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Background: Excess radiation exposure is a limiting factor in percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO)., Objectives: The aim of this study was to analyze changes in radiation dose for CTO PCI with increasing risk awareness during the past decade and the determinants of these changes., Methods: A total of 16,439 procedures performed by 14 operators continuously participating in the European Registry of CTO-PCI from 2012 to 2023 were analyzed. Changes in air kerma (AK) were assessed, and a dose rate index (DRI) was calculated as AK per fluoroscopy time (FT)., Results: Lesion complexity increased from a median J-CTO (Multicenter CTO Registry in Japan) score of 2 (Q1-Q3: 1-3) to 3 (Q1-Q3: 2-3) (P < 0.001), and technical success improved from 89.1% to 94.9% (P < 0.001), with stable FT. AK decreased from 2.50 Gy (Q1-Q3: 1.54-4.04 Gy) to 1.20 Gy (Q1-Q3: 0.66-2.12 Gy), a reduction of 52.0% (P < 0.001). Excess radiation of AK >5 Gy was reduced from 15.8% in 2012-2013 to 3.7% in 2022-2023. Clinical determinants of excess radiation were body mass index, gender, and previous bypass surgery; procedural determinants were FT, retrograde approach, and intravascular ultrasound use; and equipment determinants were radiographic equipment updates and fluoroscopy dose mode. Operators reduced DRI by 21.7% from 62.6 mGy/min (Q1-Q3: 44.7-89.3 mGy/min) to 49.0 mGy/min (Q1-Q3: 35.4-71.2 mGy/min) before a radiographic equipment update; after the update, DRI was further reduced to 31.5 mGy/min (Q1-Q3: 22.0-45.6 mGy/min), a decrease of 28.0% (P < 0.001) The interoperator comparison of DRI indicated considerable variability in radiation management., Conclusions: AK for CTO PCI was reduced during the past decade to a level such that most procedures no longer must be aborted because of excess radiation. Equipment updates were instrumental, but interoperator differences remained., Competing Interests: Funding Support and Author Disclosures Dr Werner has received speaker honoraria from Asahi Intecc, Abbott Vascular, Daiichi-Sankyo, Orbus-Neich, Philips-Volcano, Siemens, and Terumo. Dr Boudou has received speaker honoraria from Asahi Intecc, Boston Scientific, and Terumo. Dr Galassi has received speaker honoraria from Asahi Intecc. Dr Garbo has received consultancy and speaker fees from Asahi Intecc, Philips, Terumo, Boston Scientific, Medtronic, iVascular, and Teleflex. Dr Bufe has received speaker honoraria from Abiomed, Biotronik, and Shockwave Medical. Dr Bryniarski has received speaker honoraria and travel grants from Berlin-Chemie, Boston Scientific, and Procardia. Dr Christiansen has received research grants from Abbott Vascular, Asahi Intecc, Orbus-Neich, Biosensors, and Philips. Dr Kalnins has received speaker honoraria from Terumo. Dr Mashayekhi has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Abiomed, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic, Orbus-Neich, Shockwave Medical, Teleflex, and Terumo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2025 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...

Background: The parallel wire technique (PW) is a classic part of the antegrade strategy to open chronic total coronary occlusions (CTO)., Aims: With modern wires and dual-lumen catheters (DLC) the approach has evolved, but this progress had not been evaluated in a contemporary registry of CTO interventions., Method: This analysis is based on 26,589 CTO procedures performed by 36 operators with > 50 procedures annually between 2015 and 2022. The different strategies and techniques were analyzed with respect to clinical and lesion characteristics, procedural resource use and periprocedural complications. Within the antegrade approach, PW was compared to antegrade wire escalation (AWE) and antegrade-dissection re-entry (ADR)., Results: The primary antegrade approach was used in 65.9%, primary retrograde in 16.9% and a strategy change in 17.2% with a wide inter-operator variability. In primary antegrade approach, PW was applied in 10.8% and ADR in 5.3%. Lesion complexity was higher in AWE and PW than with single wire, and highest in ADR procedures, leading to more complex procedures with higher contrast and radiation usage. Complications increased with ADR, while they were similar with PW and AWE. Through the observation period PW adoption increased steadily from 6.7% to 10.7%, as the DLC use facilitating PW increased from 8.3% to 17.0% over the observation period., Conclusion: In this largest database of contemporary CTO PCI from Europe, PW adoption increased over time but remained low at about 10%. While there was a wide individual variety among the operators, it was a safe and successful technique., (© 2024 Wiley Periodicals LLC.) more...

Background: The CTO-ARC (Chronic Total Occlusion Academic Research Consortium) recognized that a nonstandardized definition of chronic total occlusion (CTO) percutaneous coronary intervention approaches can bias the complications' attribution to each crossing strategy., Objectives: The study sought to describe the numbers, efficacy, and safety of each final CTO crossing strategy according to CTO-ARC recommendations., Methods: In this cross-sectional study, data were retrieved from the European Registry of Chronic Total Occlusions between 2021 and 2022., Results: Out of 8,673 patients, antegrade and retrograde approach were performed in 79.2% and 20.8% of cases, respectively. The antegrade approach included antegrade wiring and antegrade dissection and re-entry, both performed with or without retrograde contribution (antegrade wiring without retrograde contribution: n = 5,929 [68.4%]; antegrade wiring with retrograde contribution: n = 446 [5.1%]; antegrade dissection and re-entry without retrograde contribution: n = 353 [4.1%]; antegrade dissection and re-entry with retrograde contribution: n = 137 [1.6%]). The retrograde approach included retrograde wiring (n = 735 [8.4%]) and retrograde dissection and re-entry (n = 1,073 [12.4%]). Alternative antegrade crossing was associated with lower technical success (70% vs 86% vs 93.1%, respectively; P < 0.001) and higher complication rates (4.6% vs 2.9% vs 1%, respectively; P < 0.001) as compared with retrograde and true antegrade crossing. However, alternative antegrade crossing was applied mostly as a rescue strategy (96.1%)., Conclusions: The application of CTO-ARC definitions allowed the reclassification of 6.7% of procedures as alternative antegrade crossing with retrograde or antegrade contribution which showed higher MACCE and lower technical success rates, as compared with true antegrade and retrograde crossing., Competing Interests: Funding Support and Author Disclosures Dr Bufe has received speaker honoraria from Biotronik and Shockwave Medical. Dr Pyxaras has received consulting/speaker/proctorship honoraria from Abiomed, AstraZeneca, Asahi Intecc, Biotronik, Boston Scientific, and Terumo. Dr Ladwiniec has received consulting/speaker/proctoring honoraria from Abbott, Biotronik, Boston Scientific, Cordis, Shockwave Medical, and SMT. Dr Werner has received speaker honoraria from Abbott, Asahi Intecc, OrbusNeich, Philips, Siemens, and Terumo. Dr Mashayekhi has received consulting/speaker/proctoring honoraria from Abbott, Abiomed, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic, OrbusNeich, Shockwave Medical, Teleflex, and Terumo. Dr Ayoub has received consultant/proctor honoraria from Boston Scientific, Teleflex, Asahi Intecc, Cordis, Terumo, and SIS Medical. Dr Goktekin has received consulting/speaker/proctoring honoraria from Boston Scientific, Medtronik, MicroPort, and Asahi Inc. Dr Agostoni has received consulting honoraria from Abbott, Boston Scientific, Cordis, iVascular, Medtronic, Neovasc, Seven Sons, Teleflex, and Terumo. Dr Diletti has received consultant/proctoring honoraria from Asahi Intecc, Terumo, IMDS, Boston Scientific, Teleflex, and Philips. Dr Rathore has received honoraria for speaker and proctoring from Abbott Vascular and Translumina Therapeutics. Dr Bozinovic has served as a speaker or proctor and/or received honoraria from Orbus Neich and Medtronic. Dr Galassi has received consulting/speaker honoraria from Asahi Intecc and Ivascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.) more...

Dissection and re-entry techniques are essential to achieve safe and effective chronic total occlusion recanalization. Several studies have demonstrated similar outcomes following extraplaque stenting compared with intraplaque stenting. Dissection techniques most often involve the use of knuckled wires to progress within and beyond the chronic total occlusion segment. In this expert consensus document, the authors compare the properties of different polymer-jacketed wires for their use in dissection techniques. The authors also describe 2 principal knuckle wire behaviors, the rolling and the traveling knuckles. Finally, several adjunctive techniques for safer dissection are described., Competing Interests: Funding Support and Author Disclosures Dr Rinfret has received consulting, speaker, and proctoring honoraria from Abiomed, Boston Scientific, Medtronic, and Teleflex. Dr Khatri has received consulting, speaker, and proctoring honoraria from Abbott, Medtronic, Terumo, Boston Scientific, and Shockwave Medical. Dr Mashayekhi has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Abiomed, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic, OrbusNeich, Shockwave Medical, Teleflex, and Terumo. Dr Alaswad has received consulting, speaker, and proctoring honoraria from Boston Scientific and Teleflex. Dr Azzalini has received consulting fees from Teleflex, Abiomed, GE Healthcare, Abbott Vascular, Reflow Medical, and Cardiovascular Systems; serves on the advisory boards of Abiomed and GE Healthcare; and owns equity in Reflow Medical. Dr Vijayaraghavan has received consulting and proctoring fees from Acist, Abbott, Asahi Intecc, Medtronic, and Biotronik. Dr Frizzell has received consulting and speaker honoraria from Asahi Intecc, Boston Scientific, Medtronic, Reflow Medical, and Shockwave Medical. Dr Avran has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Asahi Intecc, Biotronik, Boston Scientific, Medtronic, Shockwave Medical, Teleflex, and Terumo. Dr McEntegart has received consulting, speaker, and proctoring honoraria from Boston Scientific and Shockwave Medical. Dr Lombardi has received consulting fees from Asahi Intecc, Abiomed, Boston Scientific, Medtronic, Siemens, and Teleflex and has received royalties from Asahi Intecc; his spouse is a Philips employee. Dr Grantham has received speaking fees and honoraria from Boston Scientific, Medtronic, and Asahi Intecc; has received advisory board fees from Teleflex and Boston Scientific; and has received institutional research grants from Asahi Intecc, Abiomed, and Boston Scientific. Dr Brilakis has received consulting and speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, the Cardiovascular Innovations Foundation (Board of Directors), Cardiovascular Systems, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, Teleflex, and Terumo; has received research support from Boston Scientific and GE Healthcare; is the owner or Hippocrates; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...

