Chronic Total Occlusion Percutaneous Coronary Intervention

HomeCirculation: Cardiovascular InterventionsVol. 11, No. 10Chronic Total Occlusion Percutaneous Coronary Intervention Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBChronic Total Occlusion Percutaneous Coronary Intervention"The Better You Get, the Better You'd Better Get" Emmanouil S. Brilakis, MD, PhD and M. Nicholas Burke, MD Emmanouil S. BrilakisEmmanouil S. Brilakis Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th St #300, Minneapolis, MN 55407. Email E-mail Address: [email protected] Minneapolis Heart Institute, MN. and M. Nicholas BurkeM. Nicholas Burke Minneapolis Heart Institute, MN. Originally published9 Oct 2018https://doi.org/10.1161/CIRCINTERVENTIONS.118.007362Circulation: Cardiovascular Interventions. 2018;11:e007362This article is a commentary on the followingTemporal Trends in Chronic Total Occlusion Interventions in EuropeSee Article by Konstantinidis et alChronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been steadily evolving over time both locally and globally with increasing success rates.1–4 The EuroCTO registry has been capturing this evolution during the past decade, and by describing temporal trends in CTO PCI, it provides several lessons relevant to contemporary CTO PCI practice (Table).5Table. Achievements and Opportunities for Further Improvement of CTO PCIAchievementsOpportunities1Use standardized definitions for CTO PCI techniques and outcomes2Treatment of increasingly complex CTOsTreat even more complex CTOs3High success rates and stable complication ratesFurther improve success and decrease complication rates4Good outcomes by experienced operatorsBridge the gap between experienced and less experienced operators and centers and improve access to excellent CTO PCI treatment5Increasing use of retrograde approachImprove the safety of the retrograde approach and use it judiciously6Increasing use of antegrade dissection/reentryImprove access and education on this technique7Increase in use of dual injectionUse dual injection in nearly all CTO PCIs8Increase in use of radial accessFurther increase use of radial access in an attempt to decrease access site complication, yet change to femoral when radial access does not provide optimal support9Decrease in radiation dose and contrast volumeFurther decrease patient (and operator) radiation dose and contrast volumeCTO indicates chronic total occlusion; and PCI, percutaneous coronary intervention.First, the definitions of the procedural aspects and outcomes of CTO PCI still vary. In the present study, procedural success was defined as angiographic success (final residual stenosis <20%) by visual estimation and TIMI (Thrombolysis in Myocardial Infarction) flow grade 3 after CTO recanalization, which is the definition of technical success in the National Cardiovascular Data Registry6 and other CTO studies. Clinical success was then defined as procedural success without periprocedural complications, which is the definition of procedural success in National Cardiovascular Data Registry. There remains great need for standardizing CTO PCI definitions to facilitate communication and comparisons between various studies around the globe.7 Definition standardization will be addressed in the CTO-Academic Research Consortium that is planned for later in 2018.Second, increasingly complex CTO lesions are being treated. Between 2008 and 2015, the mean Japan CTO score increased from 1.76 to 2.17. Attempted CTOs had longer length, longer duration, and were more likely to be because of in-stent restenosis. This suggests that CTO operators are willing to attempt increasingly difficult lesions.Third, despite increasing lesion complexity, technical success increased from ≈80% in 2008 to 89% in 2015. This is very similar to the technical success rates reported by other registries, in the United States,2 Europe,3 and Japan.4 Conversely, the risk for major in-hospital complications remained low (0.5%–0.7%) throughout the study, which is lower than other registries (≈3%).2,3 These data provide useful benchmarks to guide decision making and discussions with patients and referring physicians. Overall, CTO PCI technical success rates by experienced operators are estimated at ≈85% to 90% and major in-hospital complications ≈1% to 3%.1Fourth, the aforementioned success and complication rates only apply to experienced operators and centers. Outcomes across all institutions and operators are less favorable: in an analysis from National Cardiovascular Data Registry technical success was 59%, although higher volume operators had better success and lower complication rates.6 Bridging this gap will require continued education and evolution of techniques and equipment. At present, concentrating CTO PCI (especially for more complex CTOs) to experienced operators and centers will likely provide the best outcomes.Fifth, use of the retrograde approach significantly increased over time from ≈10% in 2008 to 2009 to 30% in 2014 to 2015, with even higher utilization (43%) among previously failed cases. Use of the retrograde approach has revolutionized CTO PCI and likely significantly contributed to the high and increasing success rates observed in the present study,8 at the cost of twice higher risk for complications as compared with antegrade wire escalation.2,3 At least part of the risk increase is likely related to higher complexity of CTO lesions requiring use of retrograde crossing.2,8 Nevertheless, judicious use of the retrograde approach remains important: most lesions (with the exception of flush ostial CTOs) may be best approached with an initial antegrade crossing attempt. If antegrade crossing fails, antegrade preparation can facilitate subsequent retrograde crossing.Sixth, use of antegrade dissection and reentry remained low in the EuroCTO registry, although it significantly increased from 0.7% in 2008 to 2009 to 5.5% in 2014 to 2015. Antegrade dissection/reentry was associated with slightly higher risk than antegrade wire escalation but lower than retrograde crossing.5,9 Local preferences and cost may limit