Validation of the BCIS CHIP Score in chronic total occlusion percutaneous coronary intervention.

BACKGROUND: The complex high-risk indicated percutaneous coronary intervention (CHIP) score is a tool developed using the British Cardiovascular Intervention Society (BCIS) database to define CHIP cases and predict in-hospital major adverse cardiac or cerebrovascular events (MACCE). AIM: To assess the validity of the CHIP score in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We evaluated the performance of the CHIP score on 8341 CTO PCIs from the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) performed at 44 centers between 2012 and 2023. RESULTS: In our cohort, 7.8% (n = 647) of patients had a CHIP score of 0, 50.2% (n = 4192) had a CHIP score of 1-2, 26.2% (n = 2187) had a CHIP score of 3-4, 11.7% (n = 972) had a CHIP score of 5-6, 3.3% (n = 276) had a CHIP score of 7-8, and 0.8% (n = 67) had a CHIP score of 9+. The incidence of MACCE for a CHIP score of 0 was 0.6%, reaching as high as 8.7% for a CHIP score of 9+, confirming that a higher CHIP score is associated with a higher risk of MACCE. The estimated increase in the risk of MACCE per one score unit increase was 100% (95% confidence interval [CI]: 65%-141%). The AUC of the CHIP score model for predicting MACCE in our cohort was 0.63 (95% CI: 0.58-0.67). There was a positive correlation between the CHIP score and the PROGRESS-CTO MACE score (Spearman's correlation: 0.37; 95% CI: 0.35-0.39; p < 0.001). CONCLUSIONS: The CHIP score has modest predictive capacity for MACCE in CTO PCI.

Predictors of successful primary antegrade wiring in chronic total occlusion percutaneous coronary intervention.

BACKGROUND: Antegrade wiring is the most commonly used chronic total occlusion (CTO) crossing technique. METHODS: Using data from the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; Clinicaltrials.gov identifier: NCT02061436), we examined the clinical and angiographic characteristics and procedural outcomes of CTO percutaneous coronary interventions (PCIs) performed using a primary antegrade wiring strategy. RESULTS: Of the 13 563 CTO PCIs performed at 46 centers between 2012 and 2023, a primary antegrade wiring strategy was used in 11 332 (83.6%). Upon multivariable logistic regression analysis, proximal cap ambiguity (odds ratio [OR]: 0.52; 95% CI, 0.46-0.59), side branch at the proximal cap (OR: 0.85; 95% CI, 0.77-0.95), blunt/no stump (OR: 0.52; 95% CI: 0.47-0.59), increasing lesion length (OR [per 10 mm increase]: 0.79; 95% CI, 0.76-0.81), moderate to severe calcification (OR: 0.73; 95% CI, 0.66-0.81), moderate to severe proximal tortuosity (OR: 0.67; 95% CI, 0.59-0.75), bifurcation at the distal cap (OR: 0.66; 95% CI, 0.59-0.73), left anterior descending artery CTO (OR [vs right coronary artery]: 1.44; 95% CI, 1.28-1.62) and left circumflex CTO (OR [vs right coronary artery]: 1.22; 95% CI, 1.07-1.40), non-in-stent restenosis lesion (OR: 0.56; 95% CI, 0.49-0.65), and good distal landing zone (OR: 1.18; 95% CI, 1.06-1.32) were independently associated with primary antegrade wiring crossing success. CONCLUSIONS: The use of antegrade wiring as the initial strategy was high (83.6%) in our registry. We identified several parameters associated with primary antegrade wiring success.

Activated clotting time and outcomes of chronic total occlusion percutaneous coronary intervention: insights from the PROGRESS-CTO Registry.