Background: Low operator and institutional volume is associated with poorer procedural and long-term clinical outcomes in patients treated with percutaneous coronary interventions (PCI). This study was aimed at evaluating the relationship between operator volume and procedural outcomes of patients treated with PCI for chronic total occlusion (CTO)., Methods: Data were obtained from the national registry of percutaneous coronary interventions (ORPKI) collected from January 2014 to December 2020. The primary endpoint was a procedural success, defined as restoration of thrombolysis in myocardial infarction (TIMI) II/III flow without in-hospital cardiac death and myocardial infarction, whereas secondary endpoints included periprocedural complications., Results: Data of 14,899 CTO-PCIs were analyzed. The global procedural success was 66.1%. There was a direct relationship between the annual volume of CTO-PCIs per operator and the procedural success (OR: 1.006 [95% CI: 1.003-1.009]; P<0.001). The nonlinear relationships of annualized CTO-PCI volume per operator and adjusted outcome rates revealed that operators performing 40 CTO cases per year had the best procedural outcomes in terms of technical success (TIMI flow II/III after PCI), coronary artery perforation rate and any periprocedural complications rate (P<0.0001). Among the other factors associated with procedural success, the following can be noted: multi-vessel, left main coronary artery disease (as compared to single-vessel disease), the usage of rotablation as well as PCI within bifurcation., Conclusions: High-volume CTO operators achieve greater procedural success with a lower frequency of periprocedural complications. Higher annual caseload might increase the overall quality of CTO-PCI. more...

Bifurcation involvement close to or within the occluded segment poses increasing difficulties for chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). However, this variable is not considered in the angiography-based CTO scoring systems nor has been extensively investigated in large multicenter series. Accordingly, we analyzed a CTO-PCI registry involving 92 European centers to explore the incidence, angiographic and procedural characteristics, and outcomes specific to CTO-PCIs with bifurcation involvement. A total of 3,948 procedures performed between January and November 2023 were examined (33% with bifurcation involvement). Among bifurcation lesions, 38% and 37% were located within 5 mm of the proximal and distal cap, respectively, 16% within the CTO body, and in 9% of cases proximal and distal bifurcations coexisted. When compared with lesions without bifurcation involvement, CTO bifurcation lesions had higher complexity (J-CTO 2.33 ± 1.21 vs 2.11 ± 1.27, p <0.001) and were associated with higher use of additional devices (dual-lumen microcatheter in 27.6% vs 8.4%, p <0.001, and intravascular ultrasound in 32.2% vs 21.7%, p <0.001). Radiation dose (1,544 [836 to 2,819] vs 1,298.5 [699.1 to 2,386.6] mGy, p <0.001) and contrast volume (230 [160 to 300] vs 190 [130 to 250] ml, p <0.001) were also higher. Technical success was similar (91.5% with bifurcation involvement vs 90.4% without bifurcation involvement, p = 0.271). However, the bifurcation lesions within the CTO segment (intralesion) were associated with lower technical success than the other bifurcation-location subgroups (83.7% vs 93.3% proximal, 93.4% distal, and 89.0% proximal and distal, p <0.001). On multivariable analysis, the presence of an intralesion bifurcation was independently associated with technical failure (odds ratio 2.04, 95% confidence interval 1.24 to 3.35, p = 0.005). In conclusion, bifurcations are present in approximately one-third of CTOs who underwent PCI. PCI of CTOs with bifurcation can be achieved with high success rates except for bifurcations within the occluded segment, which were associated with higher technical failure., Competing Interests: Declaration of competing interest Dr. Werner: speaker honoraria from Abbott Vascular, ASAHI Intecc, Daiichi-Sankyo, Orbus-Neich, Pfizer (New York, NY, United States), Philips-Volcano, and Siemens-Healthineers. TerumoWerner: speaker honoraria from Abbott Vascular, ASAHI Intecc, Daiichi-Sankyo, Orbus-Neich, Pfizer (New York, NY, United States), Philips-Volcano, Siemens-Healthineers, and Terumo. Myron Zaczkiewicz: speaker honoraria from Orbus-Neich, Medtronic, iVascular. Proctoring for Orbus-Neich and Asahi Intecc. Institutional: Abiomed. Dr. Boudou: minor fees as consultant from ASAHI Intecc and Terumo. Dr. Avran: proctoring for Boston Scientific, Biotronik, Vascular Therapy, ASAHI Intecc, Abbott Vascular, and Teleflex. Dr. Agostoni: consulting fees from Boston Scientific, CardiaWave, iVascular, Neovasc, Seven Sons, Teleflex, and Terumo. The remaining authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.) more...

"Full moon" is a central calcification that occludes the entire vessel on coronary computed tomography angiography (CCTA). We examined the association of full moon calcification as identified by CCTA, on clinical and procedural outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We studied patients who underwent elective CTO-PCI in 2 European centers and had preprocedural CCTA. The primary end point was the inability to cross the lesion and/or the need for extensive debulking techniques. Secondary end points were procedural success, in-hospital cardiac mortality, the need for extensive debulking techniques, myocardial infarction, major adverse cardiac events (defined as in-hospital death, myocardial infarction, and clinically driven target vessel revascularization), and stent thrombosis. Secondary procedural end points included procedural time, fluoroscopy time, number of guidewires and balloons, stent length, number and diameter, and contrast volume. Multivariable logistic regression analysis was performed, identifying potential covariates related to the primary outcome according to knowledge and previous studies. Subsequently, a stepwise selection approach was performed to select factors with the greatest predictive value. Of 140 patients included, 28 (20%) had a full moon calcified CTO plaque. Patients in the full moon group were older and had more cardiovascular risk factors. There was not significant difference in the need for retrograde approach and anterograde dissection and reentry techniques between the full moon group and the other groups (32.1% vs 37.5%, p = 0.59 and 0% vs 1.7%, p = 0.47, respectively). Patients in the full moon group had greater incidence of the primary outcome than did those who did not have full moon morphology (53.5% vs 12.5%, p <0.001). On multivariable analysis that included chronic kidney failure and previous coronary artery bypass surgery, full moon calcification was associated with greater incidence of the primary end point (odds ratio 6.5, 95% confidence interval 2.1 to 20.5, p = 0.001). Moreover, less procedural success (71.4% vs 87.5%, p = 0.03), greater incidence of coronary perforations (14.2% vs 3.5%, p <0.02), and greater procedural (172.5 [118.0 to 237.5] vs 144.0 [108.50 to 174.75], p = 0.02) and fluoroscopic time (62.6 [38.1 to 83.0] vs 42.8 [29.5 to 65.7], p = 0.03) were observed in the full moon group. Overall major adverse cardiac events did not differ between the 2 groups (1 patient in the full moon group vs 1 patient in the non-full moon group; 3.5% vs 0.8%, p = 0.29). In conclusion, full moon calcification on CCTA was independently associated with procedural complexity and adverse outcomes in CTO-PCI., Competing Interests: Declaration of competing interest Dr. Mashayekhi reports consulting/speaker/proctoring honoraria from Abbott Vascular, Abiomed, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi Sankyo, Medtronic, Shockwave Medical, Teleflex, and Terumo. The remaining authors have no competing interests to declare., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.) more...

Safety is of critical importance to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). This global consensus statement provides guidance on how to optimise the safety of CTO) PCI, addressing the following 12 areas: 1. Set-up for safe CTO PCI; 2. Guide catheter--associated vessel injuries; 3. Hydraulic dissection, extraplaque haematoma expansion, and aortic dissections; 4. Haemodynamic collapse during CTO PCI; 5. Side branch occlusion; 6. Perforations; 7. Equipment entrapment; 8. Vascular access considerations; 9. Contrast-induced acute kidney injury; 10. Radiation injury; 11 When to stop; and, 12. Proctorship. This statement complements the global CTO crossing algorithm; by advising how to prevent and deal with complications, this statement aims to facilitate clinical practice, research, and education relating to CTO PCI., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.) more...

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) continues to evolve. This review summarizes recent publications categorized by outcomes, techniques, complications, and ongoing studies in this rapidly growing area. more...

