Single-operator CTO PCI cases confer shorter procedures, similar outcomes vs. multiple
Registry data suggest single-operator PCI cases for chronic total occlusion had lower procedural and fluoroscopy times compared with multiple-operator cases, as well as similar technical and procedural success and risk for complications.
“‘Double‐scrubbing,’ a term often used to refer to interventional procedures involving a collaborative two‐operator approach, is often advocated in CTO PCI to improve patient outcomes,” Yader Sandoval, MD, interventional cardiologist and associate professor of medicine at Minneapolis Heart Institute and Abbott Northwestern Hospital and Center for Coronary Artery Disease, and colleagues wrote in Catheterization and Cardiovascular Interventions. “Some programs have implemented a routine multiple-operator approach for CTO PCI. The presumed advantages are complex procedural shared decision‐making, complementary technical expertise, partnership that can facilitate maintenance and enhancement of procedural skills, and avoidance of a single operator’s mental and technical fatigue.”
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However, the researchers noted that there are limited data on the impact of a second attending operator on CTO PCI outcomes.
Sandoval and colleagues analyzed the association between multiple operators, defined as more than one attending operator, and procedural outcomes of 9,296 CTO PCI procedures performed between 2012 and 2021 at 37 centers.
Across centers, CTO PCI was performed by a single operator in 85% of cases and by multiple operators in 15%. The mean age of patients was 64 years; 81% were men.
The single-operator cases were more complex, with higher Japan‐CTO scores compared with multiple-operator cases (mean, 2.38 vs. 2.28; P = .005) as well as higher PROGRESS-CTO scores (mean, 1.13 vs. 0.97; P < .001) compared with multiple-operator cases.
In multiple-operator cases, mean procedural time (131 minutes vs. 112 minutes; P < .001), fluoroscopy time (49 minutes vs. 42 minutes; P < .001), air kerma radiation dose (2.32 vs. 2.1; P < .001) and contrast volume (230 vs. 210; P < .001) were higher compared with single-operator cases.
Cases performed by multiple operators and single operators had similar technical success rates (86% in both groups; P = .9) and procedural success rates (multiple, 84%; single, 85%; P = .7), as well as major adverse complication event rates (multiple, 2.17%; single, 2.42%; P = .6).
In multivariable analyses, procedures with multiple operators were not associated with higher technical success or lower MACE rates, according to researchers.
“First, a multiple-operator approach is infrequent (15%),” the researchers wrote. “Second, despite the anticipated benefits of double scrubbing, a multiple-operator approach was not associated with higher procedural success or lower complications rates as compared with a single operator approach. Third, CTO PCIs in the multiple-operator group had longer procedural times and were associated with a higher use of radiation and contrast. Fourth, single-operator cases were more often performed by a high‐volume operator as compared with multiple-operator cases.”
The researchers noted that although the study findings do not support a multiple-operator approach for CTO PCIs, it could be beneficial in some cases.
“A multiple-operator approach could help improve individual volumes and facilitate maintenance and growth in PCI skills, as well as allow more exposure to complex cases,” the researchers wrote. “It may also enhance referral of appropriately selected patients for complex procedures. It could also facilitate on‐the‐job training of interventionists with an interest in CTO PCI, including an environment for supervised autonomy and growth and development of junior operators.”
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