Cardiovascular Revascularization Medicine Available online 1 August 2018 In Press, Corrected ProofWhat are Corrected Proof articles? Percutaneous coronary intervention of chronic total occlusions: When and how to treat☆☆☆ Author links open overlay panelStefan P.SchumacheraWijnand J.StuijfzandaMaksymilian P.OpolskibAlbert C.van RossumaAlexanderNapaPaulKnaapena https://doi.org/10.1016/j.carrev.2018.07.025Get rights and content Under a Creative Commons license open access Highlights • CTOs have a detrimental effect on patients' quality of life and long-term prognosis. • Patient selection for CTO PCI should be focused on anticipated clinical benefit. • Indication for CTO PCI depends on the presence of symptoms, ischemia and viability. • The hybrid approach has led to technical success rates over 90% in CTO PCI. • The hybrid approach has led to acceptable complication rates in complex CTO PCI. Abstract Chronic coronary total occlusions (CTO) are diagnosed in up to 20% of patients with coronary artery disease and have a detrimental effect on patients' quality of life and long-term prognosis. The exponential developments in CTO percutaneous coronary intervention (PCI) equipment, recanalizationtechniques, and operator expertise have been merged into the hybrid approach that represents a percutaneous revascularization algorithm for treating CTOs and has led to technical success over 90% at experienced centers. Therefore, patient selection for CTO PCI should be focused on anticipated patient benefit in terms of health status and long-term prognosis rather than coronary anatomic complexity. Table of contents This review will provide an overview of the clinical presentation and characteristics of patients with a CTO and will discuss the essential needs toward judicious patient selection for percutaneous CTO revascularization according to contemporary knowledge. Furthermore, the current high standard revascularization techniques in dedicated CTO PCI will be discussed. Abbreviations ADR antegrade dissection and reentry AWE antegrade wire escalation CABG coronary artery bypass graft surgery CAD coronary artery disease CART controlled antegrade and retrograde subintimal tracking CTO chronic coronary total occlusions IRA infarct-related artery J-CTO score Japanese CTO score LAST limited antegrade subintimal tracking LVF left ventricular function MI myocardial infarction OMT optimal medical therapy PCI percutaneous coronary intervention RDR retrograde dissection and reentry RWE retrograde wire escalation STAR subintimal tracking and reentry STEMI ST elevation myocardial infarction TIMI thrombolysis in myocardial infarction Keywords Chronic total occlusion Coronary artery disease Percutaneous coronary intervention 1. Introduction Chronic coronary total occlusions (CTO) can be considered the final stage of obstructive coronary artery disease (CAD) and are associated with a negative impact on long-term prognosis [1]. A CTO is defined as a complete luminal obstruction of a native coronary artery for a duration of ≥3 months. The minimal duration of a CTO is preferably determined by previous coronary angiography or, if unavailable, estimated based on clinical grounds [2]. CTOs are classified by the Thrombolysis in Myocardial Infarction (TIMI) flow grade on invasive coronary angiography as a “true” or “functional” CTO (TIMI flow grade 0 and 1, respectively). In large clinical registries, a CTO has been diagnosed in 16–18,4% of patients with CAD [3,4]. These large registries showed that the current mainstay in the treatment of patients presenting with a CTO is optimal medical therapy (OMT), and only a minority of these individuals receive additional surgical (22–26%) or percutaneous (10–22%) revascularization [3,4]. The general preference for OMT in patients with a CTO originates from the concerns regarding clinical and prognostic patient benefit of revascularization, complexity of CTO percutaneous coronary intervention (PCI) with historically low technical success and high complication rates, high contrast and radiation use, and doubts about the presence of ischemia or viability in the myocardial territory subtended by the occluded artery [5,6]. However, the availability of specialized CTO PCI equipment has been increasingly expanding along with an ongoing progress in percutaneous revascularization techniques and operator expertise [7,8]. This has resulted in enhanced technical success rates from 50–70% to over 90% achieved by high-volume operators [5,[8], [9], [10]]. Therefore, CTO PCI has emerged as a feasible and valuable treatment option warranting new perceptions regarding the traditionally conservative era in CTO treatment. The present review provides an overview of the clinical characteristics and management of patients with a CTO, next to updated perspectives and technical standards in CTO PCI. 2. Clinical presentation of patients with a chronic total occlusion In general, patients with a CTO are older, more frequently male, and have a relatively unfavorable cardiac risk factor profile as compared with patients with non-occlusive CAD [3,4]. A higher prevalence of diabetes mellitus (34 vs. 26%), hypertension (75 vs. 68%), hyperlipidemia (82 vs. 78%), current smoking (33 vs. 24%), peripheral vascular disease (8 vs. 4%) and prior myocardial infarction (MI) (40% vs. 23%) is observed among patients with a CTO as compared to patients with non-occlusive CAD [3]. This observation illustrates that pronounced CAD, as depicted by a CTO, is accompanied by severe comorbidity. An undiagnosed or untreated acute thrombotic event is regularly the origin of CTO development, which is supported by electrocardiographic evidence of pathological Q-waves corresponding to the myocardial territory subtended by an occluded artery in a quarter of patients [3]. However, the majority of patients (60%) with a CTO did not suffer from previous MI [3]. In these patients, the occlusion seems to be the result of long-term gradual luminal narrowing allowing for recruitment of collaterals to the occluded vessel. The recruitment of collaterals has a protective role by supplying myocardial blood flow to the CTO territory and thereby preventing acute myocardial ischemia. Preserved viable myocardium subtended by the occluded artery and absence of cardiac symptoms are therefore common observations [11]. The development of a CTO, either after a thrombotic event or by long-term gradual luminal narrowing, is not reserved to the natural vessel wall only and can occur in a previously implanted stent in patients treated with PCI earlier on [12]. Approximately one out of four patients with a CTO does not experience symptoms [13]. Chest pain is a fairly late expression in the ischemic cascade and symptoms can even be absent in the presence of intermittent moderate-to-severe ischemia [14]. The lack of symptoms may be amplified due to autonomic neuropathy in diabetic patients, whom are strongly represented in the CTO patient population [3]. In symptomatic CTO patients, typical cardiac chest pain may be less prominent than shortness of breath or atypical symptoms including physical activity limitation, extensive fatigue, or palpitations due to ventricular arrhythmias [4,6]. Patients with a CTO and an implantable cardioverter defibrillator for primary or secondary prevention of sudden cardiac death have a higher incidence of appropriate delivered therapies and shocks as compared to patients with ischemic cardiomyopathy without a CTO [15]. A CTO in an infarct-related artery (IRA) has been identified as an independent predictor for the occurrence of ventricular arrhythmias, resulting in a two to three-fold higher recurrence rate, even after ventricular tachycardia ablation [15,16]. It could be hypothesized that an IRA-CTO with additional residual ischemia around the necrotic area and the potentially negative influence on long-term remodeling of myocardial scar acts as an initiator for ventricular arrhythmias [15,16].
Journal of the American College of Cardiology Volume 59, Issue 11, 13 March 2012, Pages 991-997 Clinical Research Interventional Cardiology Current Perspectives on Coronary Chronic Total Occlusions: The Canadian Multicenter Chronic Total Occlusions Registry Author links open overlay panelPaulFeferMD⁎†Merril L.KnudtsonMD‡Asim N.CheemaMD, PhD§P. DianeGalbraithBN, MSc‡Azriel B.OsherovMD⁎SergeyYalonetskyMD⁎SharonGannotBS†MichelleSamuel⁎MaxWeisbrod⁎DanielBierstone⁎John D.SparkesMSc⁎Graham A.WrightPhD⁎Bradley H.StraussMD, PhD⁎ https://doi.org/10.1016/j.jacc.2011.12.007Get rights and content Under an Elsevier user license open archive Objectives The purpose of this study was to determine the prevalence, clinical characteristics, and management of coronary chronic total occlusions (CTOs) in current practice. Background There is little evidence in contemporary literature concerning the prevalence, clinical characteristics, and treatment decisions regarding patients who have coronary CTOs identified during coronary angiography. Methods Consecutive patients undergoing nonurgent coronary angiography with CTO were prospectively identified at 3 Canadian sites from April 2008 to July 2009. Patients with previous coronary artery bypass graft surgery or presenting with acute ST-segment elevation myocardial infarction were excluded. Detailed baseline clinical, angiographic, electrocardiographic, and revascularizationdata were collected. Results Chronic total occlusions were identified in 1,697 (18.4%) patients with significant coronary artery disease (>50% stenosis in ≥1 coronary artery) who were undergoing nonemergent angiography. Previous history of myocardial infarction was documented in 40% of study patients, with electrocardiographic evidence of Q waves corresponding to the CTO arteryterritory in only 26% of cases. Left ventricular function was normal in >50% of patients with CTO. Half the CTOs were located in the right coronary artery. Almost half the patients with CTO were treated medically, and 25% underwent coronary artery bypass graft surgery (CTO bypassed in 88%). Percutaneous coronary intervention was done in 30% of patients, although CTO lesions were attempted in only 10% (with 70% success rate). Conclusions Chronic total occlusions are common in contemporary catheterizationlaboratory practice. Prospective studies are needed to ascertain the benefits of treatment strategies of these complex patients. Previous article in issue Next article in issue Key Words chronic total occlusion coronary artery disease prevalence revascularization treatment Abbreviations and Acronyms ACS acute coronary syndrome(s) CAD coronary artery disease CCS Canadian Cardiovascular Society CTO chronic total occlusion LV left ventricular LVEF left ventricular ejection fraction MI myocardial infarction PCI percutaneous coronary intervention There is growing