CrossBoss First, REVASC: Evolving trends in CTO PCI

Antegrade dissection and re-entry for antegrade crossing of chronic total occlusions was linked to similar crossing time, success and procedural MACE rates and similar equipment utilization and cost vs. antegrade wire escalation, according to the results of the CrossBoss First trial, presented at TCT 2017.

According to the study, CTO PCI is evolving, and the equipment and technology are rapidly improving, but there is still debate regarding the optimal initial crossing strategy during CTO PCI.

“There are currently several algorithms in different parts of the world for crossing CTOs,” 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 press conference. “The CrossBoss catheter (Boston Scientific) is a catheter designed to do subintimal dissection and has never been tried in a randomized trial to see if upfront use of that catheter is going to improve crossing time.”

Brilakis and colleagues designed a 246-patient, multicenter, randomized controlled trial comparing the upfront use of the coronary CTO crossing catheter and antegrade wire escalation with the primary endpoints of time required to cross the CTO or abort the procedure and the frequency of procedural MACE.

There were well-balanced clinical and angiographic characteristics between the two study groups.

Similar outcomes

The researchers found that rates of technical and procedural success were similarly high in both groups (87.8% and 84.1%, respectively).

Crossing time in the coronary CTO crossing catheter group was 56 minutes (interquartile range, 33-95) and 66 minutes in the wire escalation group (interquartile range, 36-105; P = .323).

A similar nonsignificant rate of procedural MACE was also found between the two groups (3.28% vs. 4.03%), and no significant differences were found in the secondary study endpoints.

Further CTO controversy

A second presentation from Kambis Mashayekhi, MD, from the University Heart Center in Freiburg, Bad Krozingen, Germany, discussing the effects of CTO PCI and no CTO PCI on left ventricular function evaluated whether CTO PCI would improve outcomes vs. optimal medical therapy.

“What we know is that we find CTO in about 18% of patients who are undergoing a diagnostic coronary angiogram, but there is still a debate going on wherever CTO PCI may improve outcomes compared to optimal medical therapy, and this is still a controversial debate,” Mashayekhi said.

The 227-patient REVASC trial had a primary endpoint of an MRI endpoint at 6 months.

According to the presentation from Mashayekhi, CTO PCI did not improve regional or global left ventricular function over no CTO PCI.

The researchers also found that CTO PCI was associated with a trend toward larger improvement in segmental wall thickening vs. no CTO PCI patients.

CTO PCI resulted in clinical benefit over no CTO PCI as evidenced by reduced MACE rates at 12 months. – by Dave Quaile

Reference s :

Brilakis ES. First Report Investigations 2. Presented at: TCT Scientific Symposium; Oct. 29-Nov. 2, 2017; Denver.

Karacsonyi J, et al. JACC Cardiovasc Interv. 2017;doi:10.1016/j.jcin.2017.10.023

Mashayekhi K, et al. First Report Investigations 2. Presented at: TCT Scientific Symposium ; Oct. 29-Nov. 2, 2017; Denver.

Disclosure s : Brilakis reports he receives consultant or speaker honoraria from Abbott Vascular, Amgen, Asahi, CSI, Elsevier, GE Healthcare and Medicure; grant support from Boston Scientific and Osprey; and his spouse is employed by Medtronic. Mashayekhi reports he receives grant/research support from Cordis and consultant fees/honoraria from Abboth, Ashai Intecc, AstraZeneca, Biotronik, Cordis, Daiichi Sankyo and Vascular Solutions.