Predicting Periprocedural Complications in Chronic Total Occlusion Percutaneous Coronary Intervention

Why complex and high risk percutaneous coronary interventions should be offered to selected octogenarians/nonagenarians

“…The decision to perform PCI depends on the balance between potential benefits and risks (Figure 1). The BCIS analysis confirms that the risks of CHiP are higher in ≥80‐year‐old patients 4 (higher mortality, higher risk of bleeding, and higher MACCE), but the absolute event rate was relatively low (0.5% mortality, 1.0% bleeding, 1.7% major cardiovascular and cerebral events [MACCE]). Moreover, the risk of bleeding and MACCE significantly decreased over time.…”

External validation of the PROGRESS‐CTO perforation risk score: Individual patient data pooled analysis of three registries

“…Moreover, in this external validation, PROGRESS-CTO perforation score performed well in patients with prior CABG, overcoming a limitation of the PROGRESS-CTO pericardiocentesis score, which was developed after excluding patients with prior CABG. 18 Our study has limitations. First, the registries are subject to the limitations of observational studies.…”

“…Due to relatively high complication risk and equivocal randomized controlled trial evidence for procedural benefit, the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions guidelines for coronary artery revascularization downgraded the recommendation for CTO PCI from class 2a to class 2b (level of evidence B): “In patients with suitable anatomy who have refractory angina on medical therapy, after treatment of non‐CTO lesions, the benefit of PCI of a CTO to improve symptoms is uncertain.” 12–16 Therefore, individualized risk/benefit assessment, procedural planning, and readiness for complication management are essential in CTO PCI. The current results suggest that the PROGRESS‐CTO perforation risk model can be a valuable tool to facilitate the risk‐benefit assessment in CTO PCI, which is critical for decision making 17,18 …”

Expanding indications: hybrid surgicalpercutaneous coronary intervention (PCI) coronary revascularization of chronic total occlusions in patients with multivessel coronary artery disease (CAD)

“…The success rate and safety of CTO PCI are high in centers with expertise in CTO PCI programs. Registries demonstrate 85%-90% success rates with a major complication rate ranging from 1.8%-7%, and more recent data confirm a contemporary complication rate of about 2% [18][19][20][21] . This is in line with the general trend of improving outcomes after PCI [22] .…”

“…The efficacy of CTO PCI for angina relief has been shown in multiple observational trials and two randomized trials, the EuroCTO trial (Randomized Multicentre Trial to Compare Revascularization With Optimal Medical Therapy for the Treatment of Chronic Total Coronary Occlusions) and the IMPACTOR-CTO trial (Impact on Inducible Myocardial Ischemia of Percutaneous Coronary Intervention versus Optimal Medical Therapy in Patients with Right Coronary Artery Chronic Total Occlusion) [20,23,24] . Two other randomized trials showed a neutral effect of CTO PCI on left ventricular ejection fraction in CTOs was found to be present in patients presenting with ST-elevation myocardial infarction, and on major adverse cardiovascular events (MACE) in stable patients presenting for CTO PCI [25,26] .…”