We sought to examine the impact of previous failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 1,213 consecutive patients who underwent 1,232 CTO PCIs from 2012 to 2015 at 12 US centers. Mean age was 65 ± 10 years, and 84.8% of patients were men. A previously failed attempt had been performed in 215 patients (17.5%). As compared with patients without previous CTO PCI failure, patients with previous failure had higher Multicenter CTO Registry in Japan CTO score (2.40 ± 1.13 vs 3.28 ± 1.29, p <0.0001) and were more likely to have in-stent restenosis (10.5% vs 28.4%, p <0.0001) and to undergo recanalization attempts using the retrograde approach (41% vs 50%, p = 0.011). Technical (90% vs 88%, p = 0.390) and procedural (89% vs 86%, p = 0.184) success were similar in the 2 study groups; however, median procedure time (125 vs 142 minutes, p = 0.026) and fluoroscopy time (45 vs 55 minutes, p = 0.015) were longer in the previous failure group. In conclusion, a previously failed CTO PCI attempt is associated with higher angiographic complexity, longer procedural duration, and fluoroscopy time, but not with the success and complication rates of subsequent CTO PCI attempts.
Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can be challenging to perform with variable success rates, depending on operator experience and expertise. Previous CTO PCI failure has been associated with lower procedural success rates and is part of the Multicenter CTO Registry in Japan CTO (J-CTO) score that was developed to predict the likelihood of successful guidewire crossing within 30 minutes. However, previous CTO PCI failure can be due to multiple factors, such as patient instability, limited local experience, or early cessation of recanalization efforts without exploring alternative CTO crossing options. We examined a contemporary multicenter registry to determine the impact of previously failed CTO PCI attempts on the outcomes of subsequent procedures.
Methods
We examined the baseline and angiographic characteristics and clinical outcomes of 1,232 consecutive CTO PCIs performed in 1,213 patients from 2012 to 2015 at 12 US centers. Enrollment was performed during only part of the study period in some centers because of participation in other studies. Data collection was performed prospectively and retrospectively and was recorded in a dedicated online CTO database (PROGRESS CTO: Prospective Global Registry for the Study of Chronic Total Occlusion Intervention, Clinicaltrials.gov Identifier: NCT02061436 ). The study was approved by the institutional review board of each site.
Coronary CTOs were defined as coronary lesions with Thrombolysis In Myocardial Infarction grade 0 flow of at least 3 months duration. Estimation of the occlusion duration was based on first onset of anginal symptoms, history of myocardial infarction in the target vessel territory, or comparison with a previous angiogram. Calcification was assessed by angiography as mild (spots), moderate (involving ≤50% of the reference lesion diameter), and severe (involving >50% of the reference lesion diameter). Proximal vessel tortuosity was defined as moderate (2 bends >70° or 1 bend >90°) or severe (2 bends >90° or 1 bend >120°). The J-CTO score was calculated as described by Morino et al. Study outcomes included technical and procedural success. Technical success was defined as successful CTO revascularization with achievement of <30% residual diameter stenosis within the treated segment and restoration of Thrombolysis In Myocardial Infarction grade 3 antegrade flow. Procedural success was defined as achievement of technical success with no in-hospital major adverse cardiac events (MACE). In-hospital MACE included any of the following adverse events before hospital discharge: death, myocardial infarction, urgent repeat target vessel revascularization with either PCI or coronary artery bypass graft surgery, tamponade requiring either pericardiocentesis or surgery, and stroke. Myocardial infarction was defined using the Third Universal Definition of Myocardial Infarction.
Patients were classified in 2 groups based on whether they had a previous unsuccessful CTO PCI attempt or not. Continuous variables were presented as mean ± SD or median (interquartile range) and were compared using the t test, or Wilcoxon rank-sum test, as appropriate. Categorical data are reported as frequencies or percentages and compared using the chi-square test. All statistical analyses were performed with JMP 11.0 (SAS Institute, Cary, North Carolina). A 2-sided p value of <0.05 was considered to indicate statistical significance.
