Long-term outcomes of staged recanalization for concurrent chronic total occlusion in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

Background In patients with acute ST-segment elevation myocardial infarction(STEMI)who undergo primary percutaneous coronary intervention(PCI),approximately 10%are concomitant with a chronic total occlusion(CTO)in a non-culprit vessel.However,the impact of staged CTO recanalization on prognosis in this cohort remains disputable.This study aimed to compare the long-term outcomes of staged CTO recanalization versus medical therapy in patients with STEMI after primary PCI.Methods Between January 2005 and December 2016,a total of 287 patients were treated with staged CTO-PCI(n=91)or medical therapy(n=196)after primary PCI in our center.The primary endpoint was major adverse cardiovascular and cerebrovascular event(MACCE),defined as a composite of all-cause death,nonfatal myocardial infarction(MI),stroke or unplanned revascularization.After propensity-score matching,77 pairs of well-balanced patients were identified.Results The mean follow-up period was 6.06 years.Overall,the incidence of the primary endpoint of MACCE was significantly lower in staged CTO-PCI group than that in medical therapy group in both overall population(22.0%vs.46.9%;hazard ratio(HR)=0.48,95%CI:0.29-0.77)and propensity-matched cohorts(22.1%vs.42.9%;HR:0.48,95%CI:0.27-0.86).In addition,staged CTO-PCI was also associated with reduced risk of the composite of cardiac death,nonfatal MI or stroke compared with medical therapy in both overall population(9.9%vs.26.5%;hazard ratio(HR)=0.39,95%CI:0.19-0.79)and propensity-matched cohorts(9.1%vs.22.1%;HR:0.40,95%CI:0.16-0.96).After correction of the possible confounders,staged CTO-PCI was independently associated with reduced risks of MACCE(adjusted HR:0.46,95%CI:0.28-0.75),the composite of cardiac death,nonfatal MI or stroke(adjusted HR:0.45,95%CI:0.22-0.94)and all-cause mortality(adjusted HR:0.32,95%CI:0.13-0.83).Moreover,the results of sensitivity analysis were almost concordant with the overall analysis.Conclusions In patients with STEMI and a concurrent CTO who undergo primary PCI,successful staged recanalization of CTO in the non-culprit vessels is associated with better clinical outcomes during long-term follow-up.

Modified subintimal plaque modification improving future recanalization of chronic total occlusion percutaneous coronary intervention

Background Subintimal plaque modification(SPM) is often performed to restore antegrade flow and facilitate subsequent lesion recanalization. This study aimed to compare the safety and efficacy of modified SPM with traditional SPM. Methods A total of 1454 consecutive patients who failed a chronic total occlusion percutaneous coronary intervention(CTO PCI) attempt and underwent SPM from January 2015 to December 2019 at our hospital were reviewed retrospectively. Fifty-four patients who underwent SPM finally were included in this study. We analyzed the outcomes of all the patients, and the primary endpoint was recanalization rate, which was defined as Thrombolysis in Myocardial Infarction(TIMI) grades 2-3 flow on angiography 30 to 90 days post-procedure. Results The baseline characteristics were similar between the two groups. In the follow-up, the recanalization rate was noticeably higher in the modified SPM group compared with the traditional SPM group(90.9% vs. 62.5%, P < 0.05). The proposed strategy in the modified group was more aggressive, including a larger balloon size(1.83 ± 0.30 vs. 2.48 ± 0.26 mm, P < 0.05) and longer subintimal angioplasty(0.59 ± 0.16 vs. 0.92 ± 0.12 mm, P < 0.05). Also, the common use of a Stingray balloon and guide catheter extension resulted in improvement of patients in the modified SMP group(12.5% vs. 100%, P < 0.05). Conclusion Modified SPM, which is associated with a high likelihood of successful recanalization, is an effective and safe CTO PCI bail out strategy.