Large vessel perforation during coronary intervention is a rare but potentially fatal complication, often requiring implantation of a covered stent for resolution. While technology is improving, the long-term patency of covered stents is less than drug-eluting stents, and implantation of covered stents should be used sparingly. Large vessel perforations are complex and often the perforation inflow is not located at the site of extravasation seen on angiography. This can lead to geographic miss when implanting covered stents and necessitate the implantation of additional covered stents which increases the risk for short- and long-term complications. We present a case series to further investigate the anatomy and mechanism of large vessel perforations and guidance on effective covered stent implantation., (© 2024 Wiley Periodicals LLC.) more...

Chronic total occlusions (CTOs) of coronary arteries can be found in the context of chronic or acute coronary syndromes; sometimes they are an incidental finding in those apparently healthy individuals undergoing imaging for preoperative risk assessment. Recently, the invasive management of CTOs has made impressive progress due to sophisticated preinterventional assessment, including advanced non-invasive imaging, the availability of novel and dedicated tools for CTO percutaneous coronary intervention (PCI), and experienced interventionalists working in specialised centres. Thus, it is crucial that referring physicians who see patients with CTO be aware of recent developments and of the initial evaluation requirements for such patients. Besides a careful history and clinical examination, electrocardiograms, exercise tests, and non-invasive imaging modalities are important for selecting the patients most suitable for CTO PCI, while others may be referred to coronary artery bypass graft or optimal medical therapy only. While CTO PCI improves angina and reduces the use of antianginal drugs in patients with symptoms and proven ischaemia, hibernation and/or wall motion abnormalities at baseline or during stress, the effect of CTO PCI on major cardiovascular events is still controversial. This clinical consensus statement specifically focuses on referring physicians, providing a comprehensive algorithm for the preinterventional evaluation of patients with CTO and the current evidence for the clinical effectiveness of the procedure. The proposed care track has been developed by members and with the support of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Association of Cardiovascular Imaging (EACVI), and the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery. more...

Background: Percutaneous coronary interventions (PCI) of chronic total occlusions (CTO) have reached high procedural success rates thanks to dedicated equipment, evolving techniques, and worldwide adoption of state-of-the-art crossing algorithms., Aims: We report the contemporary results of CTO PCIs performed by a large European community of experienced interventionalists. Furthermore, we investigated the impact of different risk factors for procedural major adverse cardiac and cerebrovascular events (MACCE) and trends of employment of specific devices like dual lumen microcatheters, guiding catheter extensions, intravascular ultrasound and calcium-modifying tools., Methods: We evaluated data from 8,673 CTO PCIs included in the European Registry of Chronic Total Occlusion (ERCTO) between January 2021 and October 2022., Results: The overall technical success rate was 89.1% and was higher in antegrade as compared with retrograde cases (92.8% vs 79.3%; p<0.001). Compared with antegrade procedures, retrograde procedures had a higher complexity of attempted lesions (Japanese CTO [J-CTO] score: 3.0±1.0 vs 1.9±1.2; p<0.001), a higher procedural and in-hospital MACCE rate (3.1% vs 1.2%; p<0.018) and a higher perforation rate with and without tamponade (1.5% vs 0.4% and 8.3% vs 2.1%, respectively; p<0.001). As compared with mid-volume operators, high-volume operators had a higher technical success rate in antegrade and retrograde procedures (93.4% vs 91.2% and 81.5% vs 69.0%, respectively; p<0.001), and had a lower MACCE rate (1.47% vs 2.41%; p<0.001) despite a higher mean complexity of the attempted lesions (J-CTO score: 2.42±1.28 vs 2.15±1.27; p<0.001)., Conclusions: The adoption of different recanalisation techniques, operator experience and the use of specific devices have contributed to a high procedural success rate despite the high complexity of the lesions documented in the ERCTO. more...

Background: The prognostic impact of contrast-associated acute kidney injury (CA-AKI) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains underestimated., Methods: We examined 2707 consecutive procedures performed in a referral CTO center between 2015 and 2019. CA-AKI was defined as an increase in serum creatinine ≥ 0.3 mg/dL or ≥ 50% within 48 h post-PCI. Primary endpoints were in-hospital major adverse cardiac and cerebrovascular events (MACCE, composite of all-cause death, myocardial infarction, target vessel revascularization, stroke) and at one year of follow-up., Results: The overall incidence of CA-AKI was 11.5%. Technical success was comparable (87.2% vs. 90.5%, p = 0.056) whereas procedural success was lower in the CA-AKI group (84.3% vs. 89.7%, p = 0.004). Overall in-hospital MACCE was 1.3%, and it was similar in patients with and without CA-AKI (1.6% vs. 1.3%, p = 0.655); however, the rate of pericardial tamponade requiring pericardiocentesis was significantly higher in patients with CA-AKI (2.2% vs. 0.5%, p = 0.001). In multivariate analysis, CA-AKI was not independently associated with higher risk for in-hospital MACCE (adjusted odds ratio [OR] 1.34, 95% confidence intervals [CI] 0.45-3.19, p = 0.563). At a median follow-up time of 14 months (interquartile range [IQR], 11 to 35 months), one-year MACCE was significantly higher in patients with vs. without CA-AKI (20.8% vs. 12.8%, p < 0.001), and CA-AKI increased the risk for one-year MACCE (adjusted hazard ratio [HR] 1.46, 95% CI 1.07-1.95, p = 0.017) following CTO PCI., Conclusions: CA-AKI in patients undergoing CTO PCI occurs in approximately one out of 10 patients. Our study highlights that patients developing CA-AKI are at increased risk for long-term MACCE. more...

Background: Contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) practice has received limited study., Aim: To examine the contemporary CTO PCI practice., Methods: We performed an online, anonymous, international survey of CTO PCI operators., Results: Five hundred forty-five CTO PCI operators and 190 interventional cardiology fellows with an interest in CTO PCI participated in this survey. Almost half were from the United States (41%), most (93%) were men, and the median h/week spent in the hospital was 58. Median annual case numbers were 205 (150-328) for PCIs and 20 (5-50) for CTO PCIs. Almost one-fifth (17%) entered CTO cases into registries, such as PROGRESS-CTO (55%) and EuroCTO (20%). More than one-third worked at academic institutions (39%), 31% trained dedicated CTO fellows, and 22% proctored CTO PCI. One-third (34%) had dedicated CTO PCI days. Most (51%) never discharged CTO patients the same day, while 17% discharged CTO patients the same day >50% of the time. After successful guidewire crossing, 38% used intravascular imaging >90% of the time. Most used CTO scores including J-CTO (81%), PROGRESS-CTO (35%), and PROGRESS-CTO complications scores (30%). Coronary artery perforation was encountered within the last month by 19%. On a scale of 0-10, the median comfort levels in treating coronary artery perforation were: covered stents 8.8 (7.0-10), coil embolization 5.0 (2.1-8.5), and fat embolization 3.7 (0.6-7.3). Most (51%) participants had a complication cart/kit and 25% conducted regular complication drills with catheterization laboratory staff., Conclusion: Contemporary CTO PCI practices vary widely. Further research on barriers to following the guiding principles of CTO PCI may improve patient outcomes., (© 2023 Wiley Periodicals LLC.) more...

Background: The recent development and widespread adoption of antegrade dissection re-entry (ADR) techniques have been underlined as one of the antegrade strategies in all worldwide CTO consensus documents. However, historical wire-based ADR experience has suffered from disappointing long-term outcomes., Aims: Compare technical success, procedural success, and long-term outcome of patients who underwent wire-based ADR technique versus antegrade wiring (AW)., Methods: One thousand seven hundred and ten patients, from the prospective European Registry of Chronic Total Occlusions (ERCTO), underwent 1806 CTO procedures between January 2018 and December 2021, at 13 high-volume ADR centers. Among all 1806 lesions attempted by the antegrade approach, 72% were approached with AW techniques and 28% with wire-based ADR techniques., Results: Technical and procedural success rates were lower in wire-based ADR than in AW (90.3% vs. 96.4%, p < 0.001; 87.7% vs. 95.4%, p < 0.001, respectively); however, wire-based ADR was used successfully more often in complex lesions as compared to AW (p = 0.017). Wire-based ADR was used in most cases (85%) after failure of AW or retrograde procedures. At a mean clinical follow-up of 21 ± 15 months, major adverse cardiac and cerebrovascular events (MACCEs) did not differ between AW and wire-based ADR (12% vs. 15.1%, p = 0.106); both AW and wire-based ADR procedures were associated with significant symptom improvements., Conclusions: As compared to AW, wire-based ADR is a reliable and effective strategy successfully used in more complex lesions and often after the failure of other techniques. At long-term follow-up, patient's MACCEs and symptoms improvement were similar in both antegrade techniques., (© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.) more...

