William Lombardi

Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Outcomes From a Multicenter Registry in the United States

OBJECTIVES This study sought to examine the contemporary outcomes of retrograde chronic total occlusion (CTO) interventions among 3 experienced U.S. centers. BACKGROUND The retrograde approach, pioneered and developed in Japan, has revolutionized the treatment of coronary CTO, yet limited information exists on procedural efficacy, safety, and reproducibility of outcomes in other settings. METHODS Between 2006 and 2011, 462 consecutive retrograde CTO interventions were performed at 3 U.S. institutions. Patient characteristics, procedural outcomes, and in-hospital clinical events were ascertained. RESULTS Mean patient age was 65 ± 9.7 years, 84% were men, and 50% had prior coronary artery bypass surgery. The CTO target vessel was the right coronary artery (66%), circumflex (18%), left anterior descending artery (15.5%), and left main artery or bypass graft (0.5%). The retrograde approach was used as the primary method in 46% of cases and after failed antegrade recanalization in 54%. Retrograde collateral vessels were septal (68%), epicardial (24%), and bypass grafts (8%). Technical and procedural success was 81.4% (n = 376) and 79.4% (n = 367), respectively. The mean contrast volume and fluoroscopy time were 345 ± 177 ml and 61 ± 40 min, respectively. A major complication occurred in 12 patients (2.6%). In multivariable analysis, years since initiation of retrograde CTO percutaneous coronary intervention (PCI) at each center, female sex, and ejection fraction ≥40% were associated with higher technical success. CONCLUSIONS Among selected U.S. programs, retrograde CTO PCI is often performed in patients with prior coronary bypass graft surgery and is associated with favorably high success and low complication rates.

Use of a novel crossing and re-entry system in coronary chronic total occlusions that have failed standard crossing techniques: Results of the FAST-CTOs (facilitated antegrade steering technique in chronic total occlusions) trial

OBJECTIVES This study sought to examine the efficacy and safety of 3 novel devices to recanalize coronary chronic total occlusions (CTOs). BACKGROUND Successful percutaneous coronary intervention (PCI) of CTOs improves clinical outcome in appropriately selected patients. CTO PCI success, however, remains suboptimal. METHODS A new crossing catheter and re-entry system was evaluated in a prospective, multicenter, single-arm trial of CTO lesions refractory to standard PCI techniques. The primary efficacy endpoint was the frequency of true lumen guidewire placement distal to the CTO (technical success). RESULTS Enrollment included 147 patients with 150 CTOs. The mean lesion length was 41 ± 17 mm. A crossing catheter crossed 56 lesions into the distal true lumen, and a re-entry catheter facilitated tapered-wire cannulation of the distal lumen in 59 CTOs initially crossed subintimally (77% technical success). Success in the first 75 CTOs was 67%, rising to 87% in the last 75 CTOs. Mean fluoroscopy and procedure times were 45 ± 16 min and 90 ± 12 min, respectively, each significantly shorter than in historical controls (p < 0.0001 for both). Coronary perforation occurred in 14 cases (9.3%), requiring treatment in 3 cases (prolonged balloon inflation, with additional coil embolization in 1 case). No tamponade or hemodynamic instability occurred. Six patients had periprocedural non-ST-segment elevation myocardial infarction. No emergency surgery, ST-segment elevation myocardial infarction, or cardiac reintervention occurred. Two deaths occurred within 30 days, neither as a direct result of the procedure. The 30-day major adverse cardiac event rate was 4.8%. CONCLUSIONS In CTOs failing standard techniques, use of a new crossing and re-entry system results in a high success rate without increasing complications.

The retrograde approach to coronary artery chronic total occlusions: a practical approach.

The retrograde approach has revolutionized the treatment of chronic total occlusions. Several retrograde techniques have recently been described. In this article, we present a practical review with step‐by‐step instructions on the indications for retrograde interventions, equipment and retrograde channel selection, and techniques for retrograde crossing and treatment of chronic total occlusions.

Procedural Outcomes of Revascularization of Chronic Total Occlusion of Native Coronary Arteries (from a Multicenter United States Registry)

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.

