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

BACKGROUND: There is limited information on the impact of the target vessel on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 11,580 CTO PCIs performed between 2012 and 2022 at 44 centers. RESULTS: The most common CTO target vessel was the right coronary artery (RCA) (53.1%) followed by the left anterior descending artery (LAD) (26.0%) and the left circumflex artery (LCX) (19.8%). RCA CTOs were longer and more complex, with a higher Japanese CTO score compared with LAD or LCX CTOs. Technical success was higher among LAD (88.8%) lesions when compared with RCA (85.7%) or LCX (85.8%) lesions (P less than .001). The incidence of major adverse cardiovascular events (MACE) was overall 1.9% (n = 220) and was similar among target vessels (P=.916). There was a tendency toward more frequent utilization of the retrograde approach for more proximal occlusions in all 3 target vessels. When compared with all other RCA lesions combined, distal RCA lesions had higher technical success (87.7% vs 85.3%; P=.048). Technical success was similar between various locations of LAD CTOs (P=.704). First/second/third obtuse marginal branch had lower technical success when compared with all other LCX lesion locations (82.7% vs 86.8%; P=.014). There was no association between MACE and CTO location in all 3 target vessels. CONCLUSIONS: LAD CTO PCIs had higher technical and procedural success rates among target vessels. The incidence of MACE was similar among target vessels and among various locations within the target vessel.

Periprocedural Mortality in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS-CTO Registry.

BACKGROUND: Death is a rare but devastating complication of chronic total occlusion (CTO) percutaneous coronary intervention. METHODS: We examined the clinical characteristics and procedural outcomes of patients who died periprocedurally in the Prospective Global Registry for the Study of CTO Interventions (PROGRESS-CTO). RESULTS: Of the 12 928 patients who underwent CTO percutaneous coronary intervention between 2012 and 2022, 52 (0.4%) died during the index hospitalization. Patients who died were more likely to have a history of heart failure (43% versus 28%; P=0.023). The J-CTO ([Multicenter CTO Registry of Japan]; 2.8±1.1 versus 2.4±1.3; P=0.019), PROGRESS-CTO mortality (2.6±0.9 versus 1.6±1.1; P<0.001), and PROGRESS-CTO pericardiocentesis (2.9±1.1 versus 1.9±1.3; P<0.001) scores were higher in patients who died. In these patients, the use of left ventricular assist devices was also higher (41% versus 3.5%; P<0.001), and retrograde crossing was more often the first crossing strategy (33% versus 13%; P<0.001). The cause of death was cardiac in 43 patients (83%) and noncardiac in 9 patients (17%). Complications leading to cardiac death were: tamponade in 30 patients (58%), acute myocardial infarction in 9 (17.3%), and cardiac arrest/shock in 4 (7.7%). Noncardiac causes of death were: stroke in 3 (5.8%), renal failure in 2 (3.8%), respiratory distress in 2 (3.8%), and hemorrhagic shock in 2 (3.8%). CONCLUSIONS: Approximately 0.4% of patients who underwent CTO percutaneous coronary intervention died during the index hospitalization. The main cause of death was tamponade in 58%. PROGRESS-CTO complication scores might help in risk stratification and procedural planning in patients undergoing CTO percutaneous coronary intervention. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique Identifier: NCT02061436.

Same day discharge versus overnight observation following chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

