Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

The number of retrograde procedures in Europe has increased, with high percents of success, low rates of major complications, and good long-term outcomes.

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Background: Gender-specific data addressing percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) in female patients are scarce and based on small sample size studies.Aims: We aimed to analyze gender-differences regarding in-hospital clinical outcomes after CTO-PCI.Methods: Data from 35,449 patients enrolled in the prospective European Registry of CTOs were analyzed. The primary outcome was the comparison of procedural success rate in the two cohorts (women vs. men), defined as a final residual stenosis less than 20%, with Thrombolysis In Myocardial Infarction grade flow = 3. In-hospital major adverse cardiac and cerebrovascular events (MACCEs) and procedural complications were deemed secondary outcomes.Results: Women represented 15.2% of the entire study population. They were older and more likely to have hypertension, diabetes, and renal failure, with an overall lower J-CTO score. Women showed a higher procedural success rate (adjusted OR [aOR] = 1.115, confidence interval [CI]: 1.011-1.230, p = 0.030). Apart from previous myocardial infarction and surgical revascularization, no other significant gender differences were found among predictors of procedural success. Antegrade approach with true-to-true lumen techniques was more commonly used than retrograde approach in females. No gender differences were found regarding inhospital MACCEs (0.9% vs. 0.9%, p = 0.766), although a higher rate of procedural complications was observed in women, such as coronary perforation (3.7% vs. 2.9%, p < 0.001) and vascular complications (1.0% vs. 0.6%, p < 0.001).Conclusions: Women are understudied in contemporary CTO-PCI practice. Female sex is associated with higher procedural success after CTO-PCI, yet no sex differences were found in terms of in-hospital MACCEs. Female sex was associated with a higher rate of procedural complications.chronic total occlusion, female sex, gender differences, major adverse cardiac and cerebrovascular events, percutaneous coronary intervention How to cite this article: Avran A, Zuffi A, Gobbi C, et al.Gender differences in percutaneous coronary intervention for chronic total occlusions from the ERCTO study. Catheter

17Summary Introduction. Despite advantages in interventional cardiology during last decade, chronic total occlusions (CTO) still remains one of the biggest problem in percutaneous coronary interventions (PCI) (10,14). CTO prevalence is high, but only less than 10% of percutaneous revascularizations are CTO interventions (17). There are no prospective randomized trials, properly powered for hard clinical endpoints, comparing modern optimal medical therapy with contemporary state of the art CTO recanalization (6). Aim of the study. The aim of our study was to compare CTO PCI procedural parameters and treatment results using anterograde and/or retrograde approach. Materials and methods. The study included all patients undergoing PCI for CTO at single tertiary PCI center between January 2007 and December 2012. 5568 PCI procedures were done in this period in our institution. 486 (8,64%) of them were CTO PCI. Retrograde approach was used in 138 (28,7% of all CTO PCI) cases. Patients were grouped according PCI year performing, approach (anterograde or retrograde) and PCI results (successful or unsuccessful). Demographic and procedural data were collected at the time of intervention. Results. A total of 405 patients undergoing CTO PCI were included. The median age was 64yrs(38-88) and 79,2% was male. Retrograde approach (RA) was used in 138(28,7%) cases. RA usage has increase from 15.9% in 2007 till 46,8% of cases in 2012(p=0,0000218). The overall patient and procedure success rates were 77,8% (315/90) and 69,9%(340/146) respectively. Overall success rate has increase from 61,4% in 2007 till 87,1% in 2012 (p<0,001). Overall survival was found better in patients group after successful procedure (Long-rank test p=0,019). Conclusions. Retrograde approach usage significantly increase CTO PCI success rate, but doesn't increase risk of complications. Long-term outcome and survival after CTO PCI is not depending on approach (anterograde or retrograde), but on procedural success.

Background and objectives: Different scoring systems are used to stratify patients with chronic total coronary artery occlusions (CTO) according to disease complexity to predict the success of the percutaneous coronary intervention (PCI). Comparison among different CTO scoring systems and long-term outcome for patients with CTO after PCI has not been well established. The objectives of the study were to assess the ability of different disease severity scoring systems to predict, first, procedural success and, second, overall survival in patients with a successful procedure. Materials and Methods: A total of 551 patients who underwent elective CTO PCI in Riga East University hospital from January 2007 to December 2016 were included in the study. Four scoring systems (J CTO, PROGRESS CTO, CL, and CASTLE) were calculated. ROC curves were used to assess the association between scores and procedural success, and the Kaplan–Meier method and Cox regression were used to estimate the association with death from any cause after a successful procedure, Results: 454 of 551cases were successful. With increasing disease complexity, the procedural success rate was significantly reduced in all scoring systems (p < 0.001): Area under the curve was 0.714 for J CTO score, 0.605 for PROGRESS CTO, 0.624 for CL and 0.641 for CASTLE scores. During the median 6.8 years of follow-up time, survival was better in the successful procedure group (p = 0.041). Among patients with procedural success, only PROGRESS and CASTLE scores showed an association with all-cause risk of death. After adjustment for baseline characteristics, patients having high PROGRESS score had almost twice higher risk of death (HR 1.81(95% CI 1.19–2.75)), and those with high and intermediate CASTLE score experienced almost four (HR 3.68(95% CI 1.50–9.05)) and two (HR 2.15, (95% CI 1.42–3.23)) times higher risk of death than the low score patients, respectively. Conclusions: All four CTO scoring systems had moderate ability to predict procedural success. More complex CTO PCI patients, assessed by PROGRESS and CASTLE scores, has worse all-cause survival in six to seven years after a successful procedure; whereas J CTO and CL scores had no association with survival.

Insulin responsiveness to glucose of isolated islets of Langerhans was studied in 'younger' and 'older' rats after feeding and fasting for various lengths of time. In 'younger' rats, after prolonged fasting (168 h) the threshold for glucose-stimulated insulin secretion was increased. This was not evident in islets from 'younger' rats fasted for 48 or 89 h. Reductions in increments of insulin secretion with increments in glucose, in the maximum insulin secreted and in the total extractable insulin of the islets were apparent after fasting for 48, 89 and 168 h as compared with islets from fed rats. In 'older' rats, prolonged fasting caused an increase in the threshold for glucose-stimulated insulin secretion, reduced incremental insulin secretion, reduced maximum insulin secretion and reduced total extractable insulin. However, the responses of islets from fed 'older' rats were similar to those of fasted (168 h) 'younger' rats. The threshold levels were similar, and there were no significant differences between increments in insulin secretion, maximum insulin secretion and insulin content of the islets. These experiments show that the responsiveness of islets of Langerhans in rats can be altered by age and fasting.