Determinants of percutaneous coronary intervention success in repeat chronic total occlusion procedures following an initial failed attempt

AIM To investigate the rates and determinants of success of repeat percutaneous coronary intervention(PCI) following an initial failed attempt at recanalising the chronic total occlusions(CTO) percutaneously.METHODS In 445 consecutive first attempt CTO-PCI procedures in our institution,procedural failure occurred in 149(33.5%). Sixty-four re-PCI procedures were performed in 58 patients(39%) all had a single CTO. Procedural and outcome data in the re-PCI population was entered into the institutional database. A retrospective analysis of clinical,angiographic and procedural data was performed. RESULTS Procedural success was achieved in 41(64%) procedures. Univariate analysis of clinical and angiographic characteristics showed that re-PCI success was associated with intravascular ultrasound(IVUS) guidance(19.5% vs 0%,P = 0.042),while failure was associated with severecalcification(30.4% vs 9.7%,P = 0.047) and a JCTO score > 3(56.5% vs 17.1% P = 0.003). Following multiple regression analysis the degree of lesion complexity(J-CTO score > 3),IVUS use,involvement of an experienced CTO operator and LAD CTO location were significant predictors of successful re-PCI. Overall the complication rate was low,with the only MACCE two periprocedural MI's neither of which required intervention. CONCLUSION Re-PCI substantially increases the overall success rate of CTO revascularization. Predictors of re-PCI success included the use of IVUS,the involvement of an experienced CTO operator in the repeat attempt and the location of the CTO.

Chronic total occlusion:To treat or not to treat

Over the last two decades,there has been increasing interest in new techniques for the percutaneous treatment of coronary chronic total occlusions(CTO),which have a success rate that is much higher than that of a few years ago.The rise in percutaneous treatment for these lesions is due to its ability to improve the symptoms and prognosis of patients in the chronic and stable phase of coronary disease.Current data suggest that successful percutaneous coronary intervention for CTO is associated with improvement in patient symptoms,quality of life,left ventricular function,and survival,compared with those with unsuccessful CTO PCI.However,all the scientific evidence supporting this treatment comes from observational studies,and no randomized study comparing percutaneous treatment with medical treatment has yet been published.A major limitation of these studies is their observational design,with limited information with regard to potential baseline differences between the successful vs unsuccessful cohorts.Pending randomized studies,patients should be selected very carefully,especially if they are asymptomatic or very few symptoms,and the benefits obtained in terms of complications during the procedure,the quality of life obtained and further ischemic events avoided should be evaluated systematically.In this review,we will consider the available information supporting percutaneous treatment for chronic occlusions,as well as the areas of uncertainty where more research projects are required.

Intravascular ultrasound guided retrograde guidewire true lumen tracking technique for chronic total occlusion intervention

Chronic total occlusion （CTO） occurs in approximately 20% known coronary atherosclerotic lesions, and CTO intervention has become a most challenging work. Although retrograde techniques have been applied and significantly increased the success rate of CTO intervention, there are still some CTOs that cannot be opened.

A simple practical balloon anchoring technique within the guide catheter for chronic total occlusion (CTO) of the coronary artery

Dear Editor： Chronic total occlusions （CTOs） of the coronary artery are commonly encountered complex lesionst11. Percutaneous coronary intervention （PCI） for CTO is technically challenging due to low procedural success ratesTM. Microcatheter is one of the important devices for treatment of CTOTM. It has been widely used attributed to the excellent crossability whenever angula- tion and tortuousity of the coronary artery is encoun- tered. In the process, the microcatheter has to be withdrawn from the guide wire after the wire is proved to locate in the true lumen.

Chronic total occlusion revascularization:A complex piece to"complete"the puzzle

Treatment of coronary chronic total occlusion(CTO)with percutaneous coronary intervention(PCI)has rapidly increased during the past decades.Different strategies and approach were developed in the recent past years leading to an increase in CTO-PCI procedural success.The goal to achieve an extended revascularization with a high rate of completeness is now supported by strong scientific evidences and consequently,has led to an exponential increase in the number of CTO-PCI procedures,even if are still underutilized.It has been widely demonstrated that complete coronary revascularization,achieved by either coronary artery bypass graft or PCI,is associated with prognostic improvement,in terms of increased survival and reduction of major adverse cardiovascular events.The application of“contemporary”strategies aimed to obtain a state-of-the-art revascularization by PCI allows to achieve long-term clinical benefit,even in highrisk patients or complex coronary anatomy with CTO.The increasing success of CTO-PCI,allowing a complete or reasonable incomplete coronary revascularization,is enabling to overcome the last great challenge of interventional cardiology,adding a“complex”piece to“complete”the puzzle.