BACKGROUND: Same day discharge (SDD) following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We evaluated the clinical, angiographic, and procedural characteristics of patients discharged the same day versus those kept for overnight observation in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO, NCT02061436). RESULTS: Of the 7181 patients who underwent CTO PCI, 943 (13%) had SDD. The SDD rate increased from 3% in 2015 to 21% in 2022. Patients with SDD were less likely to have a history of heart failure (21% vs. 26%, p = 0.005), chronic lung disease (10% vs. 15%, p = 0.001), or anemia (12% vs. 19%, p < 0.001). Technical success (87% vs. 88%, p = 0.289) was similar, but in-hospital major adverse cardiovascular events (0.0% vs. 0.4%, p = 0.041) were lower in SDD. In multivariable logistic regression analysis, prior myocardial infarction odds ratio (OR): 0.71 (95% confidence interval [CI]: 0.59-0.87, p = 0.001), chronic lung disease OR: 0.64 (95% CI: 0.47-0.88, p = 0.006), and increasing procedure time OR: 0.93 (95% CI: 0.91-0.95, p < 0.001, per 10-min increase) were associated with overnight observation, while radial-only access OR: 2.45 (95% CI: 2.03-2.96, p < 0.001) had the strongest association with SDD. In the SDD, 2 (0.4%) of 514 patients were readmitted, due to retroperitoneal bleeding (n = 1) and ischemic stroke (n = 1). CONCLUSION: The overall frequency of SDD after CTO PCI was 13% and has been increasing over time. SDD is feasible in select patients following CTO PCI, and radial-only access had the strongest association with SDD.

Equipment Utilization in Chronic Total Occlusion Percutaneous Coronary Interventions: Update From the PROGRESS-CTO Registry.

BACKGROUND: Guidewires and microcatheters are critical to the success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We examined equipment utilization in 11,202 CTO-PCIs performed in 10,952 patients at 42 United States (US) and non-US centers between 2012 and 2022. RESULTS: Antegrade-only crossing was attempted in 7628 CTO-PCIs (68%) and the retrograde approach was used in 3574 CTO-PCIs (32%). The median number of guidewires used during antegrade wiring increased with lesion complexity from 3 (interquartile range [IQR], 2-4) for J-CTO score of 0 to 5 (IQR, 4-7) for J-CTO score of 5 (P<.001). Antegrade-only procedures had higher technical (90% vs 79%; P<.001) and procedural success (89% vs 77%; P<.001) compared with retrograde procedures. In antegrade-only cases, Pilot 200 (28%; Abbott Vascular) and Fielder XT (24%; Asahi Intecc) were the most frequently used guidewires, while Corsair (21%; Asahi Intecc) and Turnpike Spiral (20%; Vascular Solutions) were the most commonly used microcatheters. In retrograde cases, Sion (32%; Asahi Intecc) was the most common guidewire used, followed by Sion Black (22%; Asahi Intecc), Pilot 200 (22%), and Suoh 03 (19%; Asahi Intecc), while Corsair (16%) and Turnpike LP (11%) were the most commonly used microcatheters. The most successful guidewire for collateral crossing was the Sion (32%), followed by Sion Black (15%) and Suoh 03 (11%). CONCLUSION: Polymer-jacketed guidewires are the most commonly used guidewires for antegrade wiring, while non-polymer-jacketed, torquable guidewires are the most frequently used guidewires for retrograde techniques. Turnpike and Corsair are the most commonly used microcatheters in CTO-PCI.

Use of Bivalirudin for Chronic Total Occlusion Percutaneous Intervention: Insights From the PROGRESS-CTO Registry.

BACKGROUND: There are limited data on the use of bivalirudin for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We compared CTO-PCIs performed using bivalirudin vs unfractionated heparin in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO; NCT02061436). The primary endpoint was net adverse cardiac events (NACE), defined as major adverse cardiac events (MACE) and vascular complications. RESULTS: Between 2012 and 2022, a total of 73 of 9723 procedures (0.75%) were performed using bivalirudin. The J-CTO score (2.4 ± 1.2 vs 2.4 ± 1.3; P=.73) and the PROGRESS-CTO score (1.4 ± 0.9 vs 1.2 ± 1.0; P=.31) were similar in both groups, and the retrograde approach was used less often in the bivalirudin group (15% vs 30%; P<.01). Procedural success (89% vs 85%; P=.35), in-hospital NACE (1.4% vs 2.1%; P>.99), incidence of MACE (0% vs 0.76%; P=.64), and vascular access complications (1.4% vs 0.9%; P=.48) were not different between the 2 groups. On multivariable analysis, use of bivalirudin was not associated with an increased risk of NACE (odds ratio, 0.99; 95% confidence interval, 0.13-7.27). CONCLUSION: Bivalirudin is infrequently used during retrograde CTO-PCI. While the incidence of adverse events was similar with unfractionated heparin, larger studies are needed to assess the safety of bivalirudin.