BACKGROUND: The optimal range of activated clotting time (ACT) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We examined the association between ACT and in-hospital ischemic and bleeding outcomes in patients who underwent CTO PCI in the Prospective Global Registry for the Study of CTO Intervention. RESULTS: ACT values were available for 4377 patients who underwent CTO PCI between 2012 and 2023 at 29 centers. The mean ACT distribution was less than 250 seconds (19%), 250 to 349 seconds (50%), and greater than or equal to 350 seconds (31%). The incidence of ischemic events, bleeding events, and net adverse cardiovascular events (NACE) was 0.8%, 3.0%, and 3.8%, respectively. In multiple logistic regression analysis, increasing nadir ACT was associated with decreasing ischemic events (adjusted odds ratio [aOR] per 50-second increments: 0.69 [95% confidence interval (CI), 0.50-0.94; P=.017]; and increasing peak ACT was associated with increasing bleeding events (aOR per 50-second increments: 1.17 [95% CI ,1.01-1.36; P=.032]). A U-shaped association was seen between mean ACT and NACE, where restricted cubic spline analysis demonstrated that patients with a low ( less than 200 seconds) or high ( greater than 400 seconds) ACT had increasing NACE risk compared with an ACT of 200 to 400 seconds (aOR 2.06, 95% CI 1.18-3.62; P=.012). CONCLUSIONS: Among patients who underwent CTO PCI, mean ACT had a U-shaped relationship with NACE, where patients with a low ( less than 200 seconds) ACT (driven by ischemic events) or high ( greater than 400 seconds) ACT (driven by bleeding) had higher NACE compared with an ACT of 200 to 400 seconds.

Frequency and outcomes of ad hoc chronic total occlusion percutaneous coronary intervention: insights from the progress-cto registry.

BACKGROUND: Although discouraged, ad hoc chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is occasionally performed. METHODS: We examined the clinical, angiographic characteristics, and procedural outcomes of patients who underwent ad hoc CTO PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). RESULTS: Of the 10,998 patients included in the registry, 899 (8.2%) underwent ad hoc CTO PCI. The incidence of ad hoc CTO PCI decreased from 18% in 2016 to 3% in 2022. Ad hoc CTO PCI patients had a lower prevalence of comorbidities and less complex angiographic characteristics demonstrated by lower J-CTO score (1.9±1.2 vs 2.4±1.3, P < .001). In these patients, PROGRESS-CTO major adverse cardiovascular events (MACE) (1.9±1.4 vs 2.5±1.7), mortality (1.2±1.0 vs 1.6±1.1), and perforation (1.5±1.2±2.2 vs 1.5) scores were lower (P < .001). Technical success was similar between the groups (86%). MACE were lower in the ad hoc CTO PCI group (.8% vs 2.0%, P=.009). Ad hoc CTO PCI was not associated with MACE after adjusting for potential confounders, odds ratio: .69 (95% confidence interval, .30-1.57). In patients with higher J-CTO scores, planned CTO PCI was associated with higher technical success (P < .001). CONCLUSION: Approximately 8% of CTO PCI procedures are performed ad hoc, usually in less complex lesions and patients with lower complication risk. While ad hoc CTO PCI might be appropriate for carefully selected cases, a staged approach is recommended for most CTO PCI.

Impact of calcium on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention.

BACKGROUND: Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We examined the impact of calcium on procedural outcomes of 13,079 CTO PCIs performed in 12,799 patients at 46 US and non-US centers between 2012 and 2023. RESULTS: Moderate or severe calcification was present in 46.6% of CTO lesions. Patients whose lesions were calcified were older and more likely to have had prior coronary artery bypass graft surgery. Calcified lesions were more complex with higher J-CTO score (3.0 ± 1.1 vs. 1.9 ± 1.2; p < 0.001) and lower technical (83.0% vs. 89.9%; p < 0.001) and procedural (81.0% vs. 89.1%; p < 0.001) success rates compared with mildly calcified or non-calcified CTO lesions. The retrograde approach was more commonly used among cases with moderate/severe calcification (40.3% vs. 23.5%; p < 0.001). Balloon angioplasty (76.6%) was the most common lesion preparation technique for calcified lesions, followed by rotational atherectomy (7.3%), laser atherectomy (3.4%) and, intravascular lithotripsy (3.4%). The incidence of major adverse cardiovascular events (MACE) was higher in cases with moderate or severe calcification (3.0% vs. 1.2%; p < 0.001), as was the incidence of perforation (6.5% vs. 3.4%; p < 0.001). On multivariable analysis, the presence of moderate/severe calcification was independently associated with lower technical success (odds ratio, OR = 0.73, 95% CI: 0.63-0.84) and higher MACE (OR = 2.33, 95% CI: 1.66-3.27). CONCLUSIONS: Moderate/severe calcification was present in nearly half of CTO lesions, and was associated with higher utilization of the retrograde approach, lower technical and procedural success rates, and higher incidence of in-hospital MACE.

