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Hybrid-trained operators achieve high CTO PCI success rates
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Trained operators who used a hybrid intervention approach for chronic total occlusion PCI achieved a 90% overall success rate and a 1.6% rate of MACE at 30 days, according to new data published in Heart.
Researchers collected data on clinical and procedural outcomes of 1,156 patients with CTO lesions who underwent PCI at seven centers between 2012 and 2014. CTO PCI was performed by dedicated CTO operators trained in hybrid techniques, including antegrade/retrograde wire escalation and dissection re-entry. Each case was graded for lesion complexity based on the Multicenter CTO Registry of Japan (J-CTO) score, with 1 point each assigned for the following: non-tapered proximal cap, any calcification, any tortuosity, occlusion length greater than 20 mm and any prior unsuccessful attempt. A score of at least 2 was considered complex.
For this study, procedural success was defined as recovery of TIMI 3 flow with less than 30% residual stenosis. Success was subcategorized as at first attempt or overall.
Despite high mean lesion complexity (mean J-CTO score, 2.5), the hybrid operators attained a 79% success rate on the first attempt. In 41% of failed first attempts, no repeat attempts were performed due to referral for CABG or patient preference for medical treatment. Among those who did undergo repeat attempts (59%), 95% had one repeat attempt, with an 87% success rate achieved ruing the subsequent procedure. This equated to an overall (per-patient) technical success rate of 90% after all attempts.
Success at first attempt was more prevalent in cases with lower J-CTO scores (J-CTO score ≤ 1, 92% vs. J-CTO score ≥ 2, 74%; P < .001).
Independent predictors of first attempt success included no/mild calcification, no proximal cap ambiguity, shorter lesion length, proximal lesion location, no prior CABG, none/mild tortuosity, lower BMI and younger age.
At 30 days, the rate of mortality was 0.3% (n = 3) and the rate of MACE was 1.6%. MACE was more prevalent in unsuccessful procedures (2.5% vs. 0.4%; P < .001).
Antegrade wire escalation achieved a high level of success in less complex lesions (J-CTO score ≤ 1, 94% vs. J-CTO score ≥ 2, 79%). As a final strategy, antegrade dissection re-entry was successful in 81% of J-CTO scores up to 1 and 65% of J-CTO scores of at least 2. Equal success was achieved with retrograde techniques in J-CTO scores up to 1 (77%) and J-CTO scores of at least 2 (77%). Antegrade dissection re-entry/retrograde dissection re-entry was more frequently utilized in complex lesions (J-CTO score ≤1, 15% vs. J-CTO score ≥ 2, 56%). Increased lesion complexity was associated with increased need for multiple approaches during each attempt (17% with J-CTO score ≤ 1 vs. 48% with J-CTO score ≥ 2). The chance of subsequent success was increased by the use of lesion modification at the end of failed first attempts (96% vs. 71%).
“These results should encourage increased adoption of PCI for symptomatic patients with CTO lesions,” the researchers wrote. “Hybrid-trained CTO operators may be best placed to assess the likelihood of successful revascularization, particularly if anatomical complexity is high.” – by Jennifer Byrne
Disclosure: Some of the researchers report various financial ties to Abbott Vascular, Asahi-Intecc, Boston Scientific, Medtronic, Nitiloop, Spectranetics, Vascular Perspectives, Vascular Solutions and Volcano.
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