Since the publication of the 2015 EAPCI consensus on rotational atherectomy, the number of percutaneous coronary interventions (PCI) performed in patients with severely calcified coronary artery disease has grown substantially. This has been prompted on one side by the clinical demand for the continuous increase in life expectancy, the sustained expansion of the primary PCI networks worldwide, and the routine performance of revascularization procedures in elderly patients; on the other side, the availability of new and dedicated technologies such as orbital atherectomy and intravascular lithotripsy, as well as the optimization of the rotational atherectomy system, has increased operators' confidence in attempting more challenging PCI. This current EAPCI clinical consensus statement prepared in collaboration with the EURO4C-PCR group describes the comprehensive management of patients with heavily calcified coronary stenoses, starting with how to use non-invasive and invasive imaging to assess calcium burden and inform procedural planning. Objective and practical guidance is provided on the selection of the optimal interventional tool and technique based on the specific calcium morphology and anatomic location. Finally, the specific clinical implications of treating these patients are considered, including the prevention and management of complications and the importance of adequate training and education., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.) more...

Objective: To assess the technical feasibility of a new method of educational training, based on audio-video (AV) communication between an interventional cardiologist and the cath lab staff members in one location and a remote expert proctor., Methods: Overall, 9 patients underwent a percutaneous coronary intervention (PCI) targeting a chronic total occlusion (CTO) between June 2021 and January 2022 at a single Belgian center using the virtual proctoring approach. For this assessment, the strategic planning of the CTO PCI and all the decisions throughout the intervention were the responsibility of the proctor. The operator was guided via an AV link, by the proctor throughout the procedure., Results: The operator performed each procedural step, guided by the remote proctor, who had continuous access to all relevant interventional details. No major adverse cardiac events (MACE) occurred during the index hospitalization or within 6 months follow-up., Conclusions: A new method of virtual proctoring based on live AV communication is feasible, even in the case of highly complex CTO PCI procedures. This strategy also appears safe and may provide the patient the benefit of incremental expertise. This approach is facilitated by advances in AV communication and allows physicians to share expertise irrespective of location. It could increase global interaction between colleagues and facilitate sharing of knowledge, which are both key aspects in the development of CTO PCI. This preliminary experience could serve as a basis for future large studies to study the potential role and benefits of virtual proctoring for complex CTO PCI procedures. more...

Guiding catheter extensions (GCEs) have become indispensable tools in the modern approach to percutaneous coronary intervention (PCI). The support offered during complex PCI of uncrossable, or tortuous lesions is particularly valuable in the setting of chronic total occlusions (CTO), both for conventional anterograde wire escalation and for anterograde or retrograde dissection and re-entry techniques. This EuroCTO consensus document describes the use of GCE during CTO recanalization and provides a practical guide to anatomies and techniques in which these devices are applicable. We describe the peculiar features of the most-used device and the practical technique for GCE delivery in standard PCI; further specific indications for antegrade and retrograde CTO PCI are discussed in a specific section. In the antegrade approach, the GCEs may be useful to increase support or facilitate antegrade dissection and re-entry techniques, while in the retrograde approach for reverse controlled antegrade and retrograde tracking, to increase retrograde support for gear delivery, for treatment of CTO in bifurcation and ipsilateral externalization with a single guide catheter. The last section of the paper describes GCE-related complications, challenges, limitations, and future perspectives., Competing Interests: Funding Support and Author Disclosures Dr Mashayekhi has received consulting/speaker/proctoring honoraria from Abbott Vascular, Abiomed, Ashai Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi Sankyo, Medtronic, Shockwave Medical, Teleflex, and Terumo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with a considerable risk of complications, and risk stratification is of utmost importance., Aims: To assess the clinical usefulness of the recently developed PROGRESS-CTO (NCT02061436) complication risk scores in an independent cohort., Methods: Individual patient data pooled analysis of 3 registries was performed., Results: Of the 4569 patients who underwent CTO PCI, 102 (2.2%) had major adverse cardiovascular events (MACE). Patients with MACE were older (69 ± 11 vs. 65 ± 10, p < 0.001), more likely to have a history of prior coronary artery bypass graft surgery, and unfavorable angiographic characteristics J-CTO score (2.4 ± 1.2 vs. 2.1 ± 1.3, p = 0.007), including blunt stump (59% vs. 49%, p = 0.047). Technical success was lower in patients with MACE (59% vs. 86%, p < 0.001). The area under the receiver operating characteristic curve of the PROGRESS-CTO complication risk models were as follows: MACE 0.72 (95% confidence interval [CI], 0.67-0.76), mortality 0.73 (95% CI, 0.61-0.85), and pericardiocentesis 0.69 (95% CI, 0.62-0.77) in the validation dataset. The observed complication rates increased with higher PROGRESS-CTO complication scores. The PROGRESS-CTO MACE score showed good calibration in this external cohort, with MACE rates similar to the original study: 0.7% (score 0-1), 1.5% (score 2), 2.2% (score 3), 3.8% (score 4), 4.9% (score 5), 5.8% (score 6-7)., Conclusion: Given the good discriminative performance, calibration, and ease of calculation, the PROGRESS-CTO complication scores could help assess the risk of complications in patients undergoing CTO PCI., (Copyright © 2022 Elsevier B.V. All rights reserved.) more...

Background: With the advent of novel recanalization techniques and emerging devices, percutaneous coronary intervention (PCI) has become a promising leading treatment option for patients with chronic total occlusions (CTO). The present study aims to evaluate the acute outcomes of PCI in previously failed re-attempted vs. first-attempted CTO-lesions., Methods: Between 2012 and 2019, 619 patients were included and treated with PCI of at least one CTO. 253 patients were re-attempted lesions, while 366 were initially attempted lesions., Results: Re-attempted lesions were more complex, including higher Japanese-CTO (J-CTO) score and the need for a retrograde approach. The procedure time and fluoroscopy time were longer in this group. Nevertheless, overall success rates were comparable between both groups of patients. In-hospital events were rare and without significant differences., Conclusions: Re-attempted CTO lesions are more complex than first-attempt lesions and are associated with longer procedural times. However, they can be safely intervened by experienced operators with a similar success rate. more...

Background: The Rotapro study was conducted to evaluate the safety and feasibility of the new Rotapro rotational atherectomy system (RAS) for lesion preparation in calcified coronary artery stenosis., Methods: Between 2015 and 2019 consecutive patients undergoing rotational atherectomy (RA) with the new Rotapro system and the conventional rotablator (Rotablator) were included from the Bad Krozingen Rotablation Registry. The primary endpoint was the incidence of in-hospital major adverse cardiovascular and cerebral event (MACCE) rate., Results: Rotablation was performed in 3.6% of all patients (n = 597) treated by percutaneous coronary intervention. Procedural outcomes were compared according to the applied RAS (n = 246 Rotapro vs. n = 351 Rotablator). Overall technical success was achieved in 98.3% of patients. The primary endpoint of in-hospital MACCE was comparable between the Rotapro- and the Rotablator-group (3.7% vs. 5.7%, respectively, p = 0.254). The Rotapro group was associated with significant reductions of fluoroscopy time (30 vs. 38 min, p < 0.0001), procedural time (82.5 vs. 96 min, p = 0.0003), applied contrast volume (210 vs. 290 mL, p < 0.0001) and radiation dose (6129 vs. 9827 cGy*cm2, p < 0.0001) compared to the Rotablator group., Conclusions: The present study demonstrates the safety and efficacy of the new Rotapro system. Inhospital MACCE rates were comparable between both RAS, whereas Rotapro was associated with less fluoroscopy time, radiation dose as well as contrast use. more...

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) in coronary bifurcation lesions (CBL) is undergoing substantial technical progress and standardization, paralleling the evolution of dedicated devices, tools, and techniques. A standard consensus to classify CTO-CBL might be instrumental to homogenize data collection and description of procedures for scientific and educational purposes. The Medina-CTO classification replicates the classical three digits in Medina classification for bifurcations, representing the proximal main vessel, distal main vessel, and side branch, respectively. Each digit can take a value of 1 if it concerns atherosclerosis and is anatomically stenosed, or 0 if it is not. In addition, the occluded segment(s) of the bifurcation are noted by a subscript, which describes key interventional features of the cap: t (tapered), b (blunt), or a (ambiguous). This approach results in 56 basic categories that can be grouped by means of different elements, depending on the specific needs of each study. Medina-CTO classification, consisting of adding a subscript describing the basic cap characteristics to the totally occluded segment(s) of the standard Medina triplet, might be a useful methodological tool to standardize percutaneous intervention of bifurcational CTO lesions, with interesting scientific and educational applications. more...

Background: The aim of this study was to describe the mechanism of subintimal shift (SIS), standardise diagnostic criteria and sensitise the interventional community to this phenomenon. The treatment of chronic total occlusions (CTO) by means of percutaneous coronary intervention (PCI) is complicated by bifurcation lesions involved in the CTO segment or adjacent to it. Extraplaque expansion of intracoronary devices during CTO PCI may extend the dissection plane over the bifurcation with the consequential side or main branch compression by an intimo-medial flap. This phenomenon is hereby described for the first time and named subintimal shift., Methods: Experienced CTO operators from 3 international high volume centers for CTO PCI retrospectively searched their personal records for paradigmatic cases of SIS, summarising key features and proposing diagnostic criteria., Results: The series comprised 7 demonstrative cases, illustrating SIS by intravascular imaging (2 cases) or indirect angiographic signs during CTO PCI (5 cases). Five cases were triggered by stent expansion, 1 by balloon inflation and 1 case was aborted after angiographic warning signs. In 4 cases, SIS resulted in total occlusion of a branch, refractory to ballooning whenever attempted. Four cases required bailout intervention and in 2 cases the branch was left occluded, resulting in a rise of cardiac markers., Conclusions: Subintimal shift is a noteworthy complication in CTO bifurcations, potentially resulting in occlusion of the relevant side or even the main branch. Intracoronary imaging prior to stenting is recommended to understand the tissue planes. Some counterintuitive peculiarities of this phenomenon, like its refractoriness to ballooning, must be known by CTO operators for its efficient resolution. more...