Impact of intracoronary imaging on in-hospital mortality and 30-day readmission rates following percutaneous coronary intervention: A nationwide readmissions database analysis.

BACKGROUND: Percutaneous coronary intervention (PCI) is well established for the treatment of obstructive coronary artery disease. This study was performed to assess the impact of in-hospital mortality and 30-day readmission with intracoronary imaging as an adjunct to baseline coronary angiography. METHODS: The study was derived from the Healthcare Cost and Utilization Project's National Readmission Database (NRD) of 2016, sponsored by the Agency for Healthcare Research and Quality. Patients who underwent PCI were identified using appropriate ICD-10 codes. Study population was further subcategorized into 2 PCI arms: intravascular imaging (''imaging'' group) and fluoroscopy guided (''angiography'' group). Primary endpoints were 30-day readmissions and in-hospital mortality. Secondary endpoints were length of stay, cost of care, predictors of 30-day readmission and in-hospital mortality in PCI related hospitalizations. RESULTS: We identified in total 188,368 index admissions, with 12,379 patients in the "imaging-guided" group and 175,989 in the "angiography-alone" group. There were no differences in 30-day readmissions between both groups (~10.8% in both arms, p = .788). However, in-hospital mortality carried a statistically significant reduction with use of imaging-guided PCI (1.72% vs 2.24%, p = .004). The median length of stay was longer in the imaging-guided arm (3 vs. 2 days, p < .001), associated with larger median total hospital costs ($32,123 USD vs. $25,162 USD, p < .001). The strongest predictor of in-hospital mortality in both univariate and multivariate analysis was having an existing coagulopathy. CONCLUSION: The results of this study did not confer benefit with regards to 30-day hospital readmission rates when utilizing intracoronary imaging versus angiography-alone in percutaneous coronary intervention, but did suggest there may be an association between the use of intracoronary imaging and improved in-hospital mortality. In addition, resource utilization was higher in the intra-coronary imaging arm of the study.

Safety and efficacy of the hybrid approach in coronary chronic total occlusion percutaneous coronary intervention: The Hybrid Video Registry.

OBJECTIVES: The aim of the Hybrid Video Registry (HVR) is to assess the acute safety and efficacy of the Hybrid Approach in comparison to other contemporary methods of CTO-PCI. BACKGROUND: Recently, multiple techniques in Percutaneous Coronary Intervention (PCI) for coronary Chronic Total Occlusions (CTO) have been synthesized into a method referred to as the "Hybrid Approach". METHODS: About 194 video-taped timed live cases from CTO-PCI training workshops were analyzed by independent data abstractors and compared to three contemporary CTO-PCI registries stratified by case complexity based on the J-CTO score. RESULTS: Overall procedural success was 95% of all cases attempted with an excellent safety profile. In the most complex lesion subset, which made up 45% of all HVR cases, success was 92.8%, which was significantly higher than either the Royal Bromptom (78.9%), or Japanese-CTO (73.3%) registries, P = 0.04 Hybrid vs. Royal Brompton, P = 0.006 Hybrid vs. Japanese-CTO). The Hybrid Approach was also associated with shorter procedure times and lower contrast utilization. CONCLUSIONS: In a real world angiographic registry of complex CTOs, the Hybrid Approach to CTO-PCI is safe, and may be superior to other contemporary approaches to CTO intervention with respect to procedural success and efficiency among a diverse group of operators and lesion complexity. © 2017 Wiley Periodicals, Inc.

