A non-interventional cardiologist's guide to coronary chronic total occlusions.
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ABSTRACT:
SUBMITTER: Cilia L
PROVIDER: S-EPMC10876789 | biostudies-literature | 2024
REPOSITORIES: biostudies-literature
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A non-interventional cardiologist's guide to coronary chronic total occlusions.
Cilia Lindsey L Megaly Michael M Davies Rhian R Tehrani Behnam N BN Batchelor Wayne B WB Truesdell Alexander G AG
Frontiers in cardiovascular medicine 20240206
Coronary chronic total occlusions (CTO) are present in up to one-third of patients with coronary artery disease (CAD). It is thus essential for all clinical cardiologists to possess a basic awareness and understanding of CTOs, including optimal evaluation and management. While percutaneous coronary intervention (PCI) for CTO lesions has many similarities to non-CTO PCI, there are important considerations pertaining to pre-procedural evaluation, interventional techniques, procedural complications ...[more]
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Project description:ObjectiveData describing the prevalence, characteristics and management of coronary chronic total occlusions (CTOs) in patients undergoing coronary CT angiography (CCTA) have not been reported. The purpose of this study was to determine the prevalence, characteristics and treatment strategies of CTO identified by CCTA.MethodsWe identified 23 745 patients who underwent CCTA for suspected coronary artery disease (CAD) from the prospective international CCTA registry. Baseline clinical data were collected, and allocation to early coronary revascularisation performed within 90 days of CCTA was determined. Multivariable hierarchical mixed-effects logistic regression reporting OR with 95% CI was performed.ResultsThe prevalence of CTO was 1.4% (342/23 745) in all patients and 6.2% in patients with obstructive CAD (≥50% stenosis). The presence of CTO was independently associated with male sex (OR 3.12, 95% CI 2.39 to 4.08, p<0.001), smoking (OR 2.02, 95% CI 1.55 to 2.64, p<0.001), diabetes (OR 1.60, 95% CI 1.22 to 2.11, p=0.001), typical angina (OR 1.51, 95% CI 1.12 to 2.06, p=0.008), hypertension (OR 1.47, 95% CI 1.14 to 1.88, p=0.003), family history of CAD (OR 1.30, 95% CI 1.01 to 1.67, p=0.04) and age (OR 1.06, 95% CI 1.05 to 1.07, p<0.001). Most patients with CTO (61%) were treated medically, while 39% underwent coronary revascularisation. In patients with severe CAD (≥70% stenosis), CTO independently predicted revascularisation by coronary artery bypass grafting (OR 3.41, 95% CI 2.06 to 5.66, p<0.001), but not by percutaneous coronary intervention (p=0.83).ConclusionsCTOs are not uncommon in a contemporary CCTA population, and are associated with age, gender, angina status and CAD risk factors. Most individuals with CTO undergoing CCTA are managed medically with higher rates of surgical revascularisation in patients with versus without CTO.Trial registration numberClinicalTrials.gov identifier NCT01443637.
| S-EPMC4578159 | biostudies-literature
Project description:Coronary chronic total occlusions (CTOs) are commonly encountered in patients with coronary artery disease. Compared to patients without coronary CTOs, those with CTO have worse clinical outcomes and lower likelihood of complete coronary revascularisation. Successful CTO percutaneous coronary intervention (PCI) can significantly improve angina and improve left ventricular function. Although currently unproven, successful CTO PCI might also reduce the risk for arrhythmic events in patients with ischaemic cardiomyopathy, provide better tolerance of future acute coronary syndrome, and possibly improve survival. Evaluation by a heart team comprised of both interventional and non-interventional cardiologists and cardiac surgeons is important for determining the optimal revascularisation strategy in patients with coronary artery disease and CTOs. Ad hoc CTO PCI is generally not recommended, so as to allow sufficient time for (a) discussion with the patient about the indications, goals, risks, and alternatives to PCI; (b) careful procedural planning; and (c) contrast and radiation exposure minimisation. Use of drug-eluting stents is recommended for CTO PCI, given the lower rates of angiographic restenosis compared to bare metal stents.