Objectives: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can improve patient symptoms, but it remains controversial whether it impacts subsequent clinical outcomes., Methods: 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., Results: 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., Conclusions: 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. more...

Objective: To compare the clinical outcomes after extraplaque (EP) versus intraplaque (IP) tracking in chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Background: The impact of modern dissection and reentry (DR) techniques on the long-term outcomes of CTO PCI remains controversial., Methods: We performed a systematic review and meta-analysis of studies that compared EP versus IP tracking in CTO PCI. Odds ratios (ORs) with 95% confidence intervals (CIs) are calculated using the Der-Simonian and Laird random-effects method., Results: Our meta-analysis included seven observational studies with 2982 patients. Patients who underwent EP tracking had significantly more complex CTOs with higher J-CTO score, longer lesion length, and more severe calcification and had significantly longer stented segments. During a median follow-up of 12 months (range 9-12 months), EP tracking was associated with a higher risk of major adverse cardiovascular events (MACE) (OR 1.50, 95% CI (1.10-2.06), p = 0.01) and target vessel revascularization (TVR) (OR 1.69, 95% CI (1.15-2.48), p = 0.01) compared with IP tracking. There was no difference in the incidence of all-cause death (OR 1.37, 95% CI (0.67-2.78), p = 0.39), myocardial infarction (MI) (OR 1.48, 95% CI (0.82-2.69), p = 0.20), stent thrombosis (OR 2.09, 95% CI (0.69-6.33), p = 0.19), or cardiac death (OR 1.10, 95% CI (0.39-3.15), p = 0.85) between IP and EP tracking., Conclusion: EP tracking is utilized in more complex CTOs and requires more stents. EP tracking is associated with a higher risk of MACE, driven by a higher risk of TVR at 1 year, but without an increased risk of death or MI compared with IP tracking. EP tracking is critically important for contemporary CTO PCI., (© 2022 Wiley Periodicals LLC.) more...

Background: Coronary chronic total occlusion lesions (CTOs) confer an increased risk of arrhythmic events among patients with ischemic cardiomyopathy (ICM) and implantable cardioverter-defibrillator (ICD) carriers, however the impact of CTO recanalization in this population remains unassessed., Aims: Evaluate the impact of CTOs percutaneous coronary interventions (PCI) on arrhythmic events., Methods: Patients with ICM and ICD from the VACTO I-II registries: patients with medically treated CTO (CTO-OMT group) and without CTO (no-CTO group) were compared after inverse-probability-weighting adjustment (IPWT) with a similar population of consecutive patients undergoing CTO-PCI. The primary endpoint was appropriate ICD therapy. The secondary endpoint was all-cause mortality., Results: The total of 622 patients (mean age 67 ± 10 years, mean left ventricular ejection fraction 36 ± 11%) included in the analysis was composed by: CTO-PCI patients n = 113, CTO-OMT patients n = 286, no-CTO patients n = 223. In the CTO-PCI group, compared to the CTO-OMT group, 5-year Kaplan Meier estimates for appropriate ICD therapy (20.4% vs. 56.4%, IPW-adjusted HR: 0.45, 95% CI 0.29-0.71) and mortality (8.8% vs. 23%, IPW-adjusted HR: 0.43, 95% CI 0.22-0.85) were lower, driven by infarct related artery CTO (IRA-CTO) PCI, while similar to those occurring in the no-CTO group., Conclusions: In this large population, those with CTO receiving PCI had lower arrhythmic event rates and lower mortality compared to the CTO-OMT group, while showing an event rate similar to no-CTO patients. Sensitivity analyses suggest that the beneficial effect on the arrhythmic outcome was driven by IRA-CTO revascularization., Classification: Chronic total occlusion., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.) more...

Background: The few randomized controlled trials (RCTs) on chronic total occlusion (CTO) percutaneous coronary intervention (PCI) are subject to selection bias., Objectives: The purpose of this study was to evaluate the differences between real-world CTO patients and those enrolled in RCTs., Methods: 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., Results: 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%)., Conclusions: 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., Competing Interests: Funding Support and Author Disclosures Dr Mashayekhi has received consulting, speaker, or proctoring honoraria from Abbott Vascular, Abiomed, Ashai Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi Sankyo, Medtronic, Shockwave Medical, Teleflex, and Terumo. Dr Grantham has received consulting fees and honoraria from Boston Scientific, Asahi Intecc, Medtronic, and Siemens Healthineers; and institutional research grants from Boston Scientific and Asahi Intecc. Dr Rinfret has served as a consultant for Boston Scientific, Abiomed, Abbott Vascular, and Soundbite Medical. Dr McEntegart has received consulting or speaker honoraria from Abbott Vascular, Biosensors, Boston Scientific, Medtronic, Shockwave Medical, and Teleflex. Dr Brilakis has received consulting or speaker honoraria from Abbott Vascular, the American Heart Association (associate editor Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, Cardiovascular Systems Inc, Ebix, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; has received research support from Regeneron and Siemens; and is a shareholder in MHI Ventures. Dr Alaswad has received consulting or speaker honoraria from Boston Scientific, Cardiovascular Systems, LivaNova, and Teleflex. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...

Background Coronary perforation is a life-threatening complication of acute percutaneous coronary intervention (PCI) for chronic total occlusions (CTO), but data on midterm outcomes are limited. Methods and Results Data from LATAM (Latin American)-CTO Registry (57 centers; 9 countries) were analyzed. We assessed the risk of 30-day, 1-year major adverse cardiac events of coronary perforation using time-to-event and weighted composite end point analysis having CTO PCI without perforation as comparators. Additionally, we studied the independent predictors of perforation in these patients. Of 2054 patients who underwent CTO PCI between 2015 and 2018, the median Multicenter CTO Registry in Japan and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention-Chronic total occlusions scores were 2.0 (1.0-3.0) and 1.0 (0.0-2.0), respectively. The perforation rate was 3.7%, of which 55% were Ellis class 1. After 1-year coronary perforation had higher major adverse cardiac events rates (24.9% versus 13.3%; P <0.01). Using weighted composite end point, perforation was associated with increased bleeding and ischemic events at 6 months ( P =0.04) and 1 year ( P <0.01). We found as independent predictors associated with coronary perforation during CTO PCI: maximum activated clotting time ( P <0.01), Multicenter CTO Registry in Japan score ≥2 ( P =0.05), antegrade knuckle wire ( P =0.04), and right coronary artery CTO PCI ( P =0.05). Conclusions Coronary perforation was infrequent and associated with anatomical and procedural complexity, resulting in higher risk of hemorrhagic and ischemic events. Landmark and weighted analysis showed a sustained burden of major events between 6 months and 1 year follow-up. more...

Introduction: Device entrapment is a life-threatening complication during percutaneous coronary intervention (PCI). However, the success for its management is predominantly based on operator experience with limited available guidance in the published literature., Methods: A systematic review was performed on December 2021; we searched PubMed for articles on device entrapment during PCI. In addition, backward snowballing (i.e., review of references from identified articles and pertinent reviews) was employed., Results: A total of 4209 articles were retrieved, of which 150 studies were included in the synthesis of the data. A methodical algorithmic approach to prevention and management of device entrapment can help to optimize outcomes. The recommended sequence of steps are as follows: (a) pulling, (b) trapping, (c) snaring, (d) plaque modification, (e) telescoping, and (f) surgery., Conclusions: In-depth knowledge of the techniques and necessary tools can help optimize the likelihood of successful equipment retrieval and minimization of complications., (© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.) more...

Objectives: The aim of this study was to identify independent predictors of procedural success after retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Background: Retrograde CTO PCI is an established technique, but predictors of success remain poorly understood., Methods: 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., Results: 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., Conclusions: 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., Competing Interests: Funding Support and Author Disclosures Dr Mashayekhi has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic, Teleflex, and Terumo. Dr Avran has received consulting, speaker, and proctoring honoraria from Asahi Intecc, Biotronik, Boston Scientific, Terumo, Alvimedica, and OrbusNeich. Dr Boudou is a proctor and consultant for Asahi Intecc, Terumo, and Boston Scientific. Dr Garbo is a proctor and consultant for Philips Volcano, Boston Europe, Terumo Italy, and Europe Teleflex. Dr Bryniarski has received speaker and proctoring honoraria from Procardia Medical, Boston Scientific, and Terumo. Prof Spratt has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Asahi Intecc, Boston Scientific, Cardinal Health, and Shockwave Medical. Dr Lesiak has received speaker and proctoring honoraria from Abbott Vascular, Boston Scientific, Biotronik, Medtronic, and Terumo Medical. Prof Di Mario has received research or educational grants from Abbott, Amgen, Asahi Intecc, AstraZeneca, Boston Scientific, Cardinal Health, Behring, Chiesi, Daiichi-Sankyo, Edwards Lifesciences, Medtronic, Menarini, Pfizer, Sanofi, Shockwave, Teleflex, and Volcano-Philips. Dr Hildick-Smith has served on the advisory boards for Abbott, Terumo, Boston Scientific, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...