Effect of Chronic Kidney Disease on Mortality in Patients Who Underwent Lower Extremity Peripheral Vascular Intervention.

It is known that chronic kidney disease (CKD) is associated with increased postoperative morbidity and mortality in patients with peripheral artery disease who underwent lower extremity surgical revascularization; however, outcomes after peripheral vascular intervention (PVI) are less well established. This study sought to determine the impact of CKD on adverse outcomes in patients with peripheral artery disease who underwent PVI. Using data from the Veteran Affairs Clinical Assessment, Reporting, and Tracking System Program, we identified a cohort of 755 patients who underwent lower extremity PVI from June 2005 to August 2010 at 33 sites. The outcomes of interest were mortality, progression to dialysis, myocardial infarction, limb amputation, and stroke. Kaplan-Meier survival analysis and Cox proportional hazard frailty models assessed the association between CKD and adverse outcomes. Of the patients who underwent lower extremity PVI, 201 patients (27%) had CKD. The presence of CKD was associated with decreased survival (5-year survival probability of CKD compared with non-CKD: 49.9% [41.6% to 59.9%] vs 80.1% [76.2% to 84.1]), which persisted after risk adjustment (HR 1.57; 95% confidence interval 1.13 to 2.19). In addition, there was a significant association between CKD and progression to dialysis (HR 6.62; 95% confidence interval 2.25 to 19.43). In contrast, there was no association between CKD and re-hospitalization for myocardial infarction, limb amputation, or stroke. In conclusion, CKD is present in 1 of 4 patients who underwent PVI and is associated with increased risk of mortality and progression to dialysis.

Patent foramen ovale.

Patent foramen ovale (PFO) is a common developmental anomaly that allows for the passage of blood and other substances from the venous to the arterial circulation. The study of PFO closure has been challenging due to widely available off-label closures performed outside the clinical trial setting. To date, no study has demonstrated benefit of closure using intention-to-treat analyses. Secondary and subpopulation analyses suggest that there is benefit to closure in patients with atrial septal aneurysms and/or substantial degrees of right-to-left shunting. This article reviews the history, associated technologies, and current data regarding PFO closure.

Comparison of a safety strategy using transradial access and dual-axis rotational coronary angiography with transfemoral access and standard coronary angiography.

OBJECTIVES: We sought to investigate the radiation exposure and contrast utilization associated with using a strategy of transradial access and rotational angiography (radial-DARCA) compared to the traditional approach of transfemoral access and standard angiography (femoral-SA). BACKGROUND: There is an increased focus on optimizing patient safety during cardiac catheterization procedures. Professional guidelines have highlighted physician responsibility to minimize radiation doses and contrast volume. Dual axis rotational coronary angiography (DARCA) is the most recently investigated type of rotational angiography. This new technique permits complete visualization of the left or right coronary tree with a single injection, and is felt to reduce contrast and radiation exposure. METHODS: A total of 56 consecutive patients who underwent radial-DARCA were identified. From the same time period, an age- and gender-matched group of 61 patients who had femoral-SA were selected for comparison. Total volume of contrast agent used, fluoroscopy time, and 2 measures of radiation dose (dose area product and air kerma) were recorded for each group. RESULTS: Mean contrast agent use and patient radiation exposure of the radial-DARCA group were significantly less than that of the femoral-SA group. There was no significant difference in fluoroscopy time between the 2 groups. CONCLUSIONS: Physicians can successfully employ an innovative safety strategy of transradial access combined with DARCA that is feasible and is associated with lower radiation doses and contrast volume than femoral artery access and traditional coronary angiography approach.

