TCT-192 Procedural Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention: A Report from NCDR

Brilakis, Emmanouil S.; Banerjee, Subhash; Karmpaliotis, Dimitri; Lombardi, William; Tsai, Thomas T.; Shunk, Kendrick A.; Kennedy, Kevin F.; Spertus, John A.; Holmes, David R.; Grantham, J. Aaron

doi:10.1016/j.jacc.2014.07.233

Cited by 115 publications

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“…24 Additionally, higher-risk patients are almost uniformly excluded from most clinical trials. Many of these patients do not even undergo the diagnostic testing necessary to by guest on May 12, 2018 http://circ.ahajournals.org/ Downloaded from make the diagnosis of severe CAD. 24,32 Furthermore, a misalignment exists in the use of cardiac catheterization in many patients relative to their predicted probability of severe CAD in which the use of catheterization appears to target patients who would derive less benefit from revascularization, consistent with a treatment-risk paradox.…”

Section: Candidacy For Revascularization: An Unmet Need For Pcimentioning

confidence: 99%

“…In the current era of PCI with advances in functionally based revascularization, adjunctive pharmacology, and PCI techniques and devices, the success rates for treating the most complex lesion subsets have improved among operators trained in specialized techniques 45,46 but have remained significantly lower among everyday interventionalists. 47 Armed with the knowledge of how and when to use these techniques, dedicated interventionalists with expertise in treating these patients could be more apt to choose the optimal treatment strategies and, most important, improve overall outcomes in these patients.…”

Section: Multidisciplinary Team-based Approach To Higher-risk Cad Patmentioning

confidence: 99%

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Treatment of Higher-Risk Patients With an Indication for Revascularization

et al. 2016

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Patients with severe coronary artery disease with a clinical indication for revascularization but who are at high procedural risk because of patient comorbidities, complexity of coronary anatomy, and/or poor hemodynamics represent an understudied and potentially underserved patient population. Through advances in percutaneous interventional techniques and technologies and improvements in patient selection, current percutaneous coronary intervention may allow appropriate patients to benefit safely from revascularization procedures that might not have been offered in the past. The burgeoning interest in these procedures in some respects reflects an evolutionary step within the field of percutaneous coronary intervention. However, because of the clinical complexity of many of these patients and procedures, it is critical to develop dedicated specialists within interventional cardiology who are trained with the cognitive and technical skills to select these patients appropriately and to perform these procedures safely. Preprocedural issues such as multidisciplinary risk and treatment assessments are highly relevant to the successful treatment of these patients, and knowledge gaps and future directions to improve outcomes in this emerging area are discussed. Ultimately, an evolution of contemporary interventional cardiology is necessary to treat the increasingly higher-risk patients with whom we are confronted.

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Section: Candidacy For Revascularization: An Unmet Need For Pcimentioning

confidence: 99%

Section: Multidisciplinary Team-based Approach To Higher-risk Cad Patmentioning

confidence: 99%

Treatment of Higher-Risk Patients With an Indication for Revascularization

et al. 2016

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“…In an analysis of 594,510 PCI cases performed between 2009 and 2013 in patients with stable coronary artery disease in the National Cardiovascular Data Registry (NCDR), CTO-PCI represented 3.8% of the total PCI volume and was associated with significantly lower procedural success (59% versus 96%, P , .001) and higher risk for complications (1.6% versus 0.8%; P , .001) compared with non-CTO-PCI. 30 Bridging the gap between what can be achieved and what is currently being achieved requires a multilevel effort, including clinician education and training, institutional support, continued evolution of techniques, and development of novel and easier to use equipment. 31 n COMPLICATIONS Chronic total occlusion-PCI is more likely to cause complications compared with non-CTO-PCI, 30 with perforation being the most concerning.…”

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confidence: 99%

“…30 Bridging the gap between what can be achieved and what is currently being achieved requires a multilevel effort, including clinician education and training, institutional support, continued evolution of techniques, and development of novel and easier to use equipment. 31 n COMPLICATIONS Chronic total occlusion-PCI is more likely to cause complications compared with non-CTO-PCI, 30 with perforation being the most concerning. As ''one ounce of prevention is worth a pound of cure,'' meticulous attention to wire and microcatheter position using dual injection and orthogonal projections can help prevent perforation (wire exit almost never causes significant perforation; however, balloon or microcatheter exit can Once a perforation occurs, a balloon is inflated proximally to stop the bleeding into the pericardial space.…”