| S-EPMC5808625 | biostudies-literature
Project description:IntroductionPercutaneous coronary intervention (PCI) in patients with advanced chronic kidney disease (CKD) is associated with a high risk of contrast-induced nephropathy and resulting progression of CKD to need for renal replacement therapy. Chronic total occlusions (CTO) PCI is increasingly utilized in the treatment of refractory stable angina and ischaemic heart failure. Recent studies have described the feasibility of 'minimal' or 'zero' contrast PCI by employing intravascular imaging and intra-coronary physiology to guide successful stent implantation with resolution of ischaemia. We extended these techniques to CTO lesions via the retrograde approach.Case presentationTwo patients with estimated glomerular filtration rate ≤15 mL/min who presented with angina symptoms and had subsequent positive stress tests were referred for CTO-PCI. The patients had diagnostic angiography with minimal contrast. After a recovery period, the patients underwent successful retrograde zero contrast CTO-PCI with the use of adjunctive intravascular ultrasound imaging.DiscussionThe described reports are the first two successful attempts at zero contrast retrograde procedures and demonstrate the feasibility of imaging and physiology-guided retrograde PCI without contrast administration in two patients with significant coronary artery disease requiring intervention. When indicated, zero contrast PCI offers the ability to treat obstructive coronary disease without worsening renal function in patients with severe CKD.
| S-EPMC6177013 | biostudies-literature
Project description:BackgroundBRS represent a new approach to treating coronary artery disease. Beneficial properties of BRS regarding the restoration of vasomotility after resorption make them attractive devices in CTO revascularization. However, experience in this setting is limited.MethodsWe systematically searched Medline, Scholar, and Scopus for reports of at least 9 patients with CTO undergoing BRS implantation. Patients' and procedural characteristics were summarized. The primary outcome of interest was target lesion revascularization (TLR). Pooled estimates were calculated using a random-effects meta-analysis. The study protocol was registered in PROSPERO (CRD42017069322).ResultsThirteen reports for a total of 843 lesions with a median follow-up of 12 months (IQR 6-12) were included in the analysis. At short-term, the summary estimate rate of TLR was 2.6% (95% CI: 1 to 4%, I2 = 0%, P = 0.887) while at mid to long-term it was 3.8% (95% CI: 2 to 6%, I2 = 0%, P = 0.803). At long-term follow-up (≥12 months), the summary estimate rate of cardiac death was 1.1% (95% CI: 0 to 2%, I2 = 0%, P = 0.887). The summary estimate rates of scaffold thrombosis and clinical restenosis were respectively 0.9% (95% CI: 0 to 2%, I2 = 0%, P = 0.919) and 1.8% (95% CI: 0 to 4%, I2 = 0%, P = 0.448). Finally, the summary estimate rate of target vessel revascularization was 6.6% (95% CI: 0 to 11%, I2 = 0%, P = 0.04).ConclusionsImplantation of BRS in a population with CTO is feasible, although further longer-term outcome studies are necessary.
| S-EPMC6419823 | biostudies-literature
Project description:ObjectiveTo assess the spatial distribution of chronic total occlusions (CTOs) within the coronary arteries and describe procedural strategies and outcomes during CTO percutaneous coronary intervention (PCI).BackgroundAcute occlusions due to plaque rupture tend to cluster within the proximal third of the coronary artery.MethodsWe examined the clinical and procedural characteristics of 1,348 patients according to lesion location within the coronary tree.ResultsA total of 1,369 lesions in 1,348 patients (mean age 66 ± 10 years, 85% male) were included. CTO PCI of proximal segments (n = 633, 46%) was more common than of mid (n = 557, 41%) and distal segments (n = 179, 13%). Patients undergoing CTO PCI of proximal segments were more likely to be smokers (P < 0.01), have prior coronary artery bypass graft surgery (P = 0.03) and lower ejection fraction (P = 0.04). CTOs occurring in proximal segments had longer length (P <0.01), proximal cap ambiguity (P < 0.01), and moderate/severe calcification (P < 0.01) compared to mid or distally located CTOs. Interventional collaterals were more often present in CTO PCI of proximal segments (64%, 53%, 56%, P < 0.01) consistent with the higher use of retrograde approach (47%, 33%, 37%, P < 0.01) relative to antegrade wire escalation (67%, 82%, 82%, P < 0.01). Procedural complexity was higher in CTO PCI of proximal segments (vs. mid and distal): contrast volume= 275 ml (200-375), 260 ml (200-350), 250 ml (175-350), P = 0.01; fluoroscopy time 53 minutes (32-83), 39 minutes (24-65), 40 minutes (22-72), P < 0.01. However, procedural success (87%, 90%, 85%, P = 0.1), technical success (89%, 91%, 88%, P = 0.24), and complications rates (2.8%, 2.5%, 2.2%, P = 0.88) were not different.ConclusionsThe most common target vessel location for CTO PCI is the proximal coronary segment. PCI of proximal occlusions is associated with adverse clinical and angiographic characteristics and often requires use of the retrograde approach, but can be accomplished with high procedural and technical success and low complication rates. © 2016 Wiley Periodicals, Inc.