Medical therapy vs early revascularization in diabetics with chronic total occlusions:A meta-analysis and systematic review

BACKGROUND Management of chronic total occlusions(CTO)in diabetics is challenging,with a recent trend towards early revascularization[ER:Percutaneous coronary intervention(PCI)and bypass grafting]instead of optimal medical therapy(OMT).We hypothesize that ER improves morbidity and mortality outcomes in diabetic patients with CTOs as compared to OMT.AIM To determine the long term clinical outcomes and to compare morbidity and mortality between OMT and ER in diabetic patients with CTOs.METHODS Potentially relevant published clinical trials were identified in Medline,Embase,chemical abstracts and Biosis(from start of the databases till date)and pooled hazard ratios(HR)computed using a random effects model,with significant P value<0.05.Primary outcome of interest was all-cause death.Secondary outcomes included cardiac death,prompt revascularization(ER)or repeat myocardial infarction(MI).Due to scarcity of data,both Randomized control trials and observational studies were included.4 eligible articles,containing 2248 patients were identified(1252 in OMT and 1196 in ER).Mean follow-up was 45-60 mo.RESULTS OMT was associated with a higher all-cause mortality[HR:1.70,95%confidence interval(CI):0.80-3.26,P=0.11]and cardiac mortality(HR:1.68,95%CI:0.96-2.96,P=0.07).Results were close to significance.The risk of repeat MI was almost the same in both groups(HR:0.97,95%CI:0.61-1.54,P=0.90).Similarly,patients assigned to OMT had a higher risk of repeat revascularization(HR:1.62,95%CI:1.36-1.94,P<0.00001).Sub-group analysis of OMT vs PCI demonstrated higher all-cause(HR:1.98,95%CI:1.36-2.87,P=0.0003)and cardiac mortality(HR:1.87,95%CI:0.96-3.62,P=0.06)in the OMT group.The risk of repeat MI was low in the OMT group vs PCI(HR:0.53,95%CI:0.31-0.91,P=0.02).Data on repeat revascularization revealed no difference between the two(HR:1.00,95%CI:0.52-1.93,P=1.00).CONCLUSION In diabetic patients with CTO,there was a trend for improved outcomes with ER regarding all-cause and cardiac death as compared to OMT.These findings were reinforced with statistical significance on subgroup analysis of OMT vs PCI.

Staged Revascularization for Chronic Total Occlusion in the Non-IRA in Patients with ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention:An Updated Systematic Review and Meta-analysis

Objectives:Meta-analysis was performed to evaluate the effect of staged revascularization with concomitant chronic total occlusion(CTO)in the non-infarct-associated artery(non-IRA)in patients with ST-segment elevation myocardial infarction(STEMI)treated with primary percutaneous coronary intervention(p-PCI).Methods:Various electronic databases were searched for studies published from inception to June,2021.The primary endpoint was all-cause death,and the secondary endpoint was a composite of major adverse cardiac events(MACEs).Odds ratios(ORs)were pooled with 95%confidence intervals(CIs)for dichotomous data.Results:Seven studies involving 1540 participants were included in thefinal analysis.Pooled analyses revealed that patients with successful staged revascularization for CTO in non-IRA with STEMI treated with p-PCI had overall lower all-cause death compared with the occluded CTO group(OR,0.46;95%CI,0.23–0.95),cardiac death(OR,0.43;95%CI,0.20–0.91),MACEs(OR,0.47;95%CI,0.32–0.69)and heart failure(OR,0.57;95%CI,0.37–0.89)com-pared with the occluded CTO group.No significant differences were observed between groups regarding myocardial infarction and repeated revascularization.Conclusions:Successful revascularization of CTO in the non-IRA was associated with better outcomes in patients with STEMI treated with p-PCI.