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confidence: 99%

Update in Chronic Total Occlusion Percutaneous Coronary Interventions

Brilakis¹,

Burke²

2017

Journal of the Minneapolis Heart Institute Foundation

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Outcomes of chronic total occlusion-percutaneous coronary intervention have significantly improved in recent years. Chronic total occlusion-percutaneous coronary intervention can provide significant clinical benefits, such as angina reduction. At experienced centers, high success rates can currently be achieved, with use of all chronic total occlusion crossing techniques (antegrade wire escalation, antegrade dissection/ reentry, and the retrograde approach) orchestrated by use of procedural algorithms, such as the hybrid algorithm. Growth of chronic total occlusion-percutaneous coronary intervention is also fueled by continuous development of novel equipment, such as guidewires, microcatheters, support catheters, and dissection/reentry equipment. Readiness and ability to treat complications, such as perforation and donor vessel closure, is critical for all centers performing the procedure. Chronic total occlusionpercutaneous coronary intervention is a powerful and continuously developing tool for achieving complete coronary revascularization.

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“…In regards to long-term clinical outcomes, the survival benefit of CTO recanalization is less clearly established, although it has been previously suggested in prior studies (3)(4)(5).…”

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Does successful chronic total occlusion recanalization fail to improve long-term survival?

Takao¹

2017

Cardiovasc. Diagn. Ther.

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There has been a significant increase in the number of patients undergoing successful CTO PCI in recent years, even though there might remains considerable controversy regarding the clinical benefit of this procedure. Although no randomized controlled clinical trials comparing CTO-PCI with medical therapy have been published to date, there is a growing body of evidence suggesting clinical benefits (1). These benefits include improvement of anginal symptoms, decreased anti-anginal medication intake, improved exercise capacity, improved left ventricular systolic function, decreased risk of arrhythmia, decreased the number of coronary artery bypass graft (CABG) procedures, and improved tolerance of future coronary occlusion events such as acute coronary syndrome among patients with successful versus failed CTO-PCI. Moreover, CTO is the most common reason for failing to achieve complete revascularization, and incomplete revascularization is associated with poorer clinical outcome compared with complete revascularization.Application of drug-eluting stents (DES) has resulted in significant reduction of target vessel revascularization in non-CTO PCI, and has also led to a surge of interest in CTO-PCI. As a consequence, second-generation DES implantation is the current therapy of choice for percutaneous revascularization of CTO, because it is clear due to supporting clinical evidence in many meta-analyses that implantation of the second-generation DES improves long-term angiographic and clinical outcomes compared with first-generation DES, bare metal stents, and balloon angioplasty without using stents (2).In regards to long-term clinical outcomes, the survival benefit of CTO recanalization is less clearly established, although it has been previously suggested in prior studies (3)(4)(5).A recent study published in this issue of JACC Cardiovasc Interv describes the long-term survival of CTO-PCI. Lee and colleagues evaluated (6) 1,173 consecutive patients with CTO of native coronary vessels requiring PCI of Asan Medical Center in Seoul between March 2003 and May 2014. The procedure was performed successfully, in 1,004 (85.6%) using DES implantation. However, successful recanalization of CTO PCI using DES was not associated with a reduction in long-term mortality over a median follow-up 4.6 years [hazard ratio (HR), 1.04; 95% confidence interval (CI), 0.53-2.04; P=0.94].This report also described that successful CTO PCI was associated with significant fewer subsequent CABG procedures. In contrast, in the group with failed CTO PCI a substantially higher rates of subsequent TVR (HR, 0.15; 95% CI, 0.10-0.25; P<0.001) and CABG procedure (HR, 0.02; 95% CI, 0.006-0.06; P<0.001) was observed.In an evaluation of details of these results, complete revascularization was achieved in 77.2% and 75.9% of patients with failed CTO PCI excluding the CTO lesion and patients with successful CTO PCI within 6 months, respectively (P=0.77). Nevertheless, patients with failed CTO PCI had significantly higher rates of TVR (4.4% vs. Editorial

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TCT-192 Procedural Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention: A Report from NCDR

Cited by 115 publications

References 0 publications

Treatment of Higher-Risk Patients With an Indication for Revascularization

Treatment of Higher-Risk Patients With an Indication for Revascularization

Update in Chronic Total Occlusion Percutaneous Coronary Interventions

Does successful chronic total occlusion recanalization fail to improve long-term survival?

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