Results
During the study period, 1,213 consecutive patients underwent 1,232 CTO PCI at 12 US centers. The baseline patient and angiographic characteristics of the study population are summarized in Table 1 . Mean age was 65.5 ± 10 years, 84.8% of the patients were men and 44.2% had diabetes. Nearly all patients had dyslipidemia (94.8%) and hypertension (90%). Nearly 1/3 of the study population had congestive heart failure (28%) and a family history of coronary artery disease (30%), 34% had previous coronary artery bypass graft surgery, and 42% had a previous myocardial infarction. Patients with a previously failed CTO PCI attempt had lower rates of congestive heart failure and active smoking, as well as higher ejection fraction and body mass index.
| Variable | Overall (n = 1,232) | Prior failed CTO PCI attempt (n = 215) | No prior failed CTO PCI attempt (n = 1,017) | P |
|---|---|---|---|---|
| Age (years) ∗ | 65 ± 10 | 64.4 ± 11 | 65.6 ± 9.8 | 0.177 |
| Men | 84.8% | 81.4% | 85.5% | 0.135 |
| Body Mass Index (kg/m 2 ) ∗ | 30.6 ± 6.3 | 31.6 ± 6.7 | 30.3 ± 6.2 | 0.026 |
| Diabetes Mellitus | 44.2% | 38.8% | 45.3% | 0.082 |
| Hypertension | 90% | 89% | 90% | 0.692 |
| Dyslipidemia | 94.8% | 95.2% | 94.7% | 0.738 |
| Smoking (current) | 28% | 21% | 30% | 0.014 |
| Left Ventricular Ejection Fraction (%) ∗ | 50 ± 14 | 53 ± 13 | 50 ± 14 | 0.016 |
| Family History of Coronary Artery Disease | 30% | 34% | 29% | 0.230 |
| Congestive Heart Failure | 28% | 19% | 30% | 0.002 |
| Prior Myocardial Infarction | 42% | 44% | 42% | 0.540 |
| Prior coronary bypass | 34% | 31% | 35% | 0.221 |
| Prior cerebrovascular disease | 11% | 8% | 11% | 0.122 |
| Prior peripheral vascular disease | 16% | 12% | 17% | 0.106 |
| Baseline creatinine (mg/dL) † | 1.0 (0.9,1.2) | 1.0 (0.9,1.3) | 1.0 (0.9,1.2) | 0.891 |
| Angiographic characteristics | ||||
| CTO Target coronary artery | ||||
| Right coronary artery | 59% | 58% | 58% | 0.953 |
| Left anterior descending artery | 22% | 23% | 22% | |
| Left circumflex artery | 19% | 19% | 19% | |
| Successful Crossing Strategy | ||||
| Antegrade wiring | 41% | 35% | 42% | 0.113 |
| Retrograde | 27% | 26% | 27% | |
| Antegrade dissection and re-entry | 24% | 29% | 22% | |
| First Crossing Strategy | ||||
| Antegrade wiring | 70% | 52% | 70% | <0.0001 |
| Retrograde | 20% | 29% | 18% | |
| Antegrade dissection and re-entry | 14% | 18% | 12% | |
| Retrograde crossing attempt | 42.5% | 50.2% | 40.8% | 0.011 |
| Japanese Multicenter CTO Registry in Japan- score ∗ | 2.55 ± 1.21 | 3.28 ± 1.29 | 2.40 ± 1.13 | <0.0001 |
| Calcification (moderate/severe) | 56.7% | 57.4% | 56.6% | 0.819 |
| Tortuosity (moderate/severe) | 34.6% | 34.8% | 34.5% | 0.940 |
| Proximal cap ambiguity | 32% | 35% | 32% | 0.423 |
| In-stent restenosis | 13.6% | 28.4% | 10.5% | <0.0001 |
| Interventional Collaterals | 59% | 60% | 59% | 0.865 |
| Side branch at the proximal cap | 45% | 44% | 46% | 0.765 |
| Blunt/no stump | 64% | 58% | 64% | 0.001 |
| Vessel diameter (mm) † | 2.75 (2.5, 3) | 3 (2.5, 3) | 2.75 (2.5, 3) | 0.014 |
| Occlusion length (mm) † | 30 (20, 45) | 30 (17, 50) | 30 (20, 40) | 0.485 |
The most common CTO PCI target vessel was the right coronary artery (59%), followed by the left anterior descending artery (22%), and the circumflex artery (19%). The mean J-CTO score was 2.55 ± 1.21. Antegrade wire escalation was the most common successful crossing strategy (41%), followed by retrograde (27%) and antegrade dissection and reentry (24%). The overall technical and procedural success rates were 90% and 89%, respectively.
