Peter Tajti

The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention: Update From the PROGRESS CTO Registry

OBJECTIVESnThe aim of this study was to determine the techniques and outcomes of hybrid chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a diverse group of patients and operators on 2 continents.nnnBACKGROUNDnCTO PCI has been evolving with constant improvement of equipment and techniques.nnnMETHODSnContemporary outcomes of CTO PCI were examined by analyzing the clinical, angiographic, and procedural characteristics of 3,122 CTO interventions performed in 3,055 patients at 20 centers in the United States, Europe, and Russia.nnnRESULTSnThe mean age was 65 ± 10 years, and 85% of the patients were men, with high prevalence of diabetes (43%), prior myocardial infarction (46%), prior coronary artery bypass graft surgery (33%), and prior PCI (65%). The CTO target vessels were the right coronary artery (55%), left anterior descending coronary artery (24%), and left circumflex coronary artery (20%). The mean J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores were 2.4 ± 1.3 and 1.3 ± 1.0, respectively. The overall technical and procedural success rate was 87% and 85%, respectively, and the rate of in-hospital major complications was 3.0%. The final successful crossing strategy was antegrade wire escalation in 52.0%, retrograde in 27.1%, and antegrade dissection re-entry in 20.9%; >1 crossing strategy was required in 40.9%. Median contrast volume, air kerma radiation dose, and procedure and fluoroscopy time were 270 ml (interquartile range: 200 to 360 ml), 2.9 Gy (interquartile range: 1.7 to 4.7 Gy), 123 min (interquartile range: 81 to 188 min) and 47 min (interquartile range: 29 to 77 min), respectively.nnnCONCLUSIONSnCTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the United States, Europe, and Russia. (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO]; NCT02061436).

Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention

Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65u2009±u200910 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, pu2009<u20090.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0u2009±u20091.2 vs 2.5u2009±u20091.3, pu2009<u20090.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency.

Randomized Comparison of a CrossBoss First Versus Standard Wire Escalation Strategy for Crossing Coronary Chronic Total Occlusions: The CrossBoss First Trial

OBJECTIVESnThe authors performed a multicenter, randomized-controlled, clinical trial comparing upfront use of the CrossBoss catheter versus antegrade wire escalation for antegrade crossing of coronary chronic total occlusions.nnnBACKGROUNDnThere is equipoise about the optimal initial strategy for crossing coronary chronic total occlusions.nnnMETHODSnThe primary endpoints were the time required to cross the chronic total occlusion or abort the procedure and the frequency of procedural major adverse cardiovascular events. The secondary endpoints were technical and procedural success, total procedure time, fluoroscopy time required to cross and total fluoroscopy time, total air kerma radiation dose, total contrast volume, and equipment use.nnnRESULTSnBetween 2015 and 2017, 246 patients were randomized to the CrossBoss catheter (nxa0= 122) or wire escalation (nxa0= 124) at 11 U.S. centers. The baseline clinical and angiographic characteristics of the study groups were similar. Technical and procedural success were 87.8% and 84.1%, respectively, and were similar in the 2 groups. Crossing time was similar: 56 min (interquartile range: 33 to 93 min) in the CrossBoss group and 66 min (interquartile range: 36 to 105xa0min) in the wire escalation group (pxa0= 0.323), as was as the incidence of procedural major adverse cardiovascular events (3.28% vs. 4.03%; pxa0= 1.000). There were no significant differences in the secondary study endpoints.nnnCONCLUSIONSnAs compared with wire escalation, upfront use of the CrossBoss catheter for antegrade crossing of coronary chronic total occlusions was associated with similar crossing time, similar success and complication rates, and similar equipment use and cost.

Chronic total occlusion percutaneous coronary intervention: Evidence and controversies

Coronary chronic total occlusions (CTOs) are defined as 100% occlusions with TIMI (Thrombolysis in Myocardial Infarction) 0 flow with at least a 3‐month duration.[1][1] Treatment options for patients with coronary CTOs include lifestyle changes and medications (as is appropriate for all patients

Update in the Percutaneous Management of Coronary Chronic Total Occlusions

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been rapidly evolving during recent years. With improvement in equipment and techniques, high success rates can be achieved at experienced centers, although overall success rates remain low. Prospective, randomized-controlled data regarding optimal use and indications for CTO PCI remain limited. CTO PCI should be performed when the anticipated benefit exceeds the potential risk. New high-quality studies of the clinical outcomes and techniques of CTO PCI are needed, as is the expansion of expert centers and operators that can achieve excellent clinical outcomes in this challenging patient and lesion subgroup. Inxa0thexa0current review the authors summarize the latest publications in CTO PCI and provide an overview of the currentxa0statexa0ofxa0the field.

Subadventitial stenting around occluded stents: A bailout technique to recanalize in-stent chronic total occlusions

To evaluate the outcomes of subadventitial stenting (SS) around occluded stents for recanalizing in‐stent chronic total occlusions (IS‐CTOs).

Prevalence, Presentation and Treatment of ‘Balloon Undilatable’ Chronic Total Occlusions: Insights from a Multicenter US Registry

The prevalence, treatment and outcomes of balloon undilatable chronic total occlusions (CTOs) have received limited study.

Sleep deprivation in interventional cardiology: Implications for patient care and physician-health

The burden and impact of sleep deprivation on both patient care and on the health of interventional cardiologists is not well understood. Due to the nature of emergent procedures occurring in the cardiac catheterization laboratory, interventionalists are prone to suffer from acute and/or chronic sleep deprivation. Sleep deprivation has been associated with numerous adverse effects, such as impaired performance, cognitive deficits, reduced psychomotor vigilance, and workplace errors and injuries, among many others. Although sleep deprivation has been linked to more errors in trainees, there is paucity of data addressing outcomes in interventional cardiology. The purpose of this overview is to explore the possible impact of sleep deprivation on interventional cardiology in relation to patient care and physician health, and examine potential approaches to this issue.

The "double stingray technique" for recanalizing chronic total occlusions with bifurcation at the distal cap

Antegrade dissection re‐entry is often discouraged for chronic total occlusions (CTOs) with a bifurcation at the distal cap due to risk of side branch occlusion that can lead to periprocedural myocardial infarction and incomplete revascularization. Antegrade dissection re‐entry, however, is often needed, especially in complex cases. We present the novel “double Stingray technique” for CTOs involving bifurcations, in which the Stingray system is used twice for re‐entry into both vessel branches, followed by two‐stent bifurcation stenting to maintain the patency of both branches.

PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH PREVIOUS CORONARY ARTERY BYPASS GRAFT SURGERY: INSIGHTS FROM A MULTICENTER REGISTRY

We sought to examine the procedural outcomes of chronic total occlusions (CTO) percutaneous coronary interventions (PCI) in patients with previous coronary artery bypass graft surgery (CABG).nnWe compared the clinical, angiographic and procedural characteristics of 2862 CTO interventions performed