| S-EPMC5425324 | biostudies-literature
Project description:BackgroundChronic total occlusion (CTO) remains the most complex anatomical subset of lesions in percutaneous coronary intervention (PCI), often requiring advanced techniques and technologies, including the use of microcatheters.MethodsThe BIOMICS study is a premarket first-in-human prospective, multicenter, open-label, single-arm trial investigating the safety and efficacy of a novel coronary microcatheter (BioMC, Biosensors International) in 100 patients with symptoms of ischemia undergoing elective CTO-PCI. The primary efficacy end point of the study was device success defined according to the CTO-ARC (Chronic Total Occlusion Academic Research Consortium) criteria namely the ability of the microcatheter to successfully facilitate placement of a guide wire beyond the occluded coronary segment. The primary safety end point was the incidence of in-hospital cardiac death or myocardial infarction at hospital discharge.ResultsHundred patients were recruited between March 2022 and January 2023. The primary efficacy end point was achieved in 75% of patients (95% CI, 65.3%-83.1%; P < .0001 for superiority compared to the prespecified performance goal of 54%). The primary safety end point of in-hospital cardiac death or myocardial infarction was observed in 2% of the patients. There were no study device-related coronary perforations or device failures.ConclusionsThe use of a novel coronary microcatheter during CTO-PCI was associated with a high device success and an excellent safety profile.
| S-EPMC11308310 | biostudies-literature
Project description:BackgroundRevascularisation of a chronic total coronary occlusion (CTO) impacts the coronary physiology of the remote myocardial territory.AimsThis study aimed to evaluate the intrinsic effect of CTO percutaneous coronary intervention (PCI) on changes in absolute perfusion in remote myocardium.MethodsA total of 164 patients who underwent serial [15O]H2O positron emission tomography (PET) perfusion imaging at baseline and three months after successful single-vessel CTO PCI were included to evaluate changes in hyperaemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) in the remote myocardium supplied by both non-target coronary arteries.ResultsPerfusion indices in CTO and remote myocardium showed a positive correlation before (resting MBF: r=0.84, hMBF: r=0.75, and CFR: r=0.77, p<0.01 for all) and after (resting MBF: r=0.87, hMBF: r=0.87, and CFR: r=0.81, p<0.01 for all) CTO PCI. Absolute increases in hMBF and CFR were observed in remote myocardium following CTO revascularisation (from 2.29±0.67 to 2.48±0.75 mL·min-1·g-1 and from 2.48±0.76 to 2.74±0.85, respectively, p<0.01 for both). Improvements in remote myocardial perfusion were largest in patients with a higher increase in hMBF (β 0.58, 95% CI: 0.48-0.67, p<0.01) and CFR (β 0.54, 95% CI: 0.44-0.64, p<0.01) in the CTO territory, independent of clinical, angiographic and procedural characteristics.ConclusionsCTO revascularisation resulted in an increase in remote myocardial perfusion. Furthermore, the quantitative improvement in hMBF and CFR in the CTO territory was independently associated with the absolute perfusion increase in remote myocardial regions. As such, CTO PCI may have a favourable physiologic impact beyond the intended treated myocardium.
