 10 years and 82% were men. Cases performed by HVOs were more complex, with higher J-CTO score compared with cases performed by MVOs and LVOs (2.72 ± 1.27 vs 2.39 ± 1.19 vs 2.12 ± 1.27, respectively; Plt;.001). Moderate/severe proximal vessel tortuosity (35% vs 23% vs 20%; Plt;.001) and proximal cap ambiguity (44% vs 34% vs 32%; Plt;.001) was also more common in the HVO group. Cases performed by HVOs had higher technical success rates (87.9% vs 86.9% vs 82.6%; Plt;.001), but also higher rates of periprocedural major cardiac adverse events compared with MVOs and LVOs (3.08% vs 2.71% vs 1.50%; Plt;.01). On multivariable analyses, HVOs and MVOs were associated with higher technical success.In a contemporary, multicenter registry, 40% of CTO-PCI cases are performed by LVOs performinglt;30 cases per year. Cases performed by HVOs were associated with higher technical and procedural success, but also higher periprocedural major complication rates, potentially due to higher lesion complexity.

Supplemental material, sj-pdf-1-vmj-10.1177_1358863X211042082 for No benefit of vorapaxar on walking performance in patients with intermittent claudication by Shirling Tsai, Yulun Liu, Mohamad Amer Alaiti, Jorge Antonio Gutierrez, Emmanouil S Brilakis and Subhash Banerjee in Vascular Medicine

Supplemental material, sj-pdf-2-vmj-10.1177_1358863X211042082 for No benefit of vorapaxar on walking performance in patients with intermittent claudication by Shirling Tsai, Yulun Liu, Mohamad Amer Alaiti, Jorge Antonio Gutierrez, Emmanouil S Brilakis and Subhash Banerjee in Vascular Medicine

Supplemental material, sj-pdf-2-vmj-10.1177_1358863X211042082 for No benefit of vorapaxar on walking performance in patients with intermittent claudication by Shirling Tsai, Yulun Liu, Mohamad Amer Alaiti, Jorge Antonio Gutierrez, Emmanouil S Brilakis and Subhash Banerjee in Vascular Medicine

Supplemental material, sj-pdf-1-vmj-10.1177_1358863X211042082 for No benefit of vorapaxar on walking performance in patients with intermittent claudication by Shirling Tsai, Yulun Liu, Mohamad Amer Alaiti, Jorge Antonio Gutierrez, Emmanouil S Brilakis and Subhash Banerjee in Vascular Medicine

Data comparing MANTA to other vascular closure devices (VCDs) after TAVR is limited. We performed a meta-analysis of all published studies reporting the outcomes of MANTA vs. other VCDs in TAVR patients. Outcomes included major and minor vascular complications, major and minor bleeding, VCD failure, blood transfusion, additional surgical or endovascular treatment, flow-limiting dissection, hematomas, pseudoaneurysm, change in hemoglobin, and length of stay (LOS). Definitions used were according to the “Valve Academic Research Consortium-2 consensus document” (VARC-2). We included five observational studies with a total of 1,410 patients (MANTA n = 601, other VCDs = 809). Three studies compared MANTA to the Proglide device (Abbot Vascular, CA, USA), and two studies compared MANTA to the Prostar XL device (Abbott Vascular, IL, USA). The prevalence of moderate to severe calcification was higher in the MANTA group (31% vs. 21%, p = 0.01) compared with other VCDs group. During the index hospitalization, there was no difference in all major or minor complications between MANTA and other VCDs. In a sensitivity analysis, comparing MANTA to Proglide, the risk of major and minor vascular complications, major and minor bleeding, and VCD failure was similar for both devices. In the TAVR population, although more used in calcified vessels, the safety profile and efficacy of the new collagen-based VCD, MANTA, is similar to currently available suture based VCD’s Proglide and Prostar XL.

