Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is a rapidly evolving area of interventional cardiology. We sought to examine the immediate procedural and in-hospital clinical outcomes of native coronary artery CTO PCI from a multicenter United States (US) registry. We retrospectively examined the procedural outcomes of 1,361 consecutive native coronary artery CTO PCIs performed at 3 US institutions from January 2006 to November 2011. Mean age was 65 ± 11 years, 85% of patients were men, 40% had diabetes, 37% had previous coronary artery bypass graft surgery, and 42% had previous PCI. The CTO target vessel was the right coronary artery (55%), circumflex (23%), left anterior descending artery (21%), and left main or bypass graft (1%). The retrograde approach was used in 34% of all procedures. The technical and procedural success rates were 85.5% and 84.2%, respectively. The mean procedural time, fluoroscopy time, and contrast utilization were 113 ± 61 minutes, 42 ± 29 minutes, and 294 ± 158 ml, respectively. In multivariate analysis, female gender, no previous coronary artery bypass surgery, and years since initiation of CTO PCI at each center were independent predictors of procedural success. Major complications occurred in 24 patients (1.8%). In conclusion, among selected US-based institutions with experienced operators, native coronary artery CTO PCI can be performed with high success and low major complication rates.
Earlier published procedural success rates of percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) have ranged from 51% to 74%. However, with the development of novel equipment and techniques procedural success rates have improved. We recently reported favorable procedural outcomes of retrograde CTO PCI among 3 selected programs within the United States (US). The purpose of the present study was to describe the contemporary outcomes of native coronary CTO PCI procedures that were performed using either or both the antegrade and retrograde approach.
Methods
We reviewed the procedural and clinical records of consecutive patients who underwent CTO PCI from January 2006 to November 2011 at 3 US centers: St. Joseph Medical Center, Bellingham, Washington; Piedmont Heart Institute, Atlanta, Georgia; and VA North Texas Healthcare System, Dallas, Texas. Patients in whom bypass graft CTOs were treated were excluded from the present study. The study was approved by the institutional review board of each institution.
Coronary CTOs were defined as angiographic evidence of a total occlusion with Thrombolysis In Myocardial Infarction grade 0 or 1 and estimated duration of at least 3 months. Estimation of occlusion duration was based on the first onset of angina pectoris, a history of myocardial infarction in the target vessel territory, or comparison with a previous angiogram. If a guidewire was introduced into a collateral channel that supplied the target CTO vessel distal to the lesion, patients were considered to have had retrograde CTO PCI.
Technical success was defined as successful CTO recanalization with achievement of <50% 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. In-hospital major adverse cardiac events included any of the following adverse events before hospital discharge: Q-wave myocardial infarction, recurrent angina requiring urgent repeat target vessel revascularization with PCI or coronary bypass surgery, tamponade requiring pericardiocentesis or surgery, or death from any cause.
Descriptive statistics were used to report clinical characteristics, angiographic measures, and in-hospital outcomes. Continuous variables are presented as mean ± SD and compared using the t test or Wilcoxon rank-sum test, as appropriate. Categorical variables are expressed as percentages and compared using the chi-square test or Fisher’s exact test, as appropriate. Logistic regression analysis was performed to identify predictors of technical success. Variables with p <0.25 on univariate analysis (age, gender, years since start of CTO PCI, and previous coronary artery bypass graft [CABG]) and variables known to be associated with more advanced coronary artery disease and more challenging PCI (diabetes mellitus and history of myocardial infarction) were included in the model. All statistical analyses were performed with JMP version 9.0 (SAS Institute, Cary, North Carolina).
Results
During the study period, 1,361 consecutive patients underwent native coronary CTO PCI at 3 US institutions: St. Joseph Medical Center, Bellingham, Washington (n = 728); Piedmont Heart Institute, Atlanta, Georgia (n = 360); and VA North Texas Healthcare System, Dallas, Texas (n = 273). The baseline clinical and angiographic characteristics of the study population are listed in Table 1 . Overall, most patients were men with mean age of 64.5 ± 11 years. More than 1/3 (37%) had previous CABG, 40% had diabetes, 42% experienced previous myocardial infarction, and 42% had a history of PCI.