Outcomes of Patients With Acute Coronary Syndromes Undergoing Chronic Total Occlusion Percutaneous Coronary Intervention.

BACKGROUND: The prevalence and outcomes of patients who presented with an acute coronary syndrome (ACS) and underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. METHODS: We examined the clinical characteristics and procedural outcomes of ACS patients who underwent CTO-PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO; NCT02061436). RESULTS: Of the 8826 patients who underwent CTO-PCI between 2012 and 2022 at 38 centers, 558 (6.3%) presented with ACS. ACS presentation was with non-ST-segment elevation myocardial infarction (MI) in 54%, unstable angina in 33%, and ST-segment elevation MI in 6.5%. ACS patients were older (66 ± 11 years vs 64 ± 10 years; P<.001) and had higher prevalence of comorbidities such as diabetes mellitus (48% vs 42%; P=.02), prior MI (52% vs 45%; P<.01), and lower left ventricular ejection fraction (49 ± 14% vs 51 ± 13%; P<.01). While the PROGRESS-CTO score (1.4 ± 1.0 vs 1.2 ± 1.0; P<.001) was higher in the ACS group, the J-CTO score was comparable (2.3 ± 1.2 vs 2.4 ± 1.3; P=.68). Technical success (88% vs 86%; P=.12) and the incidence of in-hospital major adverse cardiovascular event (MACE) (0.9% vs 2.1%; P=.06) and adverse events at 3-month follow-up (3.4% vs 7.2%; Kaplan-Meier log-rank P=.16) were similar between ACS and non-ACS patients, respectively. CONCLUSION: Approximately 6% of patients who underwent CTO-PCI presented with an ACS. Technical success, in-hospital MACE, and the incidence of adverse events up to 3 months were similar between patients who presented with vs without an ACS.

Prevalence and outcomes of balloon undilatable chronic total occlusions: Insights from the PROGRESS-CTO.

BACKGROUND: The prevalence, treatment, and outcomes of balloon undilatable lesions encountered in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. METHODS: We examined the clinical characteristics and procedural outcomes of balloon undilatable lesions in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). RESULTS: Of 6535 CTO PCIs performed between 2012 and 2022, 558 (8.5%) lesions were balloon undilatable. In this subset, patients were older (mean age 67 ± 10 vs. 64 ± 10, p < 0.001) and had higher prevalence of comorbidities: diabetes mellitus (54% vs. 40%, p < 0.001), prior PCI (71% vs. 59%, p < 0.001), prior myocardial infarction (52% vs. 45%, p = 0.003), and prior coronary artery bypass graft surgery (44% vs. 25%, p < 0.001). The CTO lesion length was estimated to be 34 ± 23 mm, mean J-CTO score was 2.9 ± 1.1 and mean PROGRESS-CTO score was 1.4 ± 1.0. A cutting balloon was used in 27%, a scoring balloon in 15%, laser in 14%, rotational atherectomy in 28%, orbital atherectomy in 10%, intravascular lithotripsy in 1% and other modalities/approaches in 5%. Balloon undilatable lesions had lower technical success (90.9% vs. 93.8%, p = 0.007) and higher incidence of major adverse cardiovascular events (MACE) (composite of in-hospital death, acute myocardial infarction, stroke, re-PCI, emergency CABG, and pericardiocentesis) (5.0% versus 1.3%, p < 0.001). CONCLUSION: Approximately 1 in 12 CTO (8.5%) lesions are balloon undilatable. Treatment of balloon undilatable lesions is associated with lower technical success and higher in-hospital MACE.

Outcomes of chronic total occlusion percutaneous coronary intervention in patients with reduced left ventricular ejection fraction.

