Success, event rates similar after PCI for in-stent, de novo CTO
PCI for in-stent chronic total occlusion had similar success rates and in-hospital complications compared with PCI for de novo CTO, according to data presented at the virtual Society for Cardiovascular Angiography and Interventions Scientific Sessions.
Results from this study were also published in JACC: Cardiovascular Interventions.
Evangelia Vemmou, MD, research fellow at the Minneapolis Heart Institute Foundation, and colleagues analyzed data from the PROGRESS-CTO registry of 5,667 CTO PCIs performed on 5,547 patients between 2012 and 2020. Of the patients in the study, 894 underwent PCI of in-stent CTO (mean age, 64 years; 83% men) and 4,653 underwent de novo CTO PCIs (mean age, 65 years; 83% men).
Technical success was defined as successful CTO revascularization with restoration of TIMI grade 3 antegrade flow and less than 30% residual diameter stenosis within the treated segment. Researchers defined procedural success as the combination of technical success and no in-hospital complications.
Patients who underwent PCI for in-stent CTO were more likely to have dyslipidemia (93% vs. 88%; P < .0001), diabetes (49% vs. 42%; P = .0002), prior MI (59% vs. 44%: P < .0001) and hypertension (95% vs. 90%; P < .0001) compared with those who underwent de novo CTO. These patients also had a higher mean J-CTO score (2.6 vs. 2.4; P = .0002).
Both in-stent CTO and de novo CTO groups had similar rates of technical (85% vs. 86%, respectively; P = .2) and procedural success (83% vs. 85%, respectively; P = .21). Patients in the in-stent CTO group had lower contrast volume (210 mL vs. 240 mL; P < .0001) and the risk for perforation (3.4% vs. 4.9%; P = .397) compared with those in the de novo CTO group. No differences were observed in pericardiocentesis rates in both groups (in-stent CTO, 0.6% vs. de novo CTO, 0.9%; P = .2).
“Our findings suggest that in-stent CTO PCI is feasible with similar success rates as de novo CTO PCI, likely due to increasing expertise in CTO PCI and equipment developments over time,” Vemmou and colleagues wrote. – by Darlene Dobkowski
References:
Nikolakopoulos I, et al. Abstract I-80. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; May 14-16, 2020 (virtual meeting).
Vemmou E, et al. JACC Cardiovasc Interv. 2020;doi:10.1016/j.jcin.2020.05.003.
Disclosures: Nikolakopoulos and Vemmou reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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The excellent outcomes for in-stent CTOs is the first takeaway. The biggest question is that, in 2020, stent implantation must be done right the first time using appropriate tools like imaging, lesion preparation and appropriate stent sizing. The problem is the legacy left behind from cavalier angiographic-based stent sizing done years ago. Once a stent occludes, it becomes a big challenge. Restenosis, when focal, can be dealt with so much more easily than when it is a 100% occlusion.
If a stent is 100% occluded, then we need to ask ourselves why did this happen? Was the implanted stent undersized? Was the run-off too poor? A mechanical issue is frequently found to be the etiology of this problem.
The challenge encountered with these procedures is that sometimes the wires and catheters we use to open these 100% occluded stents can get behind the stent. The good news is that the study shows that CTOs can be opened up with roughly the same degree of efficiency and success and with the same complication rate as other types of CTOs.
A stent should not impact your decision of whether a PCI is performed for CTO. It should all be based on clinical information and patient-related symptoms.
If we can find a technology device either with imaging or otherwise that prevents you from getting behind the struts of these stents that we put in vessels, it would prevent us from running into technical challenges from opening up these vessels. This includes imaging and, potentially, methods and technologies to prevent us from getting behind the stent.
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Vemmou E, et al. JACC Cardiovasc Interv. 2020;doi:10.1016/j.jcin.2020.05.003.