A comparison of procedural success rate and long-term clinical outcomes between in-stent restenosis chronic total occlusion and de novo chronic total occlusion using multicenter registry data

Abstract

Background There have been little data about outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusion (CTO) in the drug eluting stent (DES) era. This study aimed to compare the procedural success rate and long-term clinical outcomes of ISR CTO and de novo CTO. Methods and results Patients who underwent PCI for ISR CTO (n = 164) versus de novo CTO (n = 1208) were enrolled from three centers in Korea between January 2008 and December 2014. Among a total of ISR CTO, a proportion of DES ISR CTO was 79.3% (n = 130). The primary outcome was major adverse cardiac events (MACEs); a composite of all-cause death, non-fatal myocardial infarction (MI), or target lesion revascularization (TLR). Following propensity score-matching (1:3), the ISR CTO group (n = 156) had a higher success rate (84.6% vs. 76.0%, p = 0.035), mainly driven by high success rate of PCI for DES ISR CTO (88.6%), but showed a higher incidence of MACEs [hazard ratio (HR): 2.06; 95% confidence interval (CI) 1.37–3.09; p < 0.001], mainly driven by higher prevalence of MI [HR: 9.71; 95% CI 2.06–45.81; p = 0.004] and TLR [HR: 3.04; 95% CI 1.59–5.81; p = 0.001], during 5 years of follow-up after successful revascularization, as compared to the de novo CTO group (n = 408). Conclusion The procedural success rate was higher in the ISR CTO than the de novo CTO, especially in DES ISR CTO. However, irrespective of successful revascularization, the long-term clinical outcomes for the ISR CTO were significantly worse than those for the de novo CTO, in terms of MI and TLR. Graphic abstract

Thirty‐day and 5‐year results of percutaneous coronary intervention for in‐stent restenotic chronic total occlusion lesions: Data from 2,659 consecutive patients

“…2 The improvement of specific devices and procedure algorithms for CTO PCI has led to an improvement in the success rate of ISR-CTO PCI, which has recently been reported to be 84.2-86% and is comparable to the results of our study. 5,16 The rates of reasonable and suboptimal recanalization in the ISR-CTO group were higher than those of the de-novo CTO group among the patients who underwent an antegrade approach in our study, despite higher J-CTO and CASTLE scores in the ISR-CTO group. This may be due to the differences in lesion composition and direction between ISR-CTO and de-novo CTO lesions.…”

“…2 In our study, ISR-CTO lesions had a higher degree of bending and a longer occlusion length than de-novo CTO lesions. The wire is able to completely or partially pass between the tortuous or underexpanded, previously deployed stent and the vessel intima during PCI, 16,17 which may increase the risk of subintimal stent deployment and the occlusion of side branches. 21 In this study, angiography data were reviewed and the occlusion of main side branches during PCI and a subintimal stent length > 10 mm were used as criteria for a suboptimal recanalization.…”

Impact of Neutrophil-Lymphocyte Ratio on Long-term Outcomes of Patients with Coronary Chronic Total Occlusion After Percutaneous Coronary Intervention

“…Moreover, new anti-ischemic drugs, drug-eluting stents, potent antiplatelet agents, and high-dose statins have contributed to reduce the progression of cardiovascular disease and atherosclerosis. However, CTO and in-stent restenosis have been shown to be a worsening clinical condition [9,10,21]. The successful treatment of CTO lesion was a strong predictor of subsequent adverse events, including cardiac death, ischemia or symptoms-driven TVR, and CTO PCI was not associated with a reduction in long-term MACE [10,21].…”

“…However, CTO and in-stent restenosis have been shown to be a worsening clinical condition [9,10,21]. The successful treatment of CTO lesion was a strong predictor of subsequent adverse events, including cardiac death, ischemia or symptoms-driven TVR, and CTO PCI was not associated with a reduction in long-term MACE [10,21]. The pathophysiological mechanism of such recurrent events after PCI for CTO is largely unknown.…”

Long-Term Outcomes of Percutaneous Coronary Intervention for Patients With In-Stent Chronic Total Occlusion Versus De Novo Chronic Total Occlusion

“…1,11,12 Additionally, treatment of in-stent occlusive segments has been identified as an independent predictor of the need for targetvessel revascularization (TVR) and subsequent adverse cardiac outcomes at short-and medium-term follow-up. 13,14 To date, few studies have compared the long-term clinical outcomes of patients with IS-CTO versus de novo CTO who undergo revascularization in the drug-eluting stent era, 13,15 especially in Chinese individuals. Similarly, the long-term status quantified by the Seattle Angina Questionnaire (SAQ) of this patient subgroup on follow-up is poorly characterized.…”