Background: The relationship between left ventricular ejection fraction (LVEF) and the success and safety of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We examined the clinical characteristics and outcomes of CTO PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO) after stratifying patients by LVEF (≤35%, 36%-49%, and ≥50%)., Results: A total of 7827 CTO PCI procedures with LVEF data were included. Mean age was 64 ± 10 years, 81% were men, 43% had diabetes mellitus, 61% had prior PCI, 45% had prior myocardial infarction, and 29% had prior coronary artery bypass graft surgery. Technical success was similar in the three LVEF strata: 85%, 86%, and 87%, p = 0.391 for LVEF ≤35%, 36%-49%, and ≥50%, respectively. In-hospital mortality was higher in lower LVEF patients (1.1%, 0.4%, and 0.3%, respectively, p = 0.001). In-hospital major adverse cardiovascular events (MACE) were numerically higher in lower EF patients (2.7%, 2.1%, and 1.9%, p = 0.271). At a median follow-up of 2 months (interquartile range: 19-350 days), patients with lower LVEF continued to have higher mortality (4.9%, 3.2%, and 1.4%, p < 0.001) while the MACE rates were similar (9.3%, 9.6%, and 7.4%, p = 0.172)., Conclusion: CTO PCI can be performed with high technical success in patients with reduced LVEF but is associated with higher in-hospital and post-discharge mortality., (© 2022 Wiley Periodicals LLC.) more...

Remarkable progress has been achieved in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in recent years, with refinement of the indications and technical aspects of the procedure, imaging, and complication management. Randomized controlled trials and rigorous prospective registries have provided high-quality data on the benefits and risks of CTO PCI. Global collaboration has led to an agreement on nomenclature, indications, endpoint definition, and principles of clinical trial design that have been distilled in global consensus documents such as the CTO Academic Research Consortium. Increased use of preprocedural coronary computed tomography angiography and intraprocedural intravascular imaging, as well as development of novel techniques and structured CTO crossing and complication management algorithms, allow a systematic, stepwise approach to this difficult lesion subset. This state-of-the-art review provides a comprehensive discussion about the most recent developments in the indications, preprocedural planning, technical aspects, complication management, and future directions of CTO PCI., Competing Interests: Funding Support and Author Disclosures Dr Azzalini has received honoraria from Teleflex, Abiomed, Asahi Intecc, Philips, Abbott Vascular, and Cardiovascular Systems, Inc. Dr Karmpaliotis has received honoraria from Boston Scientific and Abbott Vascular; and has equity in Saranas, Traverse Vascular, and Soundbite. Dr Santiago has received speaker and proctoring honoraria from Boston Scientific, Abbott Vascular, and Teleflex. Dr Mashayekhi has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Ashai Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic, Teleflex, and Terumo. Dr Di Mario has received research grants from Amgen, Behring, Boston Scientific, Chiesi, Daiichi-Sankyo, Edwards Lifesciences, Medtronic, Shockwave Medical, and Volcano/Philips. Dr Rinfret has received consulting honoraria from Boston Scientific, Teleflex, Abbott Vascular, Medtronic, and Soundbite Medical. Dr Nicholson has received proctoring and advisory board honoraria from Abbott Vascular, Boston Scientific, Medtronic, and Asahi Intecc. Dr Tsuchikane has received consulting honoraria from Asahi Intecc, Kaneka, Nipro, and Boston Scientific. Dr Brilakis has received consulting and speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, Cardiovascular Systems, Inc, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; is an owner of Hippocrates; and is a shareholder in MHI Ventures and Cleerly Health. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...

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 EuroCTO consensus document describes current DLMC and suggests a practical guide to anatomies and techniques in which these devices are applicable. more...

Background: Recent improvements in clinical skills, technology, and hardware have 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- 3.4%), mortality 0.44% (95% CI: 0.23-0.84%), stroke 0.2% (95% CI: 0.1-0.3%); myocardial infraction 1.6% (95% CI: 1.1-2.2%); 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. more...

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., Competing Interests: Funding Support and Author Disclosures Dr Wu has received research funding from Abiomed, OrbusNeich, Asahi Intecc; has received consulting honoraria from Boston Scientific and Abbott Vascular; is a member of the board of directors for APCTO Club; and holds stock in Abbott Vascular. Dr Brilakis has received consulting and speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (board of directors), ControlRad, CSI, Ebix, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; has received research support from Regeneron and Siemens; is an owner of Hippocrates; and is a shareholder in MHI Ventures. Dr Mashayekhi has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic, Teleflex, and Terumo. Dr Tsuchikane is a consultant for Boston Scientific, Asahi Intecc, Nipro, and Kaneka. Dr Avran has received consulting, speaker, and proctoring honoraria from Asahi Intecc, Biotronik, Boston Scientific, Terumo, Alvimedica, and OrbusNeich. Dr Azzalini has received consulting fees from Abiomed and Teleflex. Dr Buller is global medical director of Teleflex. Dr Burke is a shareholder in Egg Medical and MHI Ventures. Dr Croce has received grants from Abbott, Takeda, Teleflex, and CSI; has received consulting honoraria from Abbott, BSCI, Biotronik, Philips, Abiomed, CSI, Takeda, and Cordis; and holds stock in Dyad Medical. Dr Damas de los Santos is a proctor, speaker, and consultant for Boston Scientific, Terumo, Abbott Vascular, and Biotronik. Dr Dens has consultancy contracts with Abbott, Boston Scientific, IMDS, Terumo, Topmedical (a distributor for Asahi); and is a chronic total occlusion proctor for Boston Scientific and Topmedical (Asahi). Dr di Mario has received research grants from Abbott, Amgen, Behring, Daiichi-Sankyo, Edwards, Medtronic, and Shockwave Medical. Dr Egred has received chronic total occlusion proctorship fees, speaker fees, honoraria, and grants from Abbott Vascular, Boston Scientific, Philips, Spectranetics, Vascular Perspectives, Merrill, Biotronik, and AstraZeneca. Dr Elbarouni has received speaker fees from Teleflex and Bayer. Dr ElGuindy has received consulting, speaker, and proctoring honoraria from Medtronic, Boston Scientific, Asahi Intecc, and Terumo. Dr Escaned has received personal fees from Abbott, Boston Scientific, Terumo, and Phillips. Dr Furkalo has a proctoring agreement with Medtronic; and has received speaker honoraria from Sanofi. Dr Garbo is a proctor and consultant for Philips Volcano, Boston Europe, Terumo Italy, and Europe Teleflex. Dr Hall has received speaker honoraria from Medtronic, OpSens Medical, and the Cardiovascular Innovations Foundation. Dr Hanna Quesada has received honoraria from Boston Scientific. Dr Harb is a consultant for Medtronic and Cardinal Health; and has received speaker honoraria from Cardinal Health and Terumo. Dr Harding has received speaker and consultancy fees from Boston Scientific, Medtronic, Bio-Excel, and Asahi Intecc. Dr Hatem is a member of the Speakers Bureau for Abbott, Boston Scientific, and Teleflex. Dr Hoye has received speaker fees from AstraZeneca and Sanofi. Dr Jaber has received proctoring fees from Abbott; and has received consulting, advisory board, and institutional funds from Medtronic. Dr Jaffer conducts sponsored research for Canon, Siemens, Teleflex, and Shockwave; is a consultant for Boston Scientific, Siemens, Biotronik, and Magenta Medical; and holds equity interest in Intravascular Imaging. Dr Jussila has a proctoring contract with Boston Scientific and EPS Vascular. Dr Kalyanasundaram has received fees from Abbott Vascular, Boston Scientific, Asahi Intecc, and Terumo. Dr Kandzari has received institutional research grant support from Abbott, Biotronik, Boston Scientific, Cardiovascular Systems, Medtronic, Teleflex, and OrbusNeich; Dr Karmpaliotis has received honoraria from Abbott Vascular and Boston Scientific; and holds equity in Saranas, Soundbite, and Traverse Vascular. Dr Kassem has received speaker honoraria from Boston Scientific, Abbott Vascular, GE, and Abiomed. Dr Khatri has received institutional research grant from Asahi Intecc and honoraria or consulting fees from Abbott Vascular, Boston Scientific, and Terumo. Dr Kornowski is a founder of NitiLoop. Dr Lamelas has received proctoring fees from Boston Scientific, Edwards Lifesciences, and Medtronic. Dr Lim has received educational support and honoraria from Asahi Intecc, Boston Scientific, Abbott Vascular, Kaneka, Biotronik, Alvimedica, Terumo, and Medtronic. Dr Lo has received speaker and proctoring honoraria from Bio-Excel, Boston Scientific, Abbott, and Terumo; and is a member of Medtronic’s advisory board. Dr Lombardi has received royalties and is a consultant for Asahi Intecc; is a consultant for Abiomed, Boston Scientific, Medtronic, Siemens, and Teleflex; and his spouse is an employee of Philips. Dr Maran is a consultant for Boston Scientific, Medtronic, and Philips. Dr Moses has received funding from Orchestra Biomedical and Ostial Corporation. Dr Munawar has received speaker and proctorship honoraria from Asahi Intecc, Terumo, Boston Scientific, Abbott Vascular, Toray, and Phillips. Dr Oksnes has proctoring contracts with Boston Scientific and EPS Vascular. Dr Olivecrona has received lecture honoraria from Abbott and Biotronik; and has received proctoring honoraria from EPS Vascular and Terumo. Dr Patel is a consultant for Abbott Vascular, Terumo, and Chiesi; and is a proctor for Medtronic. Dr Quadros has received honoraria from Boston Scientific; and has received research funding from Boston and Terumo. Dr Abi Rafeh is a proctor and consultant for Boston Scientific, Abbott, and Shockwave Medical. Dr Råmunddal has received consulting honoraria from EPS Vascular, Boston Scientific, and Abbott Vascular. Dr Riley is an advisory board and Speakers Bureau member for and has received consulting honoraria from Boston Scientific, Asahi Intecc, and Medtronic. Dr Saghatelyan has received proctoring and speaker honoraria from Asahi Intecc and Terumo. Dr Spaedy is a consultant for Boston Scientific and Abbott Vascular. Dr Stone has received speaker or other honoraria from Cook and Terumo; is a consultant to Valfix, TherOx, Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions, Miracor, Neovasc, V-Wave, Abiomed, Ancora, MAIA Pharmaceuticals, Vectorious, Reva, Matrizyme, Cardiomech, Elucid Bio, and Occlutech; and holds equity or options with Ancora, Cagent, Applied Therapeutics, the Biostar family of funds, SpectraWave, Orchestra Biomed, Aria, Cardiac Success, the MedFocus family of funds, and Valfix. Dr Tammam has a proctorship agreement with Terumo. Dr Tremmel has received honoraria from Abbott Vascular and Boston Scientific. Dr Wollmuth has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Abiomed, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Systems, Medtronic, and Philips. Dr Ybarra has received consulting and speaker fees from Abbott Vascular Canada and SoundBite Medical Solutions. Dr Yeh has received research grants from Abbott Vascular, AstraZeneca, Cook, BD Bard, Boston Scientific, Medtronic, and Philips; and is a consultant for Abbott Vascular, AstraZeneca, Boston Scientific, Edwards Lifesciences, Medtronic, Shockwave Medical, and Zoll. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.) more...

