The learning curve in treating coronary chronic total occlusion early in the experience of an operator at a tertiary medical center: The role of the hybrid approach

Shammas, Nicolas W.; Shammas, Gail A.; Robken, Jon; Harris, Thomas S.; Madison, Ashley; Dinklenburg, Catherine; Shammas, Andrew N.; Harb, Christine; Jerin, Michael

doi:10.1016/j.carrev.2015.09.004

Cited by 16 publications

(5 citation statements)

References 15 publications

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“…The latter was investigated in a retrospective single-center study, which found that an interventionist’s experience in EVT for AIS was significantly associated with shorter procedures and less radiation exposure 2. This relation between increased experience levels and shorter procedures and lower contrast doses was also found in studies that investigated PCI,18–22 and CAS procedures 19…”

Section: Discussionmentioning

confidence: 85%

“…Previous studies found no or small effects of the interventionist’s experience on clinical outcomes and/or mortality after EVT for AIS, but also after PCI, and carotid artery stenting (CAS) procedures 3 6 7 18 19. All but one of these studies defined experience as the total number of previously performed procedures, which could explain the effect sizes found.…”

Section: Discussionmentioning

confidence: 99%

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Influence of the interventionist’s experience on outcomes of endovascular thrombectomy in acute ischemic stroke: results from the MR CLEAN Registry

Olthuis

Hartog

Kuijk

et al. 2022

J NeuroIntervent Surg

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BackgroundThe relationship between the interventionist’s experience and outcomes of endovascular thrombectomy (EVT) for acute ischemic stroke of the anterior circulation, is unclear.ObjectiveTo assess the effect of the interventionist’s level of experience on clinical, imaging, and workflow outcomes. Secondly, to determine which of the three experience definitions is most strongly associated with these outcome measures.MethodsWe analysed data from 2700 patients, included in the MR CLEAN Registry. We defined interventionist’s experience as the number of procedures performed in the year preceding the intervention (EXPfreq), total number of procedures performed (EXPno), and years of experience (EXPyears). Our outcomes were the baseline-adjusted National Institutes of Health Stroke Scale (NIHSS) score at 24–48 hours post-EVT, recanalization (extended Thrombolysis in Cerebral Infarction (eTICI) score ≥2B), and procedural duration. We used multilevel regression models with interventionists as random intercept. For EXPfreq and EXPno results were expressed per 10 procedures.ResultsIncreased EXPfreq was associated with lower 24–48 hour NIHSS scores (adjusted (a)β:−0.46, 95% CI −0.70 to −0.21). EXPno and EXPyears were not associated with short-term neurological outcomes. Increased EXPfreq and EXPno were both associated with recanalization (aOR=1.20, 95% CI 1.11 to 1.31 and aOR=1.08, 95% CI 1.04 to 1.12, respectively), and increased EXPfreq, EXPno, and EXPyears were all associated with shorter procedure times (aβ:−3.08, 95% CI−4.32 to −1.84; aβ:−1.34, 95% CI−1.84 to −0.85; and aβ:−0.79, 95% CI−1.45 to −0.13, respectively).ConclusionsHigher levels of interventionist’s experience are associated with better outcomes after EVT, in particular when experience is defined as the number of patients treated in the preceding year. Every 20 procedures more per year is associated with approximately one NIHSS score point decrease, an increased probability for recanalization (aOR=1.44), and a 6-minute shorter procedure time.

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Section: Discussionmentioning

confidence: 85%

Section: Discussionmentioning

confidence: 99%

Influence of the interventionist’s experience on outcomes of endovascular thrombectomy in acute ischemic stroke: results from the MR CLEAN Registry

Olthuis

Hartog

Kuijk

et al. 2022

J NeuroIntervent Surg

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“…CTO‐PCI has consistently been identified as the strongest risk factor for coronary perforations, 3,5 associated with a sevenfold increase in the adjusted risk compared to non‐CTO‐PCI. As previously reported, 7 several factors including the evolution of CTO expertise, 13,14 and probably the higher complexity of interventional procedures that are routinely attempted in clinical practice, may have contributed to the growing incidence of coronary perforations, particularly during CTO‐PCI. Several registries 2,4,6 have detailed outcomes of coronary perforations in the specific setting of CTO‐PCI: in‐hospital complications and death were associated with perforation severity.…”

Section: Discussionmentioning

confidence: 91%

Grade 3 coronary artery perforations in chronic total occlusion‐percutaneous coronary intervention: Mechanisms, locations, and outcomes from the G3CAP Registry