use of antegrade dissection/reentry, but its availability could facilitate success, especially in cases without good retrograde options. Addressing barriers to use of these techniques, such as cost and training opportunities, would be key to facilitate use.10 Limited dissection/reentry techniques that minimize the length of subintimal crossing are preferred, although use of the subintimal tracking and reentry technique has been increasing in recent years, usually when all other crossing strategies fail.11 Advancing a knuckled guidewire usually achieves spontaneous reentry into the distal true lumen. Balloon angioplasty is then performed within the subintimal space without stent implantation (investment procedure), and the patient is asked to return in 2 to 3 months. Repeat angiography often reveals restoration of antegrade flow, allowing easy wiring and stenting.12Seventh, use of basic, yet fundamental, CTO PCI techniques significantly increased over time: dual injection increased from 39% to 66%. Dual injection increases both the success and safety of CTO PCI because it allows confirmation of equipment position in relation to the distal true lumen, helping avoid perforation and other complications. The simple steps of (1) inserting a second guide catheter, along with (2) always using a microcatheter to support the guidewire can have an immediate and profound impact on CTO PCI outcomes for both beginner and experienced operators.13Eighth, use of radial access significantly increased over time from 16% to 34%, while reaching similar success rates with femoral access in more recent years. Radial access can reduce the risk for vascular access complications, while still providing adequate support for most cases.14,15 The most common access configuration for many operators currently is femoral/radial, with femoral access used for the antegrade and radial access used for the retrograde guide catheter. Biradial CTO PCI is also frequently performed with excellent results but may cause operator discomfort by having to lean over, especially in heavier patients. Access site selection should never be dogmatic: if vessel engagement or guide support is suboptimal with radial access in some patients, there should be a low threshold for changing to femoral access, a concept often referred to as the rational radial approach.Ninth, despite the significant progress documented in the EuroCTO registry, several challenges and opportunities remain. Approximately 1 out of 10 CTO PCIs fail.2–5 Should 100% success remain the goal? Perhaps not, as striving for 100% may result in significant increase in complication rates. Also, the use of contrast and radiation dose remain substantial: in EuroCTO during 2014 to 2015, mean fluoroscopy time was 43 minutes (air kerma radiation dose was not collected in the registry) and mean contrast volume was 280 mL. Reducing radiation dose for both the patient and the operator remain high priorities and could be achieved by careful attention to the basics of radiation protection (time, distance, shielding) and use of newer x-ray systems with lower radiation settings.16–18 Zero contrast CTO PCI may be too aggressive of a goal,19 but hydrating the patients before the procedure and minimizing contrast volume through judicious injections, use of intravascular imaging, and use of contrast-sparing devices can help decrease the risk for contrast nephropathy.The present study has limitations. It does not include the subsequent clinical outcomes of the study patients. Did their symptoms improve? Did they have high restenosis rates and frequent need for repeat procedures? Fifty-three operators are not enough for all of Europe: how many other operators are at various stages of development in CTO PCI and what can be done to increase their number so that all patients in need have access to state-of-the-art CTO PCI?The EuroCTO Club should be congratulated for aggregating and reporting the CTO PCI practice in Europe over the past decade, as well as performing the first randomized-controlled clinical trial of CTO PCI versus medical therapy.20 By documenting the progress achieved and identifying opportunities for further improvement, the EuroCTO operators, as well as operators from all over the world can maximize the likelihood that future patients who need CTO PCI receive the best possible care. Because as David Allen said in his book Ready for Anything: "The better you get, the better you'd better get."DisclosuresDr Brilakis receives consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), Cardiovascular Systems Inc, Elsevier, GE Healthcare, and Medtronic; research support from Siemens, Regeneron, and Osprey. He is also a shareholder in the MHI Ventures and Board of Trustees in the Society of Cardiovascular Angiography and Interventions. Dr Burke receives consulting and speaking honoraria from Abbott Vascular and Boston Scientific.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th St #300, Minneapolis, MN 55407. Email [email protected]comReferences1. 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A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions.Eur Heart J. 2018; 39:2484–2493. doi: 10.1093/eurheartj/ehy220CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kelbæk H, Yeh R, Engstrøm T, Neumann F, Serruys P, Windecker S, Belardi J, Qiao S, Xu B, Liu M and Silber S (2021) Five-year clinical outcomes of zotarolimus-eluting stents in coronary total occlusions, EuroIntervention, 10.4244/EIJ-D-19-00866, 16:16, (1326-1332), Online publication date: 1-Mar-2021. Related articlesTemporal Trends in Chronic Total Occlusion Interventions in EuropeNikolaos V. Konstantinidis, et al. Circulation: Cardiovascular Interventions. 2018;11 October 2018Vol 11, Issue 10 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.118.007362PMID: 30354649 Originally publishedOctober 9, 2018 KeywordsJapanregistriesEditorialspercutaneousstentschronic total occlusioncoronary interventionPDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsPercutaneous Coronary InterventionTreatment

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