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Procedural Success and Outcomes With Increasing Use of Enabling Strategies for Chronic Total Occlusion Intervention
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- Data from the British Cardiovascular Society dataset were analyzed to evaluate the changes in the use of enabling strategies (ESs) during percutaneous coronary intervention for chronic total occlusive disease (CTO-PCI) between 2006 and 2014 and associated outcomes. There was a significant increase in the use of ESs over the study period, which paralleled with a stepwise increase in CTO-PCI success. The rate of CTO-PCI success was 83.8% when three or more ESs were used. The overall rate of CTO-PCI success increased from 55.4% in 2006 to 66.9% in 2014, with the greatest increases in procedural success seen in cases using three or more ESs. There was a significant increase in the rate of coronary perforation from 1.2% with no ES use to 4.0% with the use of three or more ESs. ES use was associated with an increased risk of arterial complications, in-hospital bleeding, in-hospital mortality, and major adverse cardiovascular or cerebrovascular events, but the risk of mortality at 30 days was similar with and without ES use.
- The use of ESs during CTO-PCI was associated with increased success rates. Although ES use increases the risk of complications and major adverse cardiovascular events, there is no associated increase in the mortality risk at 30 days.
abstract
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Access this abstract nowBackground
Enabling strategies (ESs) are increasingly used during percutaneous coronary intervention for chronic total occlusive disease (CTO-PCI), enhancing procedural success. Using the British Cardiovascular Society dataset, we examined changes in the use of ESs and procedural/clinical outcomes for CTO-PCI.Methods and Results
ESs were defined as intravascular ultrasound, rotational/laser atherectomy, dual arterial access, use of microcatheters, penetration catheters or CrossBoss, and procedures categorized by number of ESs used. Data were analysed on all elective CTO-PCI procedures performed in England and Wales between 2006 and 2014. Multivariable logistic regression was used to identify predictors of procedural success. During 28 050 CTO-PCIs, there were significant temporal increases in ES use. There was a stepwise increase in CTO success with increased ES use, with 83.8% of cases successful where ≥3 ESs were used. Overall, CTO-PCI success rate for the whole cohort increased from 55.4% in 2006 to 66.9% in 2014 (P<0.001), but the greatest increase in procedural success was associated with ≥3 ES use. In multivariable analysis, any ES use and the number of ESs used were predictive of procedural success. Coronary perforation increased from 1.2% with zero ES use to 4.0% with ≥3 (P<0.001). After adjustment, although arterial complication, in-hospital bleeding, in-hospital mortality, and major adverse cardiovascular or cerebrovascular events remained more likely with ES use, 30-day mortality was not significantly different between groups.Conclusions
ES use during CTO-PCI was associated with significant improvements in CTO-PCI success. ES use was associated with increased procedural complications and in-hospital major adverse cardiovascular events, but not with 30-day mortality.
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Circulation: Cardiovascular Interventions
Although chronic total occlusion percutaneous coronary interventions (CTO PCI) can be performed with high success (85-90%) and acceptable complication rates (approximately 3%) at experienced centers, outcomes in non-selected centers have been less favorable. In an analysis from NCDR, success was 55.5% in 2009 and increased to 61.9% in 2013, but limited information was provided on techniques used). Kinnaird et al. provide a dense and insightful analysis of success and complications rates of CTO PCI in England and Wales (BCIS registry). The CTO-PCI success rate increased from 55.4% in 2006 to 66.9% in 2014. Higher operator volume and higher use of enabling strategies (dual injection, intravascular ultrasound, atherectomy, penetration catheters, microcatheters, or CrossBoss/Stingray balloon) were associated with higher procedural success but also higher risk for complications.
This BCIS study highlights the progress achieved in CTO PCI in recent years and the importance of implementing various CTO crossing strategies during the same procedure—a concept emphasized in various CTO crossing algorithms, such as the hybrid algorithm and the Asia Pacific algorithm. At the same time, it demonstrates that CTO PCI is associated with increased risk for complications, especially with use of multiple crossing or other “enabling” strategies (although 30-day mortality was not increased). Estimating the balance between potential benefits and risks for every patient with coronary CTOs should be the basis for deciding whether CTO PCI should be performed and how aggressive the CTO PCI attempts should be.