Supplemental material, VMJ775593_Supplementary_Table for Adjunctive stent use during endovascular intervention to the femoropopliteal artery with drug coated balloons: Insights from the XLPAD registry by Damianos G Kokkinidis, Haekyung Jeon-Slaughter, Houman Khalili, Emmanouil S Brilakis, Nicolas W Shammas, Subhash Banerjee and Ehrin J Armstrong in Vascular Medicine

Introduction: The presence of severe coronary artery calcification is associated with higher rates of angiographic complications during percutaneous coronary intervention (PCI), as well as higher major adverse cardiac events compared with non-calcified lesions. Incorporating orbital atherectomy (OAS) for effective preparation of severely calcified lesions can help maximize the benefits of PCI by attaining maximal luminal gain (or stent expansion) and improve long-term outcomes (by reducing need for revascularization). Areas covered: In this manuscript, the prevalence, risk factors, and impact of coronary artery calcification on PCI are reviewed. Based on current data and experience, the authors review orbital atherectomy technique and best practices to optimize lesion preparation. Expert Commentary: The coronary OAS is the only device approved for use in the U.S. as a treatment for de novo, severely calcified coronary lesions to facilitate stent delivery. Advantages of the device include its ease of use and a mechanism of action that treats bi-directionally, allowing for continuous blood flow during treatment, minimizing heat damage, slow flow, and subsequent need for revascularization. The OAS technique tips reviewed in this article will help inform interventional cardiologists treating patients with severely calcified lesions.

We sought to determine the contemporary prevalence and management of coronary chronic total occlusions (CTO) in a veteran population.The prevalence and management of CTOs in various populations has received limited study.We collected clinical and angiographic data in consecutive patients that underwent coronary angiography at our institution between January 2011 and December 2012. Coronary artery disease (CAD) was defined as ≥50% diameter stenosis in ≥1 coronary artery. CTO was defined as total coronary artery occlusion of ≥3 month duration.Among 1,699 patients who underwent angiography during the study period, 20% did not have CAD, 20% had CAD and prior coronary artery bypass graft surgery (CABG), and 60% had CAD but no prior CABG. The prevalence of CTO among CAD patients with and without prior CABG was 89 and 31%, respectively. Compared to patients without CTO, CTO patients had more co-morbidities, more extensive CAD and were more frequently referred for CABG. Percutaneous coronary intervention (PCI) to any vessel was performed with similar frequency in patients with and without CTO (50% vs. 53%). CTO PCI was performed in 30% of patients without and 15% of patients with prior CABG with high technical (82 and 75%, respectively) and procedural success rates (80 and 73%, respectively).In a contemporary veteran population, coronary CTOs are highly prevalent and are associated with more extensive co-morbidities and higher likelihood for CABG referral. PCI was equally likely to be performed in patients with and without CTO.

Background Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)), an inflammatory enzyme expressed in atherosclerotic plaques, is a therapeutic target being assessed in trials of vascular disease prevention. We investigated associations of circulating Lp-PLA(2) mass and activity with risk of coronary heart disease, stroke, and mortality under different circumstances. Methods With use of individual records from 79 036 participants in 32 prospective studies (yielding 17 722 incident fatal or non-fatal outcomes during 474 976 person-years at risk), we did a meta-analysis of within-study regressions to calculate risk ratios (RRs) per 1 SD higher value of Lp-PLA(2) or other risk factor. The primary outcome was coronary heart disease. Findings Lp-PLA(2) activity and mass were associated with each other (r=0.51, 95% CI 0.47-0.56) and proatherogenic lipids. We noted roughly log-linear associations of Lp-PLA(2) activity and mass with risk of coronary heart disease and vascular death. RRs, adjusted for conventional risk factors, were: 1.10 (95% CI 1.05-1.16) with Lp-PLA(2) activity and 1.11 (1.07-1.16) with Lp-PLA(2) mass for coronary heart disease; 1.08 (0.97-1.20) and 1.14 (1.02-1.27) for ischaemic stroke; 1.16 (1.09-1.24) and 1.13 (1.05-1.22) for vascular mortality; and 1.10 (1.04-1.17) and 1.10 (1.03-1.18) for non-vascular mortality, respectively. RRs with Lp-PLA(2) did not differ significantly in people with and without initial stable vascular disease, apart from for vascular death with Lp-PLA(2) mass. Adjusted RRs for coronary heart disease were 1.10 (1.02-1.18) with non-HDL cholesterol and 1.10 (1.00-1.21) with systolic blood pressure. Interpretation Lp-PLA(2) activity and mass each show continuous associations with risk of coronary heart disease, similar in magnitude to that with non-HDL cholesterol or systolic blood pressure in this population. Associations of Lp-PLA(2) mass and activity are not exclusive to vascular outcomes, and the vascular associations depend at least partly on lipids. Funding UK Medical Research Council, GlaxoSmithKline, and British Heart Foundation.

