Revascularization of coronary chronic total occlusions with subintimal tracking and reentry followed by deferred stenting: Experience from a high‐volume referral center

Background When crossing into the distal true lumen fails during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification (SPM) is often performed to restore antegrade flow and facilitate subsequent lesion recanalization. Methods Between January 2012 and May 4, 2019, 4,659 CTO PCIs were included in the PROGRESS‐CTO registry, of which 935 (20%) had a prior unsuccessful attempt. Of those 935 patients, 119 (13%) had prior SPM. We analyzed the outcomes of the 58 SPM procedures for which data were available, as well as the outcomes of the 60 subsequent CTO PCI attempts. Results Mean patient age was 67 ± 9 years and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%) diabetes (48%), prior PCI (61%), and prior coronary artery bypass graft surgery (47%). The target CTO lesions often had proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J‐CTO score (mean 3.2 ± 1.1). The technical and procedural success of subsequent CTO PCI were high (83% for both) with an acceptable rate of in‐hospital major adverse cardiovascular events (3.3%). Technical and procedural success were higher for repeat attempts that were performed ≥60 days after the index CTO PCI (94% vs. 69%, p = .015). Median (interquartile range) subsequent procedure time was 147 (100, 215) min, contrast volume was 185 (150, 260) ml, and air kerma radiation dose was 2.5 (1.4, 4.2) Gray. Conclusion Repeat CTO PCI attempts after SPM are associated with high likelihood for successful revascularization with acceptable risks.

Section: Discussionmentioning

confidence: 72%

“…Given limited published data on SPM, 8-10 we investigated the frequency of SPM and outcomes of subsequent PCIs in a large, contemporary multicenter CTO PCI registry.…”

Section: Introductionmentioning

confidence: 99%

Outcomes of subintimal plaque modification in chronic total occlusion percutaneous coronary intervention

Xenogiannis

Choi

Alaswad

et al. 2019

“…Balloon technique (to provide a better distal outflow) and deferred stenting for unsuccessful CTO PCI has already been described, with encouraging results. [7][8][9] It was associated with better patientreported health status at 30 days, increased overall procedural success, similar complication rates compared to no plaque modification and to ad hoc stenting, and, possibly, with lower rates of death and myocardial infarction.…”

Section: Casementioning

confidence: 93%

Drug‐coated balloon after subintimal plaque modification in failed coronary chronic total occlusion percutaneous coronary intervention: A novel concept

Ybarra

Dandona

Daneault

et al. 2019

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is a technically challenging procedure. In failed cases, plaque modification strategy (also known as “investment procedure”), defined as the intentional dilation of the subintimal space through the CTO segment, can be applied. The typical dilation device used in this strategy is a regular angioplasty balloon (either semi‐ or noncompliant). Performing this technique with a drug‐coated balloon (DCB) may facilitate a staged procedure by promoting a better vessel healing. Herein, we present three cases of failed CTO PCI, managed with DCB plaque modification, and their follow‐up staged procedure.

“…In this issue of the Journal, Goleski et al present outcomes of 32 patients (4.2% of total CTO PCI volume) who underwent deferred stenting post STAR in a world renowned CTO PCI reference center . These were highly complex patients (62% had prior CABG) and lesions (median J‐CTO score was 2.5).…”

Section: Spm At a Cto Pci Expert Centermentioning

confidence: 99%

Hybrid 2.0: Subintimal plaque modification for facilitation of future success in chronic total occlusion percutaneous coronary intervention

Hall

Brilakis

2019