BACKGROUND: The relationship between left ventricular ejection fraction (LVEF) and the success and safety of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We examined the clinical characteristics and outcomes of CTO PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO) after stratifying patients by LVEF (≤35%, 36%-49%, and ≥50%). RESULTS: A total of 7827 CTO PCI procedures with LVEF data were included. Mean age was 64 ± 10 years, 81% were men, 43% had diabetes mellitus, 61% had prior PCI, 45% had prior myocardial infarction, and 29% had prior coronary artery bypass graft surgery. Technical success was similar in the three LVEF strata: 85%, 86%, and 87%, p = 0.391 for LVEF ≤35%, 36%-49%, and ≥50%, respectively. In-hospital mortality was higher in lower LVEF patients (1.1%, 0.4%, and 0.3%, respectively, p = 0.001). In-hospital major adverse cardiovascular events (MACE) were numerically higher in lower EF patients (2.7%, 2.1%, and 1.9%, p = 0.271). At a median follow-up of 2 months (interquartile range: 19-350 days), patients with lower LVEF continued to have higher mortality (4.9%, 3.2%, and 1.4%, p < 0.001) while the MACE rates were similar (9.3%, 9.6%, and 7.4%, p = 0.172). CONCLUSION: CTO PCI can be performed with high technical success in patients with reduced LVEF but is associated with higher in-hospital and post-discharge mortality.

Impact of Intravascular Ultrasound Utilization for Stent Optimization on 1-Year Outcomes After Chronic Total Occlusion Percutaneous Coronary Intervention.

BACKGROUND: The impact of intravascular ultrasound (IVUS) utilization for stent optimization on the long-term outcomes in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We examined the outcomes of CTO-PCI with and without IVUS use for stent optimization in 922 CTO-PCIs performed between 2012 and 2019 at 12 United States centers. Major adverse cardiac event (MACE) was defined as the composite of cardiac death, acute coronary syndrome, and target-vessel revascularization. RESULTS: IVUS was used in 344 procedures (37%) for stent optimization. Mean patient age was 65 ± 10 years and 83% were men. Patients in the IVUS group were less likely to have a prior myocardial infarction (39% vs 50%; P<.01), more likely to undergo right coronary artery CTO-PCI (49% vs 55%; P=.01), and had higher mean J-CTO score (2.6 ± 1.1 vs 2.4 ± 1.2; P=.04). The final crossing strategy in patients in the IVUS group was less likely to be antegrade wire escalation (54% vs 57%) and more likely to be retrograde (29% vs 21%; P<.01). Median follow-up was 141 days (interquartile range, 30-365 days). The incidence of 12-month MACE was similar in the IVUS and no-IVUS groups (20.3% vs 18.3%; log-rank P=.67). CONCLUSION: IVUS was used for stent optimization in approximately one-third of CTO-PCIs. Despite higher lesion complexity in the IVUS group, the incidence of MACE was similar during follow-up.

A review of high-dose statin therapy: targeting cholesterol and inflammation in atherosclerosis.

Lipid lowering with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors or 'statins' has dramatically reduced morbidity and mortality in patients with established cardiovascular disease. Recently, there have been multiple studies investigating the role of high-dose statin therapy with more aggressive lipid lowering in this setting. Concomitantly, there is increasing evidence implicating a role of inflammation in the pathogenesis of atherosclerosis. These high-dose statin trials and other studies have also provided a wealth of data suggesting that statins have anti-inflammatory and anti-oxidant properties that go beyond their lipid-lowering effects. In this review, we will provide a brief overview of recent, large-scale, randomized, placebo and active controlled trials of high-dose statin therapy in the setting of stable and unstable coronary artery disease and percutaneous coronary intervention. Further, we will discuss the evidence for effects of high-dose statin therapy on inflammation and C-reactive protein.

Use of ticlopidine and cilostazol after intracoronary drug-eluting stent placement in a patient with previous clopidogrel-induced thrombotic thrombocytopenic purpura: a case report.

