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.

Complete Revascularization of Coronary Artery

Twenty five casses of complete revascularization for coronary artery discase by sequential aortocoronary saphaneous bypass operation were performed from April 1990 to July 1993.

Anaortic Off-Pump Complete Arterial Revascularization Using Composite LIMA RIMA Y Sequential 5 Grafts in a Patient with Triple Vessel Disease Performed in a Low Resource Country: A Case Report

The use of bilateral internal thoracic arteries to treat coronary artery disease is very less despite of improved long-term survival. In this case report, a patient presented with TVD has been managed with anaortic off-pump complete arterial revascularization (OPCABG) by using composite LIMA RIMA Y Sequential 5 grafts to achieve complete arterial revascularization successfully. This type of operative procedure is technically difficult in a resource poor country like Bangladesh. However, this has been done by a group of young cardiac surgeon. During follow up, the patient is in a good condition.

Prognostic factors of non-infarct-related arterial revascularization in STEMI patients with multivessel disease

Background Multivessel disease(MVD)is common in patients presenting with ST-segment elevation myocardial infarction(STEMI).But there is controversy over how to manage significant lesions in non-infarct-related artery(non-IRA).Methods A total of 221 patients diagnosed with STEMI and MVD who underwent percutaneous coronary intervention(PCI)at our cardiology department between January 2018 and June 2021 were included in this study.Among them,115 patients underwent complete revascularization within 30 days and were assigned to the complete revascularization group,while 106 patients who did not undergo complete revascularization within 30 days were assigned to the IRA-only revascularization group.Patients were followed up at 12 months.The primary endpoint event was adverse cardiovascular events(MACEs).Results There was no significant statistical difference in MACEs between the two groups of patients,but the incidence of heart failure in the IRA-Only group was significantly higher than that in the complete revascularization group.In the complete revascularization group,the number of stents,Killip class Ⅱ/Ⅲ on admission,and complete revascularization time were independent predictors of MACEs.Receiver operating characteristic curve(ROC)curve analysis showed that complete revascularization time had good predictive power for MACEs(Area under the curve:0.74695%CI:0.680-0.801),with a cut-off value of 10.3 days.Conclusions For STEMI patients with concurrent MVD,complete revascularization can reduce the incidence of heart failure.What's more,short-term staged(within 10 days)complete revascularization may further improve clinical outcomes.

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.