Effect of complete percutaneous revascularization on improving long-term outcomes of patients with chronic total occlusion and multi-vessel disease

Background:Limited data are available on the comparison of clinical outcomes of complete vs.incomplete percutaneous coronary intervention(PCI)for patients with chronic total occlusion(CTO)and multi-vessel disease(MVD).The study aimed to compare their clinical outcomes.Methods:A total of 558 patients with CTO and MVD were divided into the optimal medical treatment(OMT)group(n=86),incomplete PCI group(n=327),and complete PCI group(n=145).Propensity score matching(PSM)was performed between the complete and incomplete PCI groups as sensitivity analysis.The primary outcome was defined as the occurrence of major adverse cardiovascular events(MACEs),and unstable angina was defined as the secondary outcome.Results:At a median follow-up of 21 months,there were statistical differences among the OMT,incomplete PCI,and complete PCI groups in the rates of MACEs(43.0%[37/86]vs.30.6%[100/327]vs.20.0%[29/145],respectively,P=0.016)and unstable angina(24.4%[21/86]vs.19.3%[63/327]vs.10.3%[15/145],respectively,P=0.010).Complete PCI was associated with lower MACE compared with OMT(adjusted hazard ratio[HR]=2.00;95%confidence interval[CI]=1.23–3.27;P=0.005)or incomplete PCI(adjusted HR=1.58;95%CI=1.04–2.39;P=0.031).Sensitivity analysis of PSM showed similar results to the above on the rates of MACEs between complete PCI and incomplete PCI groups(20.5%[25/122]vs.32.6%[62/190],respectively;adjusted HR=0.55;95%CI=0.32–0.96;P=0.035)and unstable angina(10.7%[13/122]vs.20.5%[39/190],respectively;adjusted HR=0.48;95%CI=0.24–0.99;P=0.046).Conclusions:For treatment of CTO and MVD,complete PCI reduced the long-term risk of MACEs and unstable angina,as compared with incomplete PCI and OMT.Complete PCI in both CTO and non-CTO lesions can potentially improve the prognosis of patients with CTO and MVD.

Percutaneous coronary intervention for chronic total occlusion in 1263 patients:a single-center report

Background Coronary chronic total occlusion （CTO） remains one of the most challenging lesion subsets in interventional cardiology, even with the development of medical device and operator expertise. This study was conducted to examine the relationship between lesion characteristics and procedural success and the incidence of in-hospital major adverse cardiac events （MACE） after percutaneous coronary intervention （PCI） for CTO. Methods Clinical and coronary angiographic data of 1263 patients with CTO who underwent PCI between June 1995 and December 2005 in Shenyang General Hospital of PLA were retrospectively analyzed. Results There were 1625 CTO lesions located in 1596 vessels with a mean occlusion time of 48.9 months. A total of 1647 coronary stents were implanted to the target lesions. The overall patient and lesion success rates were 90.8 % （1147/1263） and 88.9 % （1445/1625）, respectively. The success rate of PCI was declined with long duration of occlusion, abrupt missing stump, bridging collaterals ≥15 mm in occluded length, moderate to severe calcification or tortuosity and ostial or distal location of CTO lesions （P〈 0.05）. Procedural failure occurred in 116 patients, caused by impossibility of guide-wire （81.0%） or balloon （19.0%） to pass through the occlusion. There was no death during procedure, but 2 patients suffered from acute stent thrombosis and other 9 patients had acute or late pericardial perforation. Those complications were all successfully treated. After procedure, 3 patients died, 4 experienced urgent target vessel revascularization because of subacute stent thrombosis and 1 underwent coronary bypass graft surgery due to coronary ftstula during in-hospital period. The overall in-hospital MACE rate was 0.6% （8/1263）. Drug-eluting stents were used in 198 patients without in-hospital MACE. Conclusions In an experienced heart center, it is possible to obtain a relatively high success rate of PCI and favorable clinical outcomes for patients with coronary CTO lesions.

Retrograde approach for the recanalization of coronary chronic total occlusion： collateral selection and collateral related complication

