Outcomes of subintimal plaque modification in chronic total occlusion percutaneous coronary intervention

Abstract

Background When crossing into the distal true lumen fails during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification (SPM) is often performed to restore antegrade flow and facilitate subsequent lesion recanalization. Methods Between January 2012 and May 4, 2019, 4,659 CTO PCIs were included in the PROGRESS‐CTO registry, of which 935 (20%) had a prior unsuccessful attempt. Of those 935 patients, 119 (13%) had prior SPM. We analyzed the outcomes of the 58 SPM procedures for which data were available, as well as the outcomes of the 60 subsequent CTO PCI attempts. Results Mean patient age was 67 ± 9 years and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%) diabetes (48%), prior PCI (61%), and prior coronary artery bypass graft surgery (47%). The target CTO lesions often had proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J‐CTO score (mean 3.2 ± 1.1). The technical and procedural success of subsequent CTO PCI were high (83% for both) with an acceptable rate of in‐hospital major adverse cardiovascular events (3.3%). Technical and procedural success were higher for repeat attempts that were performed ≥60 days after the index CTO PCI (94% vs. 69%, p = .015). Median (interquartile range) subsequent procedure time was 147 (100, 215) min, contrast volume was 185 (150, 260) ml, and air kerma radiation dose was 2.5 (1.4, 4.2) Gray. Conclusion Repeat CTO PCI attempts after SPM are associated with high likelihood for successful revascularization with acceptable risks.

Staged CTO PCI: The investment that pays dividends

“…At the intersection of benefit versus risk is where subintimal plaque modification (SPM) becomes the correct decision that will pay its dividend in the near future. This multicenter registry further proves that “investment procedures” such as SPM, is another tool that can be used as a primer step in successfully treating challenging CTOs 4 . It is important for operators to not only be well experienced, highly skilled, and equipped with the appropriate tools but also to consider the benefits in an investment procedure before classifying an intervention as a failed attempt.…”

Use of the Limited Antegrade Subintimal Tracking Technique in Chronic Total Occlusion Percutaneous Coronary Intervention

“…14 STAR without stenting is currently used as a bailout strategy (investment procedure). 15 An evolution of STAR was contrast-guided STAR in which a large contrast volume (3-4 mL) is injected in the subintimal/extraplaque space to allow hydraulic recanalization of the…”

The Impact of Calcium on Chronic Total Occlusion Management

“…In a subset of patients from the PROGRESS registry in whom initial CTO PCI was unsuccessful and who underwent subintimal plaque modification (or a ‘modification procedure’), the prevalence of moderate or severe calcification was 73%. [ 13 ] In a Japanese cohort of patients who underwent CTCA prior to attempted CTO PCI, 50% of those for whom the attempt was unsuccessful had severe calcification identified on CTCA, compared with 16% of those for whom the procedure was successful. [ 14 ] When CTO PCI was successful in these cases, severe calcification was associated with higher rates of restenosis and re-occlusion.…”