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CTO PCI for stable CAD infrequent, but growing in US
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From July 2009 to March 2013, chronic total occlusion PCI accounted for 3.8% of the total PCI volume for patients with stable CAD in the National Cardiovascular Data Registry CathPCI Registry. CTO PCI was associated with lower procedural success and higher complication rates compared with non-CTO PCI, but greater operator experience was associated with better outcomes.
Researchers evaluated the frequency, success and outcomes of CTO PCI compared with non-CTO PCI in elective patients with stable CAD.
Emmanouil S. Brilakis, MD, PhD, from the VA North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas and Cardiology Today’s Intervention Editorial Board member, and colleagues reported that the use of CTO PCI ranged from 0% to 44% across U.S. centers. Although CTO PCI represented a low proportion of total PCI volume for this population, its use has increased in recent years, from 3.2% in 2009 to 4.8% in 2013.
Emmanouil S. Brilakis
The overall procedural success rate was 59% for CTO PCI vs. 96% for non-CTO PCI (P < .001) and varied across centers and operators. During the study period, however, procedural success with CTO PCI significantly increased, from 55.5% in 2009 to 61.9% in 2013 (P < .001). Success was highest (75%) for operators who performed more than 10 CTO PCI procedures per year and lower (52%) for those who performed fewer than five procedures per year. CTO PCI was also associated with increased contrast volume and fluoroscopy time compared with non-CTO PCI. Older age, current smoking, right coronary artery CTO target vessel, less operator experience, and history of cardiac arrest, MI, CABG and peripheral arterial disease were predictors of poorer success, according to multivariate analyses.
The MACE rate was 1.6% for patients who underwent CTO PCI vs. 0.8% for non-CTO PCI (P < .001). However, MACE after CTO PCI declined from 1.9% in 2009 to 1.3% in 2013. The incidence of MACE was also lower among more-experienced operators; the average MACE rate for operators who performed more than 10 CTO PCIs per year was 1% and the average rate for sites that performed more than 30 CTO PCIs per year was 0%. The researchers also reported that successful CTO PCI was associated with lower in-hospital mortality compared with failed CTO PCI (0% vs. 1.1%; P < .001).
“Although the overall results are a sobering reminder that CTO PCI remains a relatively low-yield undertaking, the report makes several positive observations that could improve clinical outcomes,” John A. Bittl, MD, of Munroe Regional Medical Center in Ocala, Florida, wrote in an accompanying editorial.
“Because CTO PCI is challenging, achieving success often requires inventive approaches. In order to transcend the natural limitations of CTOs, interventional cardiologists might consider the philosophical tool of ‘negative thinking’ to replace one-dimensional techniques with multidimensional strategies, augment the antegrade route with retrograde approached, supplement a narrow selection of devices with a broad assortment of new wires and microcatheters, and so transform CTO PCI failures into clinical successes,” Bittl wrote.
Disclosure: Brilakis reports receiving consulting honoraria/speaker fees from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Somahlution, St. Jude Medical and Terumo; a research grant from Guerbet and InfraRedx; and his spouse is an employee of Medtronic. Bittl reports no relevant financial disclosures.
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