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Impact of Crossing Strategy on Intermediate-term Outcomes After Chronic Total Occlusion Percutaneous Coronary
Suwetha Amsavelu1, Georgios E Christakopoulos1, Aris Karatasakis1
1VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas, USA.
Insights
Optimal crossing strategies for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remain debated. This study found antegrade dissection/re-entry and retrograde approaches offer similar outcomes to antegrade wire escalation in CTO PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Controversy exists regarding optimal crossing strategies for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
- The relative merits of antegrade dissection/re-entry versus retrograde approaches in CTO PCI are particularly debated.
- Understanding these strategies is crucial for improving patient outcomes.
Purpose of the Study:
- To compare the clinical outcomes of different CTO PCI crossing strategies.
- To evaluate the effectiveness of antegrade dissection/re-entry and retrograde approaches compared to antegrade wire escalation.
- To identify factors influencing the choice of CTO PCI crossing strategy.
Main Methods:
- Retrospective examination of 173 consecutive patients undergoing successful CTO PCI between January 2012 and March 2015.
- Categorization of successful CTO crossing strategies: antegrade wire escalation, antegrade dissection/re-entry, retrograde wire escalation, and retrograde dissection/re-entry.
- Analysis of patient demographics, lesion characteristics, procedural details, and 12-month clinical outcomes.
Main Results:
- The retrograde approach was more frequently used for lesions with interventional collaterals, moderate/severe calcification, blunt stumps, and higher Japan CTO scores.
- Dissection and re-entry techniques (antegrade and retrograde) were associated with bifurcations, distal caps, longer CTO occlusion length, and longer stent length.
- 12-month outcomes (death, myocardial infarction, composite of ACS/TLR/TVR) were similar across intimal and subintimal crossing strategies.
Conclusions:
- Antegrade dissection/re-entry and retrograde approaches are frequently employed in CTO PCI.
- These strategies demonstrated similarly favorable intermediate-term outcomes compared to antegrade wire escalation.
- The choice of strategy is influenced by lesion characteristics and anatomical complexity.
Background:
There is ongoing controversy about the optimal crossing strategy selection for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially regarding the relative merits of antegrade dissection/re-entry and the retrograde approach.
Methods:
We retrospectively examined the clinical outcomes of 173 consecutive patients who underwent successful CTO PCI at our institution between January 2012 and March 2015.
Results:
The mean age was 65 ± 8 years, and 98% of the patients were men with a high prevalence of diabetes (60%), previous coronary artery bypass grafting (CABG) (31%), and previous PCI (54%). The successful CTO crossing strategy was antegrade wire escalation in 79 patients (45.5%), antegrade dissection/re-entry in 58 patients (33.5%), retrograde wire escalation in 11 patients (6.4%), and retrograde dissection and re-entry in 25 patients (14.5%). The retrograde approach was more commonly used in lesions with interventional collaterals (P < 0.0001), moderate/severe calcification (P = 0.02), blunt stump (P = 0.01), and a higher Japan Chronic Total Occlusion score (P = 0.0002). Use of dissection and re-entry (both antegrade and retrograde) was associated with bifurcation and the distal cap (P = 0.004), longer CTO occlusion length (P < 0.0001), and longer stent length (P < 0.0001). Median follow-up was 11 months. The 12-month incidence of death, myocardial infarction, and the composite of acute coronary syndrome/target lesion revascularization/target vessel revascularization was 2.5%, 4.9%, and 24.4%, respectively, and was similar with intimal and subintimal crossing strategies.
Conclusions:
Antegrade dissection/re-entry and retrograde approaches are frequently used during CTO PCI and were associated with similarly favorable intermediate-term outcomes as antegrade wire escalation.
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