Background/objective: Microcatheters and dedicated guidewires for both chronic total occlusion (CTO) and non-CTO percutaneous coronary intervention (PCI) are increasingly being used to overcome complex coronary anatomy with severe tortuosity and calcification. In extremely resistant lesions, a potential over-rotation and device fatigue may result in entrapment or even fracture causing abrupt vessel closure and hinder successful revascularization., Method/result: We demonstrate two consecutive cases complicated with dislodged microcatheter tip which was rescued uniquely with coronary laser atherectomy. We describe an algorithmic approach for management of microcatheter fracture which are increasingly occur in contemporary practice of complex PCI., Conclusion: In summary, our cases illustrate the feasibility of using coronary excimer laser system to release fractured and entrapped intracoronary MC tips when other conventional percutaneous techniques fail., Competing Interests: Declaration of competing interest Kambis Mashayekhi MD: honoraria/consulting fees from Ashai Intecc, Boston, Medtronic, Teleflex, Cardinal Health, Abboth, Biotronik, Terumo, AstraZeneca, Daiichi Sankyo. Remaining authors: nothing to disclose., (Copyright © 2020. Published by Elsevier Inc.) more...

Aims: Radiation exposure is a limiting factor for percutaneous coronary interventions (PCI) of chronic total coronary occlusion (CTO) lesions. This study was designed to analyze changes in patient radiation dose for CTO-PCI and parameters associated with radiation dose., Methods and Results: We analyzed a cohort of 12,136 procedures performed by 23 operators between 2012 and 2017 from the European Registry of CTO-PCI. Radiation exposure was recorded as air kerma (AK) and dose area product (DAP). A dose rate index (DRI) was calculated as AK per fluoroscopy time to normalize for individual differences in fluoroscopy time. The lesion complexity increased from Japanese-CTO (J-CTO) score of 2.19 ± 1.44 to 2.46 ± 1.28, with an increase of retrograde procedures from 31.1% to 40.7%; still, procedural success improved from 87.7% to 92.1%. Fluoroscopy time remained similar, but AK decreased by 14.9%, from 2.35 Gy (interquartile range [IQR], 1.29-4.14 Gy) to 2.00 Gy (IQR, 1.08-3.45 Gy) and DAP decreased by 21.5%, from 130 Gy•cm² (IQR, 70-241 Gy•cm²) to 102 Gy•cm² (IQR, 58-184 Gy•cm²). Radiation exposure was determined by the lesion complexity (J-CTO score) and procedural complexity (antegrade or retrograde). DRI was determined by fluoroscopy frame rate and type of equipment used, but the major influence remained interoperator differences., Conclusions: Radiation exposure decreased during the observation period despite an increase in lesion and procedural complexity. While many operators already achieved a goal of low radiation exposure, there were considerable interoperator differences in radiation management, indicating further potential for improvement. more...

Recanalisation of chronic total coronary occlusions - what is the evidence and which patients will benefit? Abstract. Continuous improvement of recanalisation techniques and newer device technologies significantly improved the success of revascularisation in percutaneous coronary intervention (PCI) of chronic total occluded coronary arteries (CTO) in the past few years. The best documented clinical benefit of CTO-PCI is symptom control, based on a reduction of myocardial ischemia. In contrast, there is still an ongoing controversial debate regarding the prognostic benefit of successful CTO-PCI shown in several observational studies. Therefore, the indication for CTO-PCI is primarily based on patients' symptoms and the extent of myocardial ischemia. The risk / benefit ratio for the individual patient has to be estimated from technical complexity of the CTO lesion, the extent of the coronary artery disease and the ventricular function. Recanalisation strategy should be escalating, as most of the CTOs can be successfully recanalised with standard antegrade recanalisation techniques. With the implementation of retrograde CTO techniques, the likelihood for recanalisation success is very high (> 90 %) even in complex anatomies, combined with low complication rates in specialised centers. According to the operator's expertise a complete catheter-based revascularisation can be achieved nowadays even in patients with CTO and coronary multi-vessel disease. more...

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 < .001). Retrograde CTO PCI was associated with a lower success rate (80.9% vs. 87.4%, p < .001). Both approaches had similar in-hospital mortality, urgent revascularization, and cerebrovascular events. Retrograde CTO PCI was associated with higher risk of in-hospital myocardial infarction (MI; odds ratio [OR] 2.37, 95% confidence intervals [CI] 1.7, 3.32, p < .001), urgent pericardiocentesis (OR 2.53, 95% CI 1.41-4.51, p = .002), and contrast-induced nephropathy (OR 2.12, 95% CI 1.47-3.08; p < .001). During a mean follow-up of 48 ± 31 months retrograde crossing had similar mortality (OR 1.79, 95% CI 0.84-3.81, p = .13), but a higher incidence of MI (OR 2.07, 95% CI 1.1-3.88, p = .02), target vessel revascularization (OR 1.92, 95% CI 1.49-2.46, p < .001), and target lesion revascularization (OR 2.08, 95% CI 1.33-3.28, p = .001)., Conclusions: Compared with antegrade CTO PCI, retrograde CTO PCI is performed in more complex lesions and is associated with a higher risk for acute and long-term adverse events., (© 2019 Wiley Periodicals, Inc.) more...

Objectives: To evaluate the incidence of vascular complication and major bleeding in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with a fully trans-wrist access (TWA) approach versus a conventional approach based on trans-femoral access (TFA)., Background: TFA is the preferred vascular access in CTO PCI, but it has been associated with a non-negligible risk of complications., Methods: This retrospective registry included all patients undergoing CTO PCI at five institutions between July 2011 and October 2018. Patients were divided into two groups: Conventional (patients treated with at least one TFA) and Fully TWA (subjects exclusively treated with one or two TWA). The primary safety endpoint was a composite of vascular complications and major bleeding. The primary efficacy endpoint was procedural success., Results: We included 1,900 patients (Conventional n = 1,496 and Fully TWA n = 404). Conventional patients showed higher occlusion complexity (J-CTO score 2.1 ± 1.2 vs. 1.5 ± 1.1, p < .001). Procedural success showed no significant difference between both groups (85.7 vs. 83.0%, p = .17). The primary safety endpoint occurred more frequently in the Conventional group (10.3 vs. 4.5%, p < .001), driven by vascular complications (9.4 vs. 3.7%, p < .001). On multivariate analysis, not using a Fully TWA approach was an independent predictor of the study endpoint, after adjusting for age, sex, diabetes, body mass index, chronic kidney disease, prior coronary artery bypass graft, and J-CTO score., Conclusions: Embracing a Fully TWA approach for CTO PCI might be associated with lower incidence of a composite endpoint of vascular complications and major bleeding, compared with a Conventional approach., (© 2019 Wiley Periodicals, Inc.) more...