interest in percutaneous treatment of chronic total occlusions (CTO) in coronary arteries due to improvements in technique and observational evidence that successful treatment of coronary CTO is associated with significant changes in cardiac function and outcome (1, 2, 3, 4, 5, 6). However, there are scant data in the literature about the prevalence, clinical characteristics, and treatment decisions regarding patients identified with CTO during diagnostic coronary angiography, particularly in the contemporary catheterization laboratory setting. Two retrospective studiesfrom the 1990s suggested that the prevalence of CTO in patients with coronary artery disease (CAD) on coronary angiograms ranged from 33% to 52%, depending on the definition of CAD (stenoses either ≥50% or ≥70%) (7, 8). These studies were limited by small numbers (7), and because the retrospective design, information regarding patient and lesion characteristics (including duration of chronicity) was lacking. The purpose of our study was to provide current data on the prevalence of CTO in current catheterization laboratory practice, and to provide detailed clinical and angiographic characteristics, and treatment strategy of patients identified with de novo CTO in a large prospective registry of consecutive patients undergoing coronary angiography at 3 academic Canadian institutions. Methods The Canadian Multicenter CTO Registry is a prospective registry of consecutive CTO patients identified at coronary angiography at 3 participating sites. Permission to collect data was provided by each participating hospital research ethics board. Clinical data regarding sociodemographic characteristics, clinical and comorbid conditions, and left ventricular (LV) function, as well as details of the index occlusion of interest and general coronary anatomy were collected from the APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary heart disease) database, which captures detailed clinical information on patients undergoing coronary angiography (9). The CTO study population was compared to a consecutive cohort of 7,680 patients who were not post-CABG and underwent nonemergent coronary angiography at 2 of the centers during the same period. Specific angiographic characteristics were collected and recorded on the Coronary Artery Reporting and Archiving Tool (CARAT). At 1 of the sites, CTO identification and characteristics were verified with a second review of all angiograms that had been identified as containing CTO by angiography operators.
Journal of the American College of Cardiology Volume 68, Issue 18, 1 November 2016, Pages 1958-1970 Original Investigation The Hybrid Algorithm for Treating Chronic Total Occlusions in Europe: The RECHARGE Registry Author links open overlay panelJorenMaeremansMScabSimonWalshMDcPaulKnaapenMD, PhDdJames C.SprattMDeAlexandreAvranMDfColm G.HanrattyMDcBenjaminFaurieMD, PhDgPierfrancescoAgostoniMDhiErwanBressolletteMDjPeterKayaertMDkAlan J.BagnallMD, PhDlmMohanedEgredMDlmDaveSmithMDnAlexanderChaseMD, PhDnMargaret B.McEntegartMD, PhDoWilliam H.T.SmithMB, BChir, PhDpAlunHarcombeMDpPaulKellyMDq…JosephDensMD, PhDab https://doi.org/10.1016/j.jacc.2016.08.034Get rights and content Under an Elsevier user license open archive Referred to by David R. Holmes, Josep Rodes-Cabau, Emmanouil S. Brilakis In the Country of the Blind, the One-Eyed Man Is King∗ Journal of the American College of Cardiology, Volume 68, Issue 18, 1 November 2016, Pages 1971-1973 Download PDF Abstract Background The hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) was developed to improve procedural outcomes. Large, prospective studies validating the algorithm in a broad multicenter setting with operators of different experience levels are lacking. Objectives The RECHARGE (REgistry of Crossboss and Hybrid procedures in FrAnce, the Netherlands, BelGium and UnitEd Kingdom) registry aims to report achievable results using the hybrid algorithm. Methods Between January 2014 and October 2015, consecutive patients undergoing hybrid CTO-PCI were prospectively enrolled in 17 centers. Procedural techniques, outcomes, and in-hospital complications were analyzed. Results A total of 1,253 CTO-PCIs were performed in 1,177 patients, of which 86% were men. Mean age was 66 ± 11 years. The average Japanese CTO score was 2.0 ± 1.0, and was higher in the failure group (2.6 ± 0.6 vs. 1.9 ± 1.0; p < 0.001). Overall procedure success was 86% and major in-hospital complications occurred in 2.6%. Antegrade wire escalation was the preferred primary strategy in 77%, followed by retrograde (17%) and antegrade dissection re-entry strategies (7%). Primary strategies were successful in 60%. Consecutive strategies were applied in 34% and were successful in 74%. Antegrade dissection re-entry and retrograde strategies were the most common bailout strategies and were successful in 67% and 62%, respectively. Median procedure and fluoroscopy time were 90 (interquartile range [IQR]: 60 to 120) min and 35 (IQR: 21 to 55) min, contrast volume was 250 (IQR: 180 to 340) ml, and radiation doses (air kerma and dose area product) were 1.6 (IQR: 1.0 to 2.7) Gy and 98 (IQR: 57 to 168) Gy·cm2, respectively. Conclusions High procedure and patient success rates, combined with a low event rate and improved procedural characteristics, support further use of the hybrid algorithm for a broad community of appropriately trained CTO operators.