Background The retrograde approach through collaterals has been applied in the treatment of chronic total occlusion （CTO） lesions during percutaneous recanalization of coronary arteries. This study was to investigate the success rate of recanalization and collateral related complications in patients when using the retrograde approach. Methods Eighty-four cases subjected to retrograde approach identified from July 2005 to July 2012 were included in this study. Patient characteristics, procedural outcomes and in-hospital clinical events were evaluated. Results Mean age of the patient was （59.6＋11.2） years old and 91.7% were men. The target CTO lesions were distributed among the left anterior descending artery in 45 cases （53.5%）, left circumflex artery in one case （1.2%）, right coronary artery in 34 cases （40.5%）, and left main in four cases （4.8%）. The overall success rate of recanalization was 79.8%. The septal collateral was three times more frequently used for retrograde access than the epicardial collateral, 68/84 （81%） vs. 16/84 （19%）. Successful wire passage through the collateral channel was achieved in 58 （72.6%） patients. The success rate of recanalization was 93.1% （54/58） in patients with and 50% （13/26） in patients without successful retrograde wire passage of the collateral channel （P 〈0.01）. Successful retrograde wire passage through the collaterals was achieved in 49 of 68 septal collaterals （72.1%） and in 9 of 16 epicardial collaterals （56.3%） （P=NS）. There was no significant difference between the septal collateral group and the epicardial group in the success rate of recanalization after retrograde wire crossing the collaterals （91.8% vs. 100%, P 〉0.05）. CART or reverse CART technique was used in 15 patients, and 14 patients （93.3%） were recanalized successfully. Collateral related perforation occurred in three （18.8%） cases with the epicardial collateral as the first choice （compared with the septal collateral group （0）, P 〈0.01 ）. There were 17 （20.2%） patients failure of recanalize the CTO lesions, among which 13 （15.5%） were due to the failure of retrograde wire crossing the collaterals. Conclusions The retrograde approach is an effective technique to recanalize CTO lesions, the septal collateral was preferable. When the epicardial collateral is selected, careful manipulation of devices and wires is essential due to the potential risk of perforation of collateral channels.

Multi-wire plaque crushing as a novel technique in treating chronic total occlusions

Background Failure of balloon catheter passing through the occluded segment accounts for 10%-15% of all procedures during percutaneous coronary intervention （PCI） for chronic total occlusion （CTO）. We sought to investigate an original technique for facilitating balloon catheter passing by multi-wire plaque crushing. Methods Between July 2000 and October 2007, 152 patients with 164 CTO lesions who had failed balloon passing were treated by multi-wire plaque crushing technique. The main process of this technique was to insert 1 or 2 wires along with the original wire located in the true lumen of CTO lesions after balloon failure for plaque crushing and then to withdraw the crushing wires to get an enlarged lumen inside of the occlusion segment, thus facilitating the balloon passing. Results Both overall lesion and technique success rates were 91.5% （150/164）. A total of 211 crushing wires were used during. PCI, including 1 crushing wire for 117 （71.3%） lesions and 2 crushing wires for 47 （28.7%） lesions. Approximately 57.3% （121/211） of all crushing wires were those already used in the same procedure. Technique failure occurred in 14 lesions （8.5%）. Technique failure was due to crushing wires entering false lumen （92.9%, 13/14） and coronary perforation （7.1%, 1/14）. Major procedural complications included coronary perforation （1 case） and severe coronary dissection （2 cases）, all of which were successfully treated. Conclusions Multi-wire plaque crushing technique is effective in facilitating balloon catheter passing during CTO PCI. It is feasible, economical and relatively safe with a low rate of procedural complications.

Retrograde approach for the recanalization of coronary chronic total occlusion： preliminary experience of a single center

Background The success rate of antegrade approach for chronic total occlusions （CTO） recanalization has not dramatically increased, especially in complex CTO subset. The retrograde technique may hold great promise. This report aimed to describe our experience of retrograde recanalization for CTO, focusing on its safety and feasibility. Methods We identified 42 patients who underwent revascularization in CTO with retrograde approach from July 2005 to November 2009 in our center.Results Three kinds of strategy were applied： retrograde as primary strategy （50.0%）, retrograde immediately after antegrade failure （26.2%） and repeat procedure after previous antegrade failure （23.8%）. Septal collaterals were more frequently used as the retrograde access route （92.9%）. Overall success rate was 88.1%. In patients with successful retrograde wire crossing collateral channel to the distal cap of CTO, the success rate of recanalization was 94.1%. In patient with failure to cross the collaterals, the success rate was 62.5%. Eight different kinds of retrograde techniques were used： kissing wire technique （35.3%）, wire trapped and reverse wire trapped technique （17.6%）, back-end balloon and microcatherer reversal technique （14.7%）, controlled antegrade and retrograde subintimal tracking （CART） technique （8.8%）, reverse CART and modified reverse CART technique （8.8%）, retrograde wire crossing technique （2.9%）. There were 4 complications occurred without in-hospital major adverse cardiac events （MACE）. In-hospital MACE was 7.7%. All of them were non-Q wave myocardial infarction. There were no cases of death or target vessel revascularization, either surgery or percutaneous.Conclusions The retrograde approach can be an effective tool for increasing the success rate of recanalization in the very complex CTO. To ensure the success and safety of the approach, careful case selection and device handling by experienced operators is essential.