Acute and medium-term outcomes of endovascular therapy of obstructive disease of diverse etiology of the common femoral artery.

BACKGROUND: Common femoral endarterectomy is regarded as the standard revascularization strategy for the treatment of common femoral artery (CFA) disease. The availability of a variety of endovascular tools has resulted in an increased number of patients with CFA disease being treated using an endovascular strategy. We sought to evaluate clinical outcomes in a contemporary series of patients who were treated for CFA disease using an endovascular-first approach. METHODS: All patients with obstructive CFA disease who were treated using endovascular therapy were retrospectively identified from a peripheral interventional database. Baseline patient characteristics, anatomic details, procedural data, and clinical outcomes were assessed. Kaplan-Meier (KM) curves for mortality, amputation-free survival, and primary and secondary patency were generated. RESULTS: Between 2006 and 2011, a total of 30 patients underwent 31 CFA procedures. The primary etiologies of CFA obstruction were atherosclerosis (58%), access-site-related complication (32%), and thromboembolism (10%). Patients presented with severe claudication (60%), critical limb ischemia (13%), or acute limb ischemia (27%). The procedure was technically successful in 90% of cases with major complications in two (7%) patients. There was no procedure-related mortality. The KM estimate of survival and amputation-free survival at 1 year was 96% (± 4%) and 96% (± 4%), respectively. In those patients who had a successful revascularization, the overall 1-year estimate for primary and secondary patency was 88% (± 6) and 92% (± 5%), respectively. There was a nonsignificant trend toward lower patency in patients treated for atherosclerotic disease compared to those with access-site-related complications and thromboembolic disease at 2-year follow-up (76 vs. 100%, P = 0.08). CONCLUSIONS: Endovascular therapy for treatment of obstructive disease of the CFA is associated with a high rate of acute technical success. Primary patency rates in the cohort treated for access-site-related complications and thromboembolic disease are excellent and support an endovascular-first approach for this patient subset. Based on lower patency rates, surgical endarterectomy for the treatment of atherosclerotic disease in the CFA remains the gold standard in patients with normal surgical risk.

Clinical outcomes with contemporary endovascular therapy of iliac artery occlusive disease.

OBJECTIVES: We sought to evaluate the clinical outcomes of a consecutive series of patients treated for iliac artery occlusive disease (IAOD) using contemporary endovascular technology and techniques. BACKGROUND: As an increasingly complex spectrum of IAOD is treated using endovascular revascularization, there is a need to examine the rates of acute procedural success, complications, and patency to validate the role of an endovascular-first approach to revascularization in contemporary practice. METHODS: All patients with IAOD who were treated using endovascular therapy between September 2005 and September 2010 were identified from a prospectively collected database. Baseline patient characteristics, anatomic details, procedural data, and clinical outcomes were assessed retrospectively. Patency and mortality rates were estimated with the Kaplan-Meier method. RESULTS: A total 59 patients underwent 62 procedures. Trans-Atlantic Inter-Society Consensus (TASC) II types B, C, and D disease accounted for 59%, 7%, and 37% of patients, respectively. The procedure was technically successful in 60 of 62 cases (97%) with no procedure-related mortality. Major complications occurred in five procedures (8%). The mean (±standard deviation) duration of follow-up was 2.3 ± 1.4 years. In patients with a successful revascularization, primary and secondary patency rates were 86% and 94% at 1 year, and 77% and 91% at 2 years, respectively. The TASC II classification of disease did not predict the rate of acute technical success or medium-term patency rates. CONCLUSIONS: The acute and medium-term clinical outcomes of this series of patients with anatomically complex IAOD support the current paradigm of an endovascular-first approach to revascularization.

Critical limb ischemia: endovascular strategies for limb salvage.