| S-EPMC9912974 | biostudies-literature
Project description:ObjectivesThis study sought to investigate the prevalence of ventricular tachycardia after percutaneous coronary intervention (PCI) of chronic total occlusion (CTO).BackgroundPCI of a CTO is associated with improvement of the left ventricular ejection fraction and possibly associated with reduced mortality. However, benefits of CTO-PCI must be weighed against a higher risk of procedure-related complications. The incidence of new-onset ventricular tachycardia after a successful CTO-PCI has not been investigated so far. In this retrospective registry we seek to describe characteristics and predictors of occurrence of post-procedural ventricular tachycardias.Methods and resultsBetween 2010 and 2015, 485 patients underwent successful CTO-PCI at Heart Center Leipzig. Of them, 342 had complete follow-up and were further analyzed. Ventricular tachycardias were detected in 9 (2.6%) patients. All of them were monomorphic ventricular tachycardias occurring in median 1 day (interquartile range [IQR] 0.25-4.75 days) after PCI and caused prolongation of the hospital stay. Patients with ventricular tachycardia were older, had worse left ventricular ejection fraction (mean 33.1%, SD 5.9%) and more frequently a CTO of an infarct-related artery. The target vessel was not associated with the occurrence of ventricular arrhythmias. In multivariable analysis, only impaired left ventricular systolic function was an independent predictor for procedure-related ventricular tachycardia. Mortality rates were not different between patients with or without ventricular tachycardia.ConclusionVentricular tachycardia can occur early after CTO-PCI as possible reperfusion arrhythmia and poorer left ventricular ejection fraction is the only independent predictor for onset. Although the occurrence of ventricular tachycardia after CTO-PCI seems not to influence mortality, awareness of this possible complication and longer monitoring may be recommended.
| S-EPMC6874319 | biostudies-literature
Project description:It has been demonstrated that gender differences are related to different procedural and long-term clinical outcomes among a general patient population treated using percutaneous coronary interventions (PCI). The objective of our analysis was to conduct assessment regarding the relationship between gender and procedural outcomes in patients treated for PCI regarding chronic total occlusions (CTO), based on a large, real-life registry. Data used to conduct the following analysis was derived from the national registry of percutaneous coronary interventions (ORPKI), upheld in co-operation with the Association of Cardiovascular Interventions (AISN) of the Polish Cardiac Society. The study involved data procured from the registry within the period from January 2014 to December 2020. All subsequent CTO procedures recorded in the registry during that period were included in the analysis. We assessed the correlation between gender and the overall rate of periprocedural complications, procedure-related mortality, and success evaluated as TIMI flow grade 3 after the procedure by univariate and multivariable modeling. At the time of conducting our investigation, there were 162 existing and active CathLabs, at which 747,033 PCI procedures were carried out during the observational period. Of those, 14,903 (1.99%) were CTO-PCI procedures, and 3726 were women (25%). The percentage share between genders did not experience any significant changes during the consecutive years observed in the current analysis. Overall periprocedural complication rate was greater among women than men (3.45% vs. 2.31%, p = 0.02). A comparable relationship was noted for procedural mortality (0.7% vs. 0.2%, p = 0.006), while procedural success occurred more often in the case of women (69.3% vs. 65.2%, p < 0.001). Women were found to be more frequently affected by periprocedural complications (OR = 1.553; 95%CI: 1.212-1.99, p < 0.001) as well as procedural success (OR = 1.294; 95%CI: 1.151-1.454, p < 0.001), evaluated using multivariable models. Based on the current analysis performed on all-comer patients treated using PCI in CTO, women are affected by more frequent procedural complication occurrence as well as greater procedural success compared to men.
| S-EPMC8911020 | biostudies-literature
Project description:Introduction: The number of chronic total occlusion (CTO) revascularization procedures has continuously increased, obtaining better results in recent years. However, there are few data regarding long-term outcomes and no comparisons to planned complex non-CTO percutaneous coronary intervention (PCI). Methods: We included all patients undergoing planned complex PCI. Our main objective was to compare a combined endpoint of all-cause death, myocardial infarction, and target vessel revascularization at the long-term follow-up of CTO PCI versus planned complex non-CTO PCI. We compared the groups using multivariable Cox regression and performed a propensity score matching analysis to control the baseline characteristics. We repeated the analysis for the separate components of the primary endpoint. Results: From January 2018 to June 2023, 1394 complex coronary PCIs were performed at our center. After excluding 393 non-planned cases, 201 CTO PCIs and 800 non-CTO PCIs were included. The mean follow-up was 2.5 ± 1.5 years. The composite endpoint occurred in 23 (11.6%) CTO PCIs and 219 (28.2%) planned non-CTO PCIs. The multivariable Cox regression using the CTO group as the reference showed a lower risk for the primary outcome (HR: 0.59; 95% CI 0.37-0.95; p = 0.031). After matching, a total of 195 adequately balanced pairs were obtained. The CTO group presented a lower risk for the primary combined outcome (HR: 0.46; 95% CI 0.27-0.76; p = 0.003). Conclusions: In patients undergoing planned complex PCI, those in the CTO group presented a reduced risk of all-cause death, myocardial infarction, and target vessel revascularization at the end of the follow-up.
| S-EPMC11818758 | biostudies-literature