| Variable | Overall, n = 1,361 (%) | Technical Success, n = 1,163 (%) | Technical Failure, n = 198 (%) | p | Antegrade Approach, n = 900 (%) | Retrograde Approach, n = 461 (%) | p |
|---|---|---|---|---|---|---|---|
| Age (yrs) ∗ | 64.5 ± 10.8 | 64.4 ± 10 | 66.3 ± 9.6 | 0.017 | 64.4 ± 10 | 65.2 ± 10 | 0.125 |
| Men | 85.1 | 84.4 | 88.9 | 0.093 | 87.1 | 84.4 | 0.114 |
| Hypertension | 89.0 | 89.1 | 89.9 | 0.771 | 87.8 | 91.8 | 0.226 |
| Hyperlipidemia | 94.0 | 94.3 | 91.7 | 0.192 | 91.9 | 97.1 | 0.007 |
| Diabetes mellitus | 40.0 | 39.2 | 42.8 | 0.368 | 36.9 | 44.6 | 0.037 |
| Heart failure | 23.7 | 23.1 | 27.3 | 0.235 | 25.5 | 22.2 | 0.463 |
| Ejection fraction <40% | 22.0 | 21.4 | 26.0 | 0.311 | 24.8 | 20.9 | 0.316 |
| Previous myocardial infarction | 42.0 | 41.7 | 42.7 | 0.800 | 38.2 | 47.6 | <0.001 |
| Previous CABG | 37.0 | 35.0 | 50.0 | <0.001 | 31.3 | 50.6 | <0.001 |
| Previous stroke | 6.0 | 5.6 | 6.8 | 0.537 | 7.1 | 5.1 | 0.060 |
| Previous PCI | 42.0 | 42.5 | 48.8 | 0.321 | 37.5 | 46.9 | 0.004 |
| Angiographic characteristics | |||||||
| CTO target coronary artery | 0.002 | <0.001 | |||||
| Right | 55.0 | 54.2 | 59.1 | 48.9 | 66.5 | ||
| Left circumflex | 23.0 | 23.1 | 21.7 | 25.7 | 17.8 | ||
| Left anterior descending | 21.0 | 22.1 | 15.7 | 24.4 | 14.7 | ||
| Left main | 1.0 | 0.5 | 3.5 | 1.0 | 1.0 | ||
| Previous failed attempt for CTO PCI | 15.0 | 15.2 | 14.1 | 0.795 | 13.9 | 17.1 | 0.123 |
| Technical success | 85.5 | NA | NA | — | 87.8 | 80.9 | <0.001 |
| Procedural success | 84.2 | NA | NA | — | 87.1 | 78.5 | <0.001 |
| Number of stents implanted ∗ | NA | 2.6 ± 1.3 | NA | — | 2.4 ± 1.3 | 3.1 ± 1.3 | <0.001 |
| Total procedure time (min) ∗ | 113 ± 61 | 109 ± 62 | 133 ± 57 | <0.001 | 95 ± 50 | 150 ± 66 | <0.001 |
| Total fluoroscopy time (min) ∗ | 42 ± 29 | 40 ± 28 | 57 ± 30 | <0.001 | 32 ± 21 | 61 ± 33 | <0.001 |
| Total air kerma radiation exposure (Gy) ∗ | 4.7 ± 3.8 | 4.5 ± 3.9 | 6.5 ± 3.0 | <0.001 | 3.7 ± 3.8 | 6.4 ± 3.2 | <0.001 |
| Total contrast volume (ml) ∗ | 294 ± 158 | 281 ± 154 | 369 ± 161 | <0.001 | 268 ± 146 | 343 ± 168 | <0.001 |
The right coronary artery was the target vessel in most patients (55%), followed by the left circumflex (23%), and left anterior descending arteries (21%). Fifteen percent of patients had at least 1 previous failed attempt for CTO recanalization.
Most PCIs (66%) were performed using an antegrade approach. The retrograde approach was used in 34% of patients. The overall technical and procedural success rates were 85.5% and 84.2%, respectively ( Table 1 ). The technical success rates for the antegrade and retrograde approach were 87.8% and 80.9%, respectively (p = 0.001). In univariate analysis, patients with failed CTO PCI were older and more likely to have previous CABG and a target CTO in the right coronary artery. Compared with successful procedures, the failed procedures were associated with longer procedural and fluoroscopy time and greater radiation exposure and contrast volume administration ( Table 1 ). Over time, the use of the retrograde approach increased, as did the technical success rate ( Table 2 ). In multivariate analysis, more years since initiation of CTO PCI at each center, female gender, and no previous CABG were independently associated with higher technical success rates ( Table 3 ).
| Year of CTO PCI | Antegrade PCI (%) | Retrograde PCI (%) | Total CTO PCI | Overall Technical Success Rate, % | Major Complications Rate, % |
|---|---|---|---|---|---|
| 2006 | 91 (91) | 9 (9) | 100 | 69 (69/100) | 0 |
| 2007 | 101 (80) | 26 (20) | 127 | 85 (108/127) | 0 |
| 2008 | 104 (71) | 43 (29) | 147 | 82 (122/148) | 2 (2/147) |
| 2009 | 117 (59) | 82 (41) | 199 | 86 (171/199) | 1.5 (3/199) |
| 2010 | 229 (60) | 155 (40) | 384 | 86 (330/384) | 2.6 (10/384) |
| 2011 | 258 (64) | 146 (36) | 404 | 90 (365/405) | 2.2 (9/404) |
| 2006–2011 | 900 (66) | 461 (34) | 1,361 | 85.5 (1,163/1,361) | 1.8 (24/1,361) |
| Variable | OR | 95% CI | p |
|---|---|---|---|
| Age (per 10 yr increase) | 0.87 | 0.73–1.03 | 0.114 |
| Years since CTO PCI initiation at each center (per 1 yr increase) | 1.52 | 1.36–1.70 | <0.001 |
| Men | 0.51 | 0.28–0.87 | 0.012 |
| Diabetes | 0.81 | 0.58–1.14 | 0.241 |
| History of myocardial infarction | 0.95 | 0.68–1.34 | 0.784 |
| History of CABG | 0.49 | 0.35–0.70 | <0.001 |
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