Thrombotic thrombocytopenic purpura (TTP) is an extremely rare but potentially fatal adverse reaction to the thienopyridines, clopidogrel and ticlopidine. We report the case of a patient with a history of clopidogrel-induced TTP who subsequently was successfully treated with aspirin, ticlopidine and cilostazol after stenting for severe, symptomatic coronary artery disease. This case supports the theory that clopidogrel and ticlopidine mediate TTP through slightly different mechanisms and that ticlopidine may be safely used in this setting if absolutely necessary. Moreover, while sufficient data are lacking, the combination of aspirin and cilostazol in this setting may provide adequate antithrombotic protection long term after drug-eluting stent placement.

A meta-analysis of randomized trials of rescue percutaneous coronary intervention after failed fibrinolysis.

Previous trials have suggested clinical benefit with rescue percutaneous coronary intervention (PCI) after failed fibrinolysis, but more recent, larger studies are conflicting. Therefore, we designed a meta-analysis to determine whether rescue PCI improves outcomes compared with conservative therapy in the setting of early failure of fibrinolysis. We searched MEDLINE for randomized trials by using the Medical Subject Heading terms "angioplasty," "myocardial infarction," "thrombolytic therapy," and "fibrinolysis." The inclusion criteria were (1) acute ST-elevation myocardial infarction initially treated with fibrinolytics, (2) randomization of patients with failed fibrinolysis to immediate PCI or conservative therapy, and (3) available short-term clinical outcome data. The primary end point was short-term mortality and secondary end points were thromboembolic stroke and heart failure. Numbers of events were tabulated for each trial and risk ratios (RRs) were computed. Five trials were included for analysis. The pooled RR estimates showed a 36% decrease in the risk of death in the rescue arm (RR 0.64, 95% confidence interval 0.41 to 1.00, p=0.048) and a marginally significant 28% decrease in the risk of heart failure (RR 0.72, 95% confidence interval 0.51 to 1.01, p=0.06). We also found a marginally increased risk of thromboembolic stroke in the rescue arm (RR 3.61, 95% confidence interval 0.91 to 14.27, p=0.07). In conclusion, rescue PCI in the setting of early fibrinolytic failure improves mortality, but this is tempered by a possible increase in the risk of thromboembolic stroke.

Use of aspirin and ibuprofen compared with aspirin alone and the risk of myocardial infarction.

BACKGROUND: Laboratory investigations suggest that the simultaneous use of aspirin and ibuprofen may attenuate the antiplatelet effect of aspirin, making it less useful for cardioprotection. To determine if there is clinical evidence of this potentially harmful interaction, we conducted a retrospective matched case-control study. METHODS: All patients issued outpatient prescriptions for aspirin or ibuprofen from January 1, 1990, to December 31, 2000, at the Durham Veterans Affairs Medical Center pharmacy were included in the study. Patients who used aspirin and ibuprofen concurrently were matched against those who used aspirin only by race, sex, age within 10 years, and cholesterol levels (either low-density lipoprotein or total cholesterol) to within 30 mg/dL (0.78 mmol/L). The rate ratio of experiencing a myocardial infarction per patient-month of drug exposure was then determined. RESULTS: Some 3859 patients received both aspirin and ibuprofen, for a total of 52 139 patient-months of medication use. This group experienced 138 infarctions. The 10 239 patients receiving aspirin only, for a total of 156 417 patient-months of use, experienced 684 infarctions. The rate ratio of having an infarction was 0.61 (95% confidence interval, 0.50-0.73) (P <.001), favoring the group that took aspirin and ibuprofen simultaneously. An analysis of diabetic patients found a rate ratio of 0.48 (95% confidence interval, 0.34-0.66) (P <.001). An examination of patients who spent time in both groups at different times resulted in a rate ratio of infarction during combined use of 0.70 (95% confidence interval, 0.59-0.83) (P <.001). CONCLUSION: There does not seem to be an increased risk of myocardial infarction among patients simultaneously consuming aspirin and ibuprofen compared with aspirin alone.