We performed a retrospective analysis of 146 chronic total occlusion CTO patients to evaluate the antecedents of success and failure in CTO – Percutaneous Coronary Intervention (PCI) in Indian patients. The study aimed to identify the technical success rate, analyse immediate patient outcomes, and understand the factors impacting the successful outcomes. Our results showed that J-CTO (Multicenter CTO Registry of Japan) scores correlate well with the success rates of CTO-PCI and two most important factors deciding failure are lesion length more than 20 mm and lesions with calcification. Most important step to success of CTO is wiring, once wire crosses the segment, success rates of the procedure is around 97%. The wire escalation strategy has to be modified once the initial soft (polymer) wire fails, it’s reasonable to use high tip load wire like conquest pro without the use of intermediate wires (except in presence of tortuosity). At 1 year follow up of these patients, there was a statistically significant drop in angina class and major adverse cardiac event rates in the successful CTO group.

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Intra-procedural stent thrombosis (IPST) is defined as the development of occlusive or non-occlusive new thrombus in or adjacent to a recently implanted stent before the PCI procedure is completed. The frequency of occurrence currently ranges between 0.5-1.7% of all PCI procedures and it seems to be considerably reduced with newer drug eluting stents and improved techniques. The occurrence of IPST is relatively rare, even in ACS patients, and is related strongly to clinical presentation and procedural factors (e.g., anticoagulation regimen, lesion type, presence of thrombus at baseline, stent under expansion and edge dissection etc.) than to baseline demographic characteristics. Imaging modalities like IVUS or OCT can prevent as well as identify the underlying cause for IPST. IPST not only decreases success rate of PCI but is also associated with higher rates of slow flow or no reflow, distal embolization and side branch closure. It is also associated with higher mortality, myocardial infarction, ischemia driven revascularisation and stent thrombosis on follow up. IPST can be managed immediately in cath lab and involves use of GP2b3a inhibitors, optimising stent apposition by repeat balloon dilatation, use of imaging to identify the cause and accordingly corrective measures to be taken. Rarely emergency CABG may be required if underlying cause cannot be corrected. Prevention is the key. IPST can be prevented by using newer anti-platelets, use of GP2b3a inhibitors especially in presence of ACS or high thrombus load, preparing the lesion well before stenting, use of atherectomy devices when needed, appropriate stent size selection and use of imaging modalities in complex lesions to optimise stent selection and apposition. We describe three cases of the intra procedural stent thrombosis under different clinical scenarios and its management.

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