As compared with patients without previous CTO PCI failure, those with previous failed attempts were more likely to have instent restenosis, larger target vessel diameter, higher J-CTO score (which was, however, because previous failure is part of the score derivation) and were more likely to undergo CTO crossing using the retrograde approach. The distribution of final successful crossing strategy was similar between patients with CTO PCI with and without previous CTO PCI failure, although a primary retrograde or antegrade dissection and reentry approach was more common in patients with previous CTO PCI failure.
Technical and procedural success were similarly high in patients with and without previously failed CTO PCI attempts ( Table 2 , Figure 1 ), whereas the incidence of MACE was numerically higher in previous failed cases (4.2% vs 2.1%, p = 0.067). Mean procedure duration was significantly longer in the group with previously failed CTO PCI attempts (142 vs 125 minutes, p = 0.026), as was mean fluoroscopy time (55 vs 45 minutes, p = 0.015), whereas mean air kerma radiation dose (4 vs 3.39 Gy, p = 0.163) and mean contrast volume (260 vs 260 ml, p = 0.893) were similar in the 2 study groups. Periprocedural bleeding occurred in 0.9% of the overall study population with similar prevalence in both groups (0.9% vs 0.9%, p = 0.949). Periprocedural bleeding occurred in 11 cases, most of which (10 cases) were access site bleedings, whereas retroperitoneal bleeding and gastrointestinal bleeding occurred only in one case each.
| Variable | Overall (n = 1,232) | Prior failed CTO PCI attempt (n = 215) | No prior failed CTO PCI attempt (n = 1,017) | P |
|---|---|---|---|---|
| Technical Success | 90 % | 88 % | 90 % | 0.390 |
| Procedural Success | 89 % | 86 % | 89 % | 0.184 |
| Procedural time (min) ∗ | 128 (87, 191) | 142 (91, 213) | 125 (85, 185) | 0.026 |
| Fluoroscopy time (min) ∗ | 47 (28, 76) | 55 (33, 82) | 45 (27, 74) | 0.015 |
| Air kerma radiation dose (Gray) ∗ | 3.47 (2.03, 5.42) | 4.00 (2.20, 5.73) | 3.39 (2.00, 5.37) | 0.163 |
| Contrast volume ∗ | 260 (200, 360) | 260 (185, 375) | 260 (200, 360) | 0.893 |
| MACE | 2.4 % | 4.2 % | 2.1 % | 0.067 |
| Death | 0.4 % | 0.9 % | 0.3 % | 0.183 |
| Acute myocardial infarction | 1.1% | 2.8% | 0.7% | 0.006 |
| Repeat percutaneous coronary intervention | 0.3% | 0.5% | 0.3% | 0.690 |
| Stroke | 0.3 % | 0 % | 0.4 % | 0.357 |
| Emergency coronary bypass | 0 % | 0 % | 0 % | – |
| Pericardiocentesis | 0.6 % | 1.4 % | 0.5 % | 0.134 |
| Periprocedural bleeding | 0.9% | 0.9% | 0.9% | 0.949 |
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