Computed tomography angiography-guided percutaneous coronary intervention in chronic total occlusion

Objective： The aim of this study is to investigate if dual-source computed tomography （DSCT） could guide the percutaneous coronary intervention （PCI） of chronic total occlusion （CTO）. Methods： We enrolled patients who were confirmed to have at least one native coronary artery CTO by DSCT before they underwent selective PCI in the period from December 2007 to October 2008. A CTO was defined as an obstruction of a native coronary artery with no luminal continuity. The CT-guided PCI procedure involved placing CT and fluoroscopic images side-by-side on the screen. DSCT images were analyzed for location, segment, plaque characteristics, calcification, and proximal lumen diameter of the CTO before PCI. The guidewire was advanced and manipulated under CT guidance. The PCI was carried out and the results were compared. Results： Seventy-four CTOs were assessed. PCI was successful in 57 cases of CTOs （77.0%）. According to the results, CTOs were divided into two groups： successfuI-PCI and failed-PCI. All coronary artery paths of CTOs were clearly recognized by DSCT. In the successfuI-PCI group, soft plaques were detected much more often than those in the failed-PCI group, but fibrous and calcified plaques were seen more often in the failed-PCI group. Calcification severity in CTO segments showed a significant difference between the groups （P=0.014）. Calcified plaques were detected in 20 （35.1%） lesions in the successfuI-PCI group. More than 70% of the failures were calcified plaques, of which there were two arc-calcified and one circular-calcified lesions. Occlusions were longer in the failed-PCI group than those in the successfuI-PCI group [（38.8±25.0） vs. （18.0±15.3） mm, respec- tively, P〈0.01]. Fewer guidewires were used in the successfuI-PCI group compared with the failed-PCI group （1.7±1.0 vs. 2.5±0.9, respectively, P〈0.01）. The logistic regression analysis indicated that predictors of recanalization of CTOs included occlusion length （P=-0.0035, risk ratio （RR）=0.93） and calcification severity （P=0.05, RR=0.27）. Multi-linear trends analysis showed that the factors affecting procedural time were CTO location （P=-0.0141） and occlusion length （P=0.0035）. Conclusions： DSCT could delineate the path of CTOs and characterize plaques. The outcomes of PCI were related to thrombolysis in myocardial infarction （TIMI） flow grade, CTO characteristics, severity of calcified plaques and the length of occlusive segments. Occlusion length and calcification severity were independent predictors of CTOs. Occlusion length and CTO segments could also help to estimate the duration of interventional procedures.

Wire trapping technique combined with retrograde approach for recanalization of chronic total occlusion

Coronary chronic total occlusion （CTO）, defined as a ,total occlusion of duration 〉3 months, remains a technical challenge for the interventional cardiologists. The major limitation in percutaneous coronary intervention （PCI） of CTO is the inability to penetrate and cross the occlusion with a guidewire. It was reported that the immediate angiographic success rate varied from 50% to 70% using the standard antegrade techniques.1 To improve this suboptimal success rate, the authors firstly introduced retrograde approach through the collateral channels as a novel technique and successfully recanalized a left main CTO using this technique when demonstrating the live cases in Transcatheter Cardiovascular Therapeutics （TCT） 2005. Recently, modified techniques based on the retrograde approach have demonstrated that this approach could provide a high success rate with PCI.3-5 In the present report, we described a new method, wire trapping technique combined with retrograde approach, which was applied successfully in three patients with CTO.