Critical limb ischemia (CLI) represents the most severe clinical manifestation of peripheral arterial disease, defined as the presence of chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease. The dominant pathology underlying CLI is atherosclerosis, distributed at multiple levels along the length of the lower extremity and with a propensity for involvement of the tibial vessels in the leg and the small vessels of the foot. To achieve limb salvage in patients with CLI, revascularization of the affected limb is generally required. In contemporary practice, endovascular techniques are rapidly replacing surgical bypass as the first option for revascularization for CLI based on high technical success rates and low rates of procedure-related morbidity and mortality. This review will describe the clinical strategy of the authors who have adopted an endovascular-first approach to revascularization in treating patients with CLI and summarize the clinical outcomes of endovascular therapy in this population.

Retrograde approach to recanalization of complex tibial disease.

A significant proportion (~ 20%) of patients with complex tibial artery occlusions cannot be treated using a conventional antegrade approach. We report our experience using the retrograde approach for the treatment of complex tibial artery occlusive disease using retrograde pedal/tibial access in 13 limbs from 12 patients. Retrograde pedal/tibial access was achieved in all cases (facilitated by surgical cutdown in one case), and procedural success was achieved in 11 of 13 limbs (85%). Based on this experience, a discussion of clinical and technical aspects of the retrograde pedal/tibial approach is provided, and a new classification for tibial artery occlusive disease is proposed.

Familial (ATTR) amyloidosis misdiagnosed as the primary (AL) variant: a case report.

INTRODUCTION: Primary (AL) Amyloidosis is arguably the most recognizable variant of the disease with many classic signs. However, it has been argued that the Familial variant (ATTR) is actually more prevalent. It is less recognizable, however, as its spectrum of organ involvement is frequently much more limited. The two variants carry significantly different prognoses, have divergent treatment strategies, and very different implications for the family members of patients. There is now a small amount of data that would suggest Familial Amyloidosis may be misdiagnosed as the AL form 2-4% of the time as a result of laboratory error. CASE PRESENTATION: Herein a case of Familial Amyloidosis initially mistaken for the AL form based on a false positive laboratory result is presented. This case illustrates the high index of suspicion required for proper diagnosis of this rare disease. CONCLUSION: Clinician awareness of the various forms of Amyloidosis and the potential for lab error is key to ensuring an accurate diagnosis. The two most common forms carry significantly different implications for treatment and for potential impact on relatives. A high index of suspicion is required particularly for the Familial form of Amyloidosis.

Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use.

STUDY OBJECTIVE: Beta-blocker use is associated with coronary artery spasm after cocaine administration but also decreases mortality in patients with myocardial infarction or systolic dysfunction. We conduct a retrospective cohort study to analyze the safety of beta-blockers in patients with positive urine toxicology results for cocaine. METHODS: The cohort consisted of 363 consecutive telemetry and ICU patients who were admitted to a municipal hospital and had positive urine toxicology results for cocaine during a 5-year period (307 patients). Fifteen patients with uncertain history of beta-blocker use before admission were excluded. The primary outcome measure was myocardial infarction; secondary outcome measure was inhospital mortality. Logistic regression analysis using generalized estimating equations models and propensity scores compared outcomes. RESULTS: Beta-blockers were given in 60 of 348 admissions. The incidence of myocardial infarction after administration of beta-blocker was significantly lower than without treatment (6.1% versus 26.0%; difference in proportion 19.9%; 95% confidence interval [CI] 10.3% to 30.0%). One of 14 deaths occurred in patients who received beta-blockade (incidence 1.7% versus 4.5% without beta-blockade; difference in proportion 2.8%; 95% CI -1.2% to 6.7%). Multivariate analysis showed that use of beta-blockers significantly reduced the risk of myocardial infarction (odds ratio 0.06; 95% CI 0.01 to 0.61). CONCLUSION: In our cohort, administration of beta-blockers was associated with reduction in incidence of myocardial infarction after cocaine use. The benefit of beta-blockers on myocardial function may offset the risk of coronary artery spasm.