Expert reviews updates from Progress CTO registry

Updated data from the Progress CTO registry offer insight into success and complication rates with chronic total occlusion PCI and risk estimates that can support treatment decisions.

Currently, the technical success rate of CTO PCI in the Progress CTO registry is 88% and the major complication rate is 2.6%, Emmanouil S. Brilakis, MD, PhD, director of the Center for Advanced Coronary Interventions at the Minneapolis Heart Institute, adjunct professor of medicine at the University of Texas Southwestern Medical School and a Cardiology Today’s Intervention Editorial Board member, said during a presentation at the Chronic Total Occlusion Summit.

Despite high success rates, the question of when to perform CTO PCI requires careful consideration, Brilakis noted.

Emmanouil S. Brilakis

“The benefit [of CTO PCI] depends on the patient’s presentation, including symptoms, ischemia and MI, as well as the likelihood of success,” he said. “However, we should not forget about the potential risk.”

To provide patients a numeric estimate regarding individual risk–benefit with CTO PCI, the researchers developed a score that is designed to determine the likelihood of technical success. It includes four components: proximal cap ambiguity, lack of interventional collaterals, moderate or severe tortuosity and circumflex CTO. As the score increases, the likelihood of technical success decreases.

The score also accounts for three major predictors of complications: older age, lesion length 23 mm and use of the retrograde approach for CTO PCI.

CTO PCI technique appears to have a significant effect on complication and success rates, Brilakis noted. Although rates differed little between use of antegrade wiring and antegrade dissection re-entry, compared with antegrade-only approaches, the retrograde approach was associated with lower rates of technical (84.8% vs. 93.7%; P < .001) and procedural success (81.9% vs. 93.3%; P < .001), as well as higher rates of complications, including MACE (4.3% vs. 1.1%; P < .001), MI (2.1% vs. 0.3%; P = .003) and pericardiocentesis (1.3% vs. 0.3%; P = .039).

“There’s no question that the retrograde approach is effective in getting success rates higher, but it does carry an increased risk for complications, and that’s a factor to be considered,” Brilakis said.

Nevertheless, he noted that the retrograde approach and antegrade dissection re-entry are important for more complex cases. For example, the need for use of antegrade dissection re-entry and the retrograde approach increases with increasing Multicenter CTO Registry of Japan (J-CTO) score.

The updated registry data also revealed wide variability in contrast volume and radiation dose, suggesting that there is opportunity for improving the safety of CTO PCI, according to Brilakis. Additionally, the researchers noted that the prevalence of uncrossable lesions has increased to 9%. Most were treated with small balloons, but laser and rotational atherectomy have become more common.

Brilakis also underscored the need to prevent side-branch loss due to the risk for subsequent clinical events and the importance of intravascular imaging for optimizing the results of CTO PCI. – by Melissa Foster

Reference:

Brilakis ES. Progress CTO registry update. Presented at: Chronic Total Occlusion Summit; Feb. 23-24, 2017; New York.

Disclosure: Brilakis reports receiving consultant or speaker honoraria from Abbott Vascular, Asahi, Cardinal Health, Elsevier and GE Healthcare; grant support from Boston Scientific and InfraRedx; and his spouse is employed by Medtronic.