Pavani

Cerrato

Franzé

et al. 2022

Cathet Cardio Intervent

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Aim The impact of Grade III coronary perforations (G3‐CP) in the setting of CTO‐PCI is not well assessed. Methods and Results We reviewed 7773 CTO‐PCI and 98,819 non CTO‐PCI performed in 10 European centers: G3 perforation occurred in 87 patients (1.1%) during CTO PCI and 224 patients (0.22%) during non CTO‐PCI (p < 0.001). G3‐CP involved the CTO segment in 68% of patients and the retrograde channels in 14% of cases. In the CTO PCI group, wire induced G3‐CP (50.5% vs. 32.5%, p = 0.02) occurred predominantly when dedicated CTO tapered and highly penetrative wires were used. Intra‐procedural and in‐hospital death rates were 4.6% vs. 5.8% and 3.6% vs. 7.5% respectively for CTO PCI and non‐CTO PCI groups (p = NS). At a median follow up of 24 months, the overall mortality and MAE were respectively 7.8% and MAE 19% without difference among groups. Conclusions We showed similar in‐hospital and long‐term outcomes when G3 perforations occurred during CTO PCI and non CTO‐PCI.

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“… 37 , 38 Recent studies have shown that a hybrid antegrade/retrograde approach to CTO intervention, a mainstay of HR‐PCI operators, can be successfully adopted by a single operator with excellent early procedural success despite a lack of prior CTO‐PCI experience. 39 , 40 Moreover, studies of operator volumes and long‐term outcomes in the United Kingdom have shown conflicting results for HR‐PCI overall as compared with a smaller subset of left main intervention procedures. 41 , 42 Physicians performing HR‐PCI in this study had an average of 9 years of experience after fellowship, and although interventionalists using a multioperator strategy worked at centers with higher annual HR‐PCI volumes, lead operators performed a similar number of HR‐PCI procedures per year compared with their single‐operator peers.…”

Section: Discussionmentioning

confidence: 99%

Clinical Characteristics and Outcomes Among Patients Undergoing High‐Risk Percutaneous Coronary Interventions by Single or Multiple Operators: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

Kovach

Hebbe

Barón³

et al. 2021

JAHA

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Background High‐risk percutaneous coronary intervention (HR‐PCI) is increasingly common among contemporary patients with coronary artery disease. Experts have advocated for a collaborative 2‐operator approach to support intraprocedural decision‐making for these complex interventions. The impact of a second operator on patient and procedural outcomes is unknown. Methods and Results Patients who underwent HR‐PCI from 2015 to 2018 within the Veterans Affairs Healthcare System were identified. Propensity‐matched cohorts were generated to compare the outcomes following HR‐PCI performed by a single or multiple (≥2) operators. The primary end point was the 12‐month rate of major adverse cardiovascular events. We identified 6672 patients who underwent HR‐PCI during the study period; 6211 (93%) were treated by a single operator, and 461 (7%) were treated by multiple operators, with a nonsignificant trend toward increased multioperator procedures over time. A higher proportion of patients treated by multiple operators underwent left main (10% versus 7%, P =0.045) or chronic total occlusion intervention (11% versus 5%, P <0.001). Lead interventionalists participating in multioperator procedures practiced at centers with higher annual HR‐PCI volumes (124±71.3 versus 111±69.2; standardized mean difference, 0.197; P <0.001) but otherwise performed a similar number of HR‐PCI procedures per year (34.4±35.3 versus 34.7±30.7; standardized mean difference, 0.388; P =0.841) compared with their peers performing single‐operator interventions. In a propensity‐matched cohort, there was no significant difference in major adverse cardiovascular events (32% versus 30%, P =0.444) between patients who underwent single‐operator versus multioperator HR‐PCI. Adjusted analyses accounting for site‐level variance showed no significant differences in outcomes. Conclusions Patients who underwent multioperator HR‐PCI had similar outcomes compared with single‐operator procedures. Further studies are needed to determine if the addition of a second operator offers clinical benefits to a subset of HR‐PCI patients undergoing left main or chronic total occlusion intervention.

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The learning curve in treating coronary chronic total occlusion early in the experience of an operator at a tertiary medical center: The role of the hybrid approach

Cited by 16 publications

References 15 publications

Influence of the interventionist’s experience on outcomes of endovascular thrombectomy in acute ischemic stroke: results from the MR CLEAN Registry

Influence of the interventionist’s experience on outcomes of endovascular thrombectomy in acute ischemic stroke: results from the MR CLEAN Registry

Grade 3 coronary artery perforations in chronic total occlusion‐percutaneous coronary intervention: Mechanisms, locations, and outcomes from the G3CAP Registry

Clinical Characteristics and Outcomes Among Patients Undergoing High‐Risk Percutaneous Coronary Interventions by Single or Multiple Operators: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

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