Application and outcomes of a hybrid approach to chronic total occlusion percutaneous coronary intervention in a contemporary multicenter US registry

BACKGROUND A hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) prioritizing and combining all available crossing techniques was developed to optimize procedural efficacy, efficiency, and safety, but there is limited published data on its outcomes. METHODS We examined the procedural techniques and outcomes of 1036 consecutive CTO PCIs performed using a hybrid approach between 2012 and 2015 at 11 US centers. RESULTS Mean age was 65 ± 10 years and 86% of the patients were men, with a high prevalence of diabetes mellitus (43%) and prior coronary artery bypass graft surgery (34%). Most target CTOs were located in the right coronary artery (59%), followed by the left anterior descending artery (23%) and the circumflex (19%). Dual injection was used in 71%. Technical success was achieved in 91% and a major procedural complication occurred in 1.7% of cases. The final successful crossing technique was antegrade wire escalation in 46%, antegrade dissection/re-entry in 26%, and retrograde in 28%. The initial crossing strategy was successful in 58% of the lesions, whereas 39% required an additional approach. Overall, antegrade wire escalation was used in 71%, antegrade dissection/re-entry in 36%, and the retrograde approach in 42% of procedures. Median contrast volume, fluoroscopy time, and air kerma radiation dose were 260 (200-360) ml, 44 (27-72) min, and 3.4 (2.0-5.4) Gray, respectively. CONCLUSION Application of a hybrid approach to CTO crossing resulted in high success and low complication rates across a varied group of operators and hospital practice structures, supporting its expanding use in CTO PCI.

Use of drug-eluting stents for chronic total occlusions: A systematic review and meta-analysis†

Aim: To perform a systematic review and meta‐analysis of studies reporting outcomes after drug‐eluting stent (DES) implantation in chronic total occlusions (CTOs). Methods: A review of publications and online databases in January 2010 retrieved 17 published studies that reported outcomes after DES implantation in CTOs: eight uncontrolled studies, seven nonrandomized comparative studies with bare‐metal stents (BMS), one post‐hoc analysis of a randomized trial, and one randomized trial. Data were pooled using random‐effects meta‐analysis models. Results: All published studies evaluated sirolimus‐ or paclitaxel‐eluting stents. All studies reporting comparative angiographic outcomes revealed less binary angiographic restenosis with DES implantation compared to BMS (odds ratio: 0.15, 95% CI: 0.08, 0.26). Over a mean follow‐up period of 18.9 ± 16.5 months, the cumulative incidence of death, myocardial infarction, or stent thrombosis was similar between DES and BMS in all studies. Target lesion revascularization (odds ratio: 0.13, 95% CI: 0.06, 0.26) and target vessel revascularization (odds ratio 0.18, 95% CI: 0.11, 0.31) at 6–12 months were consistently lower among DES‐treated patients. Similar patterns of safety and efficacy event rates were also observed in studies reporting >12 month outcomes. Conclusions: Compared with BMS, treatment of chronic total coronary occlusions with DES is associated with significant reductions in angiographic and clinical restenosis with similar safety. The consistency and magnitude of treatment effect across both individual trials and the pooled analysis establish DES as the preferred therapy for percutaneous revascularization of CTOs.

Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularisation: insights from a multicentre US registry

Objective To investigate the impact of prior coronary artery bypass graft (CABG) surgery on the outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Design Observational retrospective study. Setting Three tertiary hospitals in the USA. Participants 1363 consecutive patients who underwent CTO PCI between 2006 and 2011. Main outcome measures Procedural success and inhospital complications, which were compared between patients with and without prior CABG. Results Compared to patients without prior CABG, those with prior CABG were older, had more comorbidities, were treated more frequently with the retrograde approach (46.7% vs 27.1%, p<0.001) and had lower technical success rates (79.7% vs 88.3%, p=0.015). Of the 24 (1.8%) major inhospital complications, 11 occurred in patients with prior CABG and 13 in patients without prior CABG (2.1% vs 1.5%, p=0.392). In multivariable analysis prior CABG was independently associated with lower technical success rate (OR 0.49, 95% CIs 0.35 to 0.70, p<0.001). Conclusions In a large multicentre registry, CTO PCI was frequently performed among patients with prior CABG, with higher use of the retrograde approach and similar complications but lower technical success rates compared to patients without prior CABG.

Retrograde recanalization of native coronary artery chronic occlusions via acutely occluded vein grafts

Treatment of acutely occluded saphenous vein grafts may be challenging due to large thrombus burden and diffuse disease. We report two cases of thrombotic saphenous vein graft occlusion, in which after percutaneous attempts to recanalize the saphenous vein graft failed, the target native coronary artery chronic total occlusions were successfully treated using a retrograde approach.

The efficacy of "hybrid" percutaneous coronary intervention in chronic total occlusions caused by in-stent restenosis: insights from a US multicenter registry.

To examine the success and complication rates in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) caused by in‐stent restenosis (ISR).

Transradial approach for coronary chronic total occlusion interventions: Insights from a contemporary multicenter registry

To examine the impact of transradial access on the procedural outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI).