Application and outcomes of a hybrid approach to chronic total occlusion percutaneous coronary intervention in a contemporary multicenter US registry

Abstract

Background A hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) prioritizing and combining all available crossing techniques was developed to optimize procedural efficacy, efficiency, and safety, but there is limited published data on its outcomes. Methods We examined the procedural techniques and outcomes of 1,036 consecutive CTO PCIs performed using a hybrid approach between 2012 and 2015 at 11 US centers. Results Mean age was 65±10 years and 86% of the patients were men, with a high prevalence of diabetes mellitus (43%) and prior coronary artery bypass graft surgery (34%). Most target CTOs were located in the right coronary artery (59%), followed by the left anterior descending artery (23%) and the circumflex (19%). Dual injection was used in 71%. Technical success was achieved in 91% and a major procedural complication occurred in 1.7% of cases. The final successful crossing technique was antegrade wire escalation in 46%, antegrade dissection/re-entry in 26%, and retrograde in 28%. The initial crossing strategy was successful in 58% of the lesions, whereas 39% required an additional approach. Overall, antegrade wire escalation was used in 71%, antegrade dissection/re-entry in 36%, and the retrograde approach in 42% of procedures. Median contrast volume, fluoroscopy time, and air kerma radiation dose were 260 (200–360) ml, 44 (27–72) min, and 3.4 (2.0–5.4) Gray, respectively. Conclusion Application of a hybrid approach to CTO crossing resulted in high success and low complication rates across a varied group of operators and hospital practice structures, supporting its expanding use in CTO PCI.

Chronic Total Occlusion Percutaneous Coronary Intervention: Evidence and Controversies

“…In recent years, several large multicenter registries have reported higher success (≈85%–90%) with acceptable complication rates in CTO PCI at various experienced centers and with operators from all around the world, although less optimal results have been reported from all‐comer PCI registries (Table 2). 8, 25, 26, 27, 28, 29, 30, 31, 32 …”

“…AWE (ie, sequential use of various guidewires in the antegrade direction, from the proximal to the distal part of the vessel) is the most commonly used initial and final CTO crossing technique (66%–78%),25, 26, 27, 28 especially for less complex occlusions 62…”

Update in Chronic Total Occlusion Percutaneous Coronary Interventions

“…Significant improvements, however, have been achieved in recent years resulting in high success rates by several expert operators and centers. 7,8 The goal of the present review is to provide an update on the current status and future directions of CTO-PCI.…”

“…Careful angiographic review by the entire catheterization team and development of a procedural plan can make the procedure more successful, efficient, and safe. If the chosen crossing strategy fails to achieve progress, the hybrid algorithm favors early change, a key factor contributing to the improving CTO-PCI outcomes in the United States 7 and around the world. 8 n PROCEDURAL SUCCESS…”

“…27 However, recently at experienced centers, success with CTO-PCI significantly increased. In a report from the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO), Christopoulos et al 7 reported 91% technical success and a 1.7% rate of major adverse cardiac events among 1,036 consecutive CTOPCIs performed using the hybrid approach between 2012 and 2015 at 11 US centers. 7 Wilson et al 8 Less favorable outcomes, however, have been observed at less experienced centers.…”