The retrograde approach to coronary chronic total occlusions (CTOs) can be used as the initial crossing strategy (primary retrograde) or after failure of antegrade crossing attempts (secondary retrograde).We compared baseline clinical and angiographic characteristics and procedural outcomes of primary vs secondary retrograde crossing for CTO percutaneous coronary intervention (PCI) among 2789 procedures performed at 34 centers between 2012 and 2021.Retrograde CTO-PCI was performed as the primary crossing strategy in 1086 cases (38.9%) and as a secondary approach in 1703 cases (61.1%). Patients in the primary group had slightly lower left ventricular ejection fraction (49.1% vs 50.4%; P=.02), were more likely to have had prior coronary artery bypass graft surgery (52.9% vs 38.4%; Plt;.001), and had higher J-CTO (3.31 ± 0.98 vs 2.99 ± 1.09; Plt;.001) and PROGRESS-CTO scores (1.47 ± 0.92 vs 1.29 ± 0.99; Plt;.001). Technical (81.4% vs 77.3%; P=.01) and procedural success rates (78.6% vs 74.1%; Plt;.01) were higher in the primary retrograde group, with no difference between in-hospital major adverse event rates (4.3% vs 4.0%; P=.66). Contrast volume (250 mL [interquartile range (IQR), 176-347] vs 270 mL [IQR, 190-367]; Plt;.001) and procedure time (175 minutes [IQR, 127-233] vs 180 minutes [IQR, 142-236]; Plt;.001) were lower in the primary group.Use of retrograde approach as the primary crossing strategy is associated with higher rates of technical and procedural success and similar rates of in-hospital major adverse cardiac events compared with secondary retrograde CTO-PCI.

AIMS The aim of the present study was to compare the midterm clinical outcomes of patients undergoing successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) according to the crossing technique used, in a large multicentre registry. METHODS AND RESULTS We compiled a multicentre registry of consecutive patients undergoing successful CTO PCI. Patients were divided into three groups: true-to-true (TTT) approach, modern dissection/re-entry (DR) techniques (CrossBoss/Stingray, reverse CART), and old DR techniques (LAST, STAR, CART). Cox regression was used to identify independent predictors of major adverse cardiac events (MACE: cardiac death, myocardial infarction and target vessel revascularisation). We included 924 patients (TTT, n=571; modern DR, n=258; old DR, n=95). Patients in both DR groups had a higher prevalence of comorbidities, angiographic and procedural complexity. The 12-month MACE rate was higher in old DR (22.1%) than in modern DR (8.9%) and TTT (9.1%, p

Chronic total occlusions (CTO) are frequently found in clinical practice, yet they are still undertreated, despite the frequent presence of clinical indications for revascularization. The presence of a CTO is a frequent cause of incomplete revascularization, which has been associated with worse long-term outcomes (including mortality), compared to complete revascularization. Such low rates of attempted revascularization can be attributed to a common misconception about the lack of benefit of CTO revascularization, combined with historically lower success rates and higher complication rates of CTO percutaneous coronary intervention. However, modern percutaneous techniques, devices and algorithms now allow successful CTO revascularization in approximately 90% of cases. Additionally, state-of-the-art surgical techniques offer complete revascularization and provide excellent long-term patency rates. The present review provides a critical appraisal of the literature supporting the rationale, indications, modalities and state-of-the-art techniques of CTO revascularization by both percutaneous and surgical approaches.

Background There are few data regarding the procedural and follow-up outcomes of different antegrade dissection/re-entry (ADR) techniques for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods We compiled a multicenter registry of consecutive patients undergoing ADR-based CTO PCI at four high-volume specialized institutions. Patients were divided according to the specific ADR technique used: subintimal tracking and re-entry (STAR), limited antegrade subintimal tracking (LAST), or device-based with the CrossBoss/Stingray system (Boston Scientific, Marlborough, MA). Major adverse cardiac events (MACE: cardiac death, target-vessel myocardial infarction and target-vessel revascularization) on follow-up were the main outcome of this study. Independent predictors of MACE were sought with Cox regression analysis. Results A total of 223 patients were included (STAR n = 39, LAST n = 68, CrossBoss/Stingray n = 116). Baseline characteristics were similar across groups. Technical and procedural success was lower with STAR (59% and 59%), as compared with LAST (96% and 96%) and CrossBoss/Stingray (89% and 87%; pÂ