Background: The percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains debated. Therefore the aim of this large-scale observational multi-center registry was to compare the long-term outcome of CTO patients undergoing different therapeutic approaches comparing successful CTO revascularization either by PCI or coronary artery bypass graft (CABG), failed CTO-PCI and optimal medical therapy (OMT) alone., Methods and Results: A total of 6630 CTO patients were enrolled from two high-volume centers to compare different treatment strategies. All procedures were performed by high-volume CTO operators in tertiary university hospital. Successful CTO-PCI was performed in 3906 patients, failed CTO-PCI in 1479 patients, 412 patients underwent CABG surgery and 833 patients were treated with OMT. During the 5-year follow-up period, 1019 (15%) patients died. Kaplan-Meier analysis unveiled a significantly improved long-term outcome for CTO patients undergoing revascularization either by PCI or by CABG compared to patients with failed CTO-PCI or OMT alone (log-rank P < 0.001). In the multivariate Cox-regression analysis successful CTO-PCI was associated with significantly improved long-term outcome compared to patients under OMT (adj. HR 0.39, 95%CI 0.33-0.45, P < 0.001) or CABG (adj. HR 0.68, 95%CI 0.53-0.86, P = 0.002) independent of clinical confounders encompassing age, BMI, diabetes, kidney function and left ventricular function., Conclusions: This study showed an improved long-term outcome for CTO revascularization compared to optimal medical therapy, independent from revascularization mode, with the highest survival rate in patients undergoing successful CTO-PCI., Competing Interests: Declaration of Competing Interest The authors declare they have no conflict of interest., (Copyright © 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.) more...

Background: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. Recanalization of ostial lesions is challenging and complex. This present study aims to evaluate the outcome of patients with ostial and non-ostial CTO-PCI with regard to acute, in-hospital outcome., Methods: Between 2012 and 2018 we included 600 patients. Ostial lesions (OL) were defined as a coronary arterial stenosis within 3 mm of the vessel origin. Antegrade and retrograde CTO-PCI techniques were used and a composite safety endpoint comprising in-hospital death, vascular complications, cardiac tamponade, stroke and acute myocardial infarction., Results: The majority of the patients were male (82.3%) and the mean age was 62.1 years (±10.3 years). The right coronary artery (RCA) was the most frequent target vessel in 58.5%, followed by the left circumflex artery (LCX) (15.4%) and the left anterior descending artery (LAD) (26.2%). The success (p = .439) and complication rates (p = .169) were independent of the target vessel. We determined that examination and fluoroscopy time were longer in patients with OL (120.7 min vs. 99.0 min, p < .001 and 44.9 min vs. 34.5 min, p < .001) and that in this group of patients the retrograde approach was used more frequent (38.8% vs. 18.2%, p < .001). Overall success rates were lower in OL than compared to NOL (74.6% vs. 86.5%, p = .016)., Conclusions: Our retrospective study suggests that recanalization of ostial CTO lesions is associated with reduced PCI success rates as well as long examination and high fluoroscopy times., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.) more...

The field of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has witnessed a dramatic evolution in the last decade. The challenging nature of CTO interventions involves regularly dealing with support-related issues, uncrossable/undilatable lesions, manipulation of equipment in the subadventitial (also known as "subintimal") space, and the treatment of complications such as perforation and equipment loss or entrapment. The CTO experience has provided numerous techniques to the creative operator facing challenges in the non-CTO PCI setting. Herewith, we discuss an armamentarium of techniques routinely used in CTO-PCI, which can also be utilized in interventions for non-occlusive coronary artery disease and have the potential to improve the efficacy and safety of these procedures. more...

Aims: This study sought to assess the prognostic impact of coronary chronic total occlusions (CTO) in patients presenting with ventricular tachyarrhythmias on admission., Methods and Results: A large retrospective registry was used, including all consecutive patients presenting with ventricular tachyarrhythmias on admission and undergoing coronary angiography from 2002 to 2016. Patients with a CTO were compared with all other patients (non-CTO) for prognostic outcomes. Statistics comprised Kaplan-Meier and Cox regression analyses. Within a total of 1,461 consecutive patients included with ventricular tachyarrhythmias on admission, a CTO was present in 20%. At midterm follow-up of 18 months, the primary endpoint all-cause mortality had occurred in 40% of CTO patients compared to 27% of non-CTO patients (HR 1.563, 95% CI: 1.263-1.934; p=0.001). The rates of secondary endpoints were higher for in-hospital all-cause mortality at index (29% versus 20%, log-rank p=0.027) and the composite endpoint of cardiac death at 24 hours, recurrent ventricular tachyarrhythmias and appropriate ICD therapies at midterm follow-up (28% versus 20%, log-rank p=0.005). Mortality rates were highest in CTO patients with stable coronary artery disease (CAD), acute myocardial infarction and in patients surviving index hospitalisation., Conclusions: In patients presenting with ventricular tachyarrhythmias on admission, the presence of a coronary CTO is independently associated with an increase of midterm all-cause mortality, in-hospital all-cause mortality and the composite endpoint of early cardiac death, recurrent ventricular tachyarrhythmias and appropriate ICD therapies. more...

Background: The plasma-derived atherogenic index (AIP) is associated with an increasing risk for cardiovascular diseases. Whether an increased AIP may predict the complexity of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO), according to available research, has never been investigated before., Methods: Three hundred seventeen patients were included prospectively and treated with PCI for at least one CTO between 2012 and 2017. High-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) plasma levels were measured 24 h before PCI. All patients were stratified into tertiles of AIP (defined as 0.11, 0.11-0.21, > 0.21) based on their TG/HDL-C (AIP) levels., Results: Mean AIP of all patients undergoing CTO-PCI was 0.53 ± 0.29. The majority of patients were male (82.6%), and mean age was 61 ± 10.4 years. Increased AIP > 0.21 was associated with longer occlusion length (statistical trend p = 0.082) and stent routes (p = 0.022) and with a higher number of implanted stents (n > 4) (statistical trend p = 0.072). Success rates were similar in all AIP categories (p = 0.461). In-hospital PCI-related complications were rare and not statistically different (p = 0.852)., Conclusions: This study demonstrates for the first time that an increased AIP may predict the complexity of CTO-PCI and additionally may help to improve planning and quality of CTO-PCI. more...

Objectives: The aim of this study was to assess the prognostic impact of post-procedural troponin T increase and mortality in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) to define the threshold at which procedure-related myocardial injury drives mortality., Background: Coronary CTO recanalization represents the most technically challenging PCI. The complexity harbors a significant increased risk for complications with CTO PCI with compared with non-CTO PCI. However, there are evidenced biomarker cutoff levels that help identify those patients at risk for unfavorable clinical outcomes., Methods: A total of 3,712 consecutive patients undergoing PCI for at least 1 CTO lesion were enrolled, and comprehensive troponin T measurements were performed 6, 8, and 24 h after the procedure. All-cause mortality was defined as the primary study endpoint., Results: Using spline curve analysis, a more than 18-fold increase of troponin above the upper reference limit was significantly associated with mortality. In a Cox regression analysis, the crude hazard ratio was 2.32 (95% confidence interval: 1.83 to 2.93; p < 0.001) for a ≥18-fold increase compared with patients with post-procedural troponin increase <18-fold of the upper reference limit. Results remained virtually unchanged after bootstrap- or clinical confounder-based adjustment., Conclusions: This large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in patients with CTOs. A threshold was defined for procedure-related myocardial injury in patients with CTOs to differentiate them from those without CTOs that may help guide post-procedural clinical care in this high-risk patient population., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...

Aims: The aim of this study was to describe the epidemiology, mechanisms, management, and outcomes of coronary artery perforation during chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods and Results: We included 1,811 consecutive patients undergoing CTO PCI at five centres between 2011 and 2018. Coronary perforation was observed in n=99 (5.5%). Patients with perforation were older, had a higher J-CTO score, more often required antegrade dissection/re-entry and the retrograde approach, and had lower success rates. The frequency of Ellis type I, II, III and III "cavity spilling" perforations was 11%, 46%, 28%, and 14%, respectively. In 48% of cases, perforation involved the CTO vessel, while the retrograde approach was responsible for 46% of cases. In 53% of cases perforations required intervention. The most frequently applied management strategies included clinical observation (47%), covered stent implantation (25%), balloon occlusion (9%), and coil/fat embolisation (9%). Tamponade was observed in 20/99 (20%) perforation cases. Ellis type III perforations were most frequently observed at the CTO site. These were accountable for 16/20 tamponades and 3/5 deaths. In-hospital mortality was 5.1% vs 0.3% in patients with versus those without perforation (p<0.001). Older age, occlusion length >20 mm, rotational atherectomy, antegrade dissection/re-entry, and the retrograde approach were independently associated with coronary perforation. Patients with perforation suffered an increased incidence of target vessel failure on short-term follow-up., Conclusions: Coronary perforation is observed in a non-negligible proportion of CTO PCIs, often requires intervention, and is associated with tamponade and mortality in a minority of patients. CTO vessel-related perforations are associated with the highest burden of morbidity and mortality. more...

Patients who undergo coronary bypass graft surgery often require subsequent cardiac catheterization and repeat coronary revascularization. Saphenous vein graft lesions have high rates for distal embolization that can be reduced with use of embolic protection devices. They also have high restenosis rates, which are similar with drug-eluting and bare-metal stents. Percutaneous coronary interventions of native coronary arteries is generally preferred over saphenous vein graft interventions, but can often be complex, requiring expertise and specialized equipment. Prolonged dual-antiplatelet therapy and close monitoring can help optimize subsequent clinical outcomes., (Copyright © 2019 American College of Cardiology Foundation. All rights reserved.) more...