Long-term outcomes of percutaneous coronary intervention for in-stent chronic total occlusion

Background:The development of the technique has improved the success rate of percutaneous coronary intervention(PCI)for instent chronic total occlusion(IS-CTO).However,long-term outcomes remain unclear.The present study sought to investigate long-term outcomes of PCI for IS-CTO.Methods:A total of 474 IS-CTO patients were enrolled at two cardiac centers from 2015 to 2018 retrospectively.These patients were allocated into either successful or failed IS-CTO PCI groups.The primary endpoint(major adverse cardiac events[MACE])consisted of recurrent angina pectoris(RAP),target-vessel myocardial infarction(MI),heart failure,cardiac death,or ischemia-driven target-vessel revascularization(TVR)at follow-up.Multivariable Cox regression analysis was used to investigate the association between treatment appropriateness and clinical outcomes.Results:A total of 367 patients were successfully treated with IS-CTO PCI while 107 patients had failed recanalization.After a median follow-up of 30 months(interquartile range:17-42 months),no significant difference was observed between the two groups for the following parameters:cardiac death(successful PCIvs.failed PCI:0.9%vs.2.7%;adjusted hazard ratio[HR]:1.442;95%confidence interval[CI]:0.21-9.887;P=0.709),RAP(successful PCIvs.failed PCI:40.8%vs.40.0%;adjusted HR:1.025;95%CI:0.683-1.538;P=0.905),heart failure(successful PCIvs.failed PCI:6.1%vs.2.7%;adjusted HR:0.281;95%CI:0.065-1.206;P=0.088),target-vessel related MI(successful PCIvs.failed PCI:1.5%vs.2.7%;adjusted HR:1.150;95%CI:0.221-5.995;P=0.868),MACE(successful PCIvs.failed PCI:44.2%vs.45.3%;adjusted HR:1.052;95%CI:0.717-1.543;P=0.797).More patients were free of angina in the successful IS-CTO PCI group compared with failed PCI in the first(80.4%vs.60%,P<0.01)and second years(73.3%vs.60.0%,P=0.02)following up.Successful IS-CTO PCI had a lower incidence of MACE in the first and second years(20.2%vs.40.0%,P<0.01;27.9%vs.41.3%,P=0.023)compared with failed PCI.After a median follow-up of 30 months,the reocclusion rate was 28.5%and TVR was 26.1%in the successful IS-CTO PCI group.Receiving>18 months of dual antiplatelet therapy(DAPT)was an independent predictor of decreased risk of TVR(HR:2.682;95%CI:1.295-5.578;P=0.008)or MACE(without TVR)(HR:1.898;95%CI:1.036-3.479;P=0.038)in successful IS-CTO PCI.Conclusions:After a median follow-up of 30 months,the successful IS-CTO PCI group had MACE similar to that of the failed PCI group.However,the successful IS-CTO PCI group had improved angina symptoms and were free from requiring coronary artery bypass grafting in the first or second years.To decrease MACE,DAPT was found to be essential and recommended for at least 18 months for IS-CTO PCI.

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion lesions in remote hospitals without on-site surgical support

Background The safety of percutaneous coronary intervention （PCI） for chronic total occlusion （CTO） lesions in remote hospitals without surgical facilities remains unknown. This study aimed to evaluate three-year outcomes after CTO for PCI in ten centers around China where no on-site coronary artery bypass grafting （CABG） support was available. Methods A total of 152 patients from 10 Chinese hospitals without on-site surgical facilities were prospectively studied. Intra-procedural and in-hospital events were assessed. Angiographic follow-up was indexed eight months after the initial procedure. Clinical follow-up was extended to three years. The primary outcome was the rate of major adverse cardiac events （MACE）, defined as cardiac death, myocardial infarction and target-vessel revascularization （TVR）. Results The incidence of CTO was 7.9% in patients who underwent PCI, Successful recanalization was achieved in 132 patients （86.8%）. Compared with patients in the PCI success group, patients with PCI procedural failure had longer lesion lengths （（42.32±22.08） mm vs （27.61±22.85） mm, P=0.023）, a higher rate of perforation （25.0% vs 0, P=0.014）, and a greater need for pericardial puncture. There were significant differences in MACE in-hospital and at one year and three years between the failure （10.0%, 30.0% and 35.0%） and the success （3.0%, 12.1% and 14.4%） groups （P=0.037, 0.034 and 0.040, respectively）. These led to a significant decrease in the MACE-free survival rate at one and three years in the failure group, compared with the success group （P=0.031 and 0.023, respectively）. Stump was the only predictor of recanalization success （HR 0.158, 95% Cl 0.041-0.612, P=0.008）, whereas procedural failure （OR 13.023, 95% CI 6.67-13.69, P=0.002）, incomplete revascularization （OR 9.71, 95% CI 2.93-5.59, P=0.005）, and total stent length （OR 6.02, 95% Cl 1.55-11.93, P=0.027） were three independent predictors of MACE. Conclusions PCI for CTO was unsafe in remote hospitals without CABG facilities. Paying attention to coronary perforation is important for successful procedures.

