Effects of a prior failed attempt on the outcomes of subsequent chronic total occlusion‐percutaneous coronary intervention

Abstract

ObjectivesPatients undergoing a prior failed attempt of chronic total occlusion‐percutaneous coronary intervention (CTO‐PCI) represent a challenging subgroup across all patients undergoing CTO‐PCI. There are limited data on the effects of a prior failed attempt on the outcomes of subsequent CTO‐PCI. We aimed to compare the procedural results and 24‐month outcomes of prior‐failed‐attempt CTO‐PCI with those of initial‐attempt CTO‐PCI.MethodsPatients who underwent attempted CTO‐PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 24‐month major adverse cardiac events (MACE) between patients who underwent prior‐failed‐attempt and initial‐attempt CTO‐PCI. MACE was defined as a composite of cardiac death, target vessel‐related myocardial infarction, and ischemia‐driven target vessel revascularization (TVR) during follow‐up.ResultsIn total, 484 patients who underwent CTO‐PCI (prior‐failed‐attempt, n = 49; initial‐attempt, n = 435) were enrolled during the study period. After propensity score matching (1:3), 147 patients were included in the initial‐attempt group. The proportion of the Japanese‐CTO (J‐CTO) score ≥2 was higher in the patients who underwent prior failed attempt than in those who underwent initial attempt (77.5% vs. 38.8%, p < 0.001). The retrograde approach was more often adopted in the prior‐failed‐attempt group than in the initial‐attempt group (32.7% vs. 3.4%, [P< 0.001). Successful CTO revascularization rates were significantly lower in the prior‐failed attempt‐group than in the initial attempt group (53.1% vs. 83.3%, P < 0.001). The multivariate analysis revealed that J‐CTO score ≥2 [odds ratio (OR), 0.359; 95% confidence interval (CI), 0.159–0.812; P = 0.014], intravascular ultrasound procedure (OR, 4.640; 95% CI, 1.380–15.603; P = 0.013), and prior failed attempt (OR, 0.285; 95% CI, 0.125–0.648; P = 0.003) were the independent predictors for successful CTO revascularization. There were no significant differences in major procedural complications (2.0% vs. 0.7%, p = 0.438) and MACE rates (4.1% vs. 8.8%, p = 0.438) between the groups, mainly due to the TVR rate (4.1% vs. 8.2%, P = 0.522).ConclusionsCompared with initial‐attempt CTO‐PCI, prior‐failed‐attempt CTO‐PCI deserves more attention, since it is associated with a lower successful CTO revascularization rate. Prior failed attempt, J‐CTO score ≥2, and IVUS procedure are the determining factors for predicting successful CTO revascularization. There are no significantly different unfavorable outcomes between patients who undergo prior‐failed‐attempt and initial‐attempt CTO‐PCI.