FEATURED Published in Cardiology and Deepak L Bhatt MD, MPH, FACC, FAHA, FSCAI, FESC Interview by Aman Shah MD Get Topic Alerts Anticoagulation for AFib After Percutaneous Coronary Intervention This multimedia content was independently funded and produced by PracticeUpdate. Publication does not constitute representation by PracticeUpdate that the data presented are correct or sufficient to support the conclusions reached. Dr. Shah: So we’re at the ACC meeting in New Orleans, and there’s an interesting trial, the AUGUSTUS trial, that talks about anticoagulation for A-Fib in patients who just had a PCI. Could you tell us a little bit more about this trial? Dr. Bhatt: Sure. This is a several-thousand-patient trial, very well done, randomized, and there are two important parts, the so-called factorial design. One is a randomization of apixaban, a factor Xa inhibitor, sometimes referred to as a NOAC or novel oral anticoagulant, versus warfarin, plain old warfarin, and there’s a second part of randomization, the aspirin or no aspirin. So in these atrial fibrillation patients undergoing PCI or with an ACS, whether there’s typically an indication for DAPT, dual antiplatelet therapy because of the ACS with a stent and an indication for anticoagulation because of the atrial fibrillation, what do you do? And in clinical practice, what many doctors do is so-called triple therapy, full-dose anticoagulation with DAPT. There are a number of studies, randomized studies that already show that’s a bad strategy, that isn’t a good strategy in trials like RE-DUAL and trials like PIONEER, older trials like WOEST as well. And meta-analyses of these trials have shown pretty consistently no loss of efficacy for using double versus triple therapy, but a lot less bleeding with double versus triple therapy as common sense would suggest—three agents, of course, you’re going to bleed more than two. But still, many doctors worry that well, what about a high ischemic risk patient, someone with a left main stent, for example, or a high CHA2DS2-VASc score, can we really get away with a less intense regimen? So AUGUSTUS, I believe, provides a definitive answer where it showed that apixaban had less bleeding than warfarin, but it also showed that placebo had less bleeding than aspirin. Of course, that was going to be the case, but importantly, there was no detectable loss of efficacy with those strategies. So in this trial, it seemed like the winning cocktail then was appropriate dose anticoagulation with apixaban plus a P2Y12 inhibitor, largely it was clopidogrel. And I think one can extrapolate from this and from other trials and say that a strategy of a NOAC plus a second antiplatelet agent, an ADP receptor antagonist, most often clopidogrel, seems to be the way to go as opposed to full-dose anticoagulation with warfarin or a NOAC, but in particular, warfarin plus clopidogrel plus aspirin, that type of triple therapy, I hope now is finally out. Dr. Shah: That does make sense. And would that be your approach in your practice to anticoagulation in PCI patients? Dr. Bhatt: It’s been my approach for a while, really. I felt that the WOEST trial, followed by PIONEER, followed by RE-DUAL provided sufficient evidence for me. But I think now we have really a large bolus of information and a trial that’s designed with a factorial design that says pretty clearly you should omit aspirin from this regimen. You can use whatever anticoagulant you want, warfarin with carefully regulated therapeutic INR, a NOAC, which would be my preference. And I’d say the data separate from here has already shown that NOACs are superior to warfarin as long as there’s careful renal dosing and so forth. And here, apixaban beat warfarin as well. So I think that the mass of data now clearly says don’t use triple therapy, use double therapy. And in general, that will be a NOAC plus an ADP receptor antagonist, most often clopidogrel. Dr. Shah: Wonderful. It’s always great when you get a clear, evidence-based recommendation with very little ambiguity. Dr. Bhatt: Yes, in this case that’s what happened.