Clinical outcomes after recanalization of a chronic total occluded vessel with bifurcation lesions： results from single-center, prospective, chronic total occlusion registry study

Background Stenting strategies and clinical outcomes of bifurcation lesions in a chronic total occlusion （CTO） vessel after successful recanalization remain to be unknown. Methods Between January 2001 and December 2009, 195 （41.1%） patients with 254 （47.0%） bifurcation lesions in CTO vessels from a pool of 564 patients with 659 CTO lesions were included and divided into proximal （n=134） and distal （n=-120） groups, according to the location of the bifurcation lesions. The primary endpoint was the occurrence of major adverse cardiac events （MACE） at the end of clinical follow-up, including cardiac death, myocardial infarction, or target vessel revascularization （TVR）. Results Collaterals with Rentrop class 3 were seen more in distal group （100% and 68.3%）, compared to proximal group （76.9% and 45.6%）. Two-stent technique for proximal bifurcation lesions was used in 24.6%, significantly different from the distal group （6.7%, P 〈0.001）, without significant difference in composite MACE between proximal and distal groups, or between one- and two-stent subgroups in proximal group. The composite MACE after 1-year in complete revascularization subgroup was 17.9% relative to 29.6% in the incomplete revascularization group （P=0.044）. Stents in long false lumen in main vessel were mainly attributive to decreased TIMI grade flow, with resultant increased in-stent restenosis, total occlusion, TVR and coronary aneurysms. Imcomplete revasculzarization （HR 2.028, P=0.049, 95% CI 1.002-4.105） and post-stenting TIMI flow （HR 6.122, P=0.020, 95% Cl 1.334-28.092） were two independent predictors of composite MACE at the 1-year follow-up. Conclusions Two-stent was more used for proximal bifurcation lesions. No significant difference was observed in MACE between proximal and distal, or between one- and two-stent subgroups in the proximal group. Placement of a safety wire was critical for proximal bifurcation lesions. Complete revascularization was mandatory to improve clinical outcomes.

Comparison of drug eluting stent implantation with coronary artery bypass surgery in the treatment of patients with chronic total occlusion and multiple vessel disease

Background In patients with chronic total occlusion （CTO） and multivessel coronary artery disease, the comparison of surgical and the percutaneous revascularization strategies has rarely been conducted. The aim of this study was to compare long term clinical outcomes of drug eluting stent （DES） implantation with coronary artery bypass surgery （CABG）in the patients with CTO and multivessel disease.Methods From a prospective registry of 6000 patients in our institution, we included patients with CTO and multivessel coronary artery disease who underwent either CABG （n=679） or DES （n=267） treatment. Their propensity risk score was used for adjusting baseline differences.Results At a median follow-up of three years, propensity score adjusted Cox regression analysis showed that the rate of major adverse cardiac cerebrovascular events （MACCE） was lower in CABG group （12.7% vs. 24.3%, hazard ratio （HR） 1.969, 95% Cl 1.219-3.179, P=0.006） mainly due to lower rate of target vessel revascularization in CABG group than in DES group （3.1% vs. 17.2%, HR 16.14, 95% CI 5.739-45.391, P ＜0.001）. The incidence of cardiac death or myocardial infarction （composite end point） was not significantly different between these two groups. On multivariate analysis, the significant predictors of MACCE were only the type of revascularization. Age, left ventricular ejection fraction （LVEF）, and complete revascularization were identified as significant predictors of composite end points.Conclusions Our study shows that in patients with CTO and multivessel coronary disease, DES can offer comparable long term outcomes in cardiac death and myocardial infraction free survival in comparison with CABG. However, there is an increased rate of MACCE which results from more repeat revascularizations. Obtaining a complete revascularization is crucial for decreasing adverse cardiac events.