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Coronary artery spatial distribution of chronic total occlusions: Insights from a large US registry
Santiago Garcia1, M Chadi Alraies1, Aris Karatasakis2
1Minneapolis VA Medical Center and University of Minnesota, Minneapolis, Minnesota.
Insights
Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) most commonly targets proximal segments. Despite complex factors, proximal CTO PCI achieves high success rates with low complications.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Vascular Biology
Background:
- Acute coronary occlusions often occur in the proximal coronary artery due to plaque rupture.
- Understanding the spatial distribution of chronic total occlusions (CTOs) is crucial for effective intervention.
Purpose of the Study:
- To analyze the spatial distribution of coronary chronic total occlusions (CTOs).
- To describe procedural strategies and outcomes for CTO percutaneous coronary intervention (PCI) based on lesion location.
Main Methods:
- A retrospective analysis of 1,348 patients undergoing CTO PCI.
- Lesions were categorized by location: proximal, mid, or distal coronary segments.
- Clinical and procedural characteristics were compared across these locations.
Main Results:
- CTO PCI most frequently involved proximal segments (46%), followed by mid (41%) and distal (13%).
- Proximal CTOs were associated with longer length, ambiguous caps, and higher calcification.
- While proximal CTO PCI required more contrast and fluoroscopy time, and a higher rate of retrograde approach, success rates and complication rates were similar across all segments.
Conclusions:
- Proximal coronary segments are the most common targets for CTO PCI.
- CTO PCI in proximal segments presents greater complexity but yields comparable high procedural and technical success rates with low complication rates compared to mid and distal segments.
Objective:
To assess the spatial distribution of chronic total occlusions (CTOs) within the coronary arteries and describe procedural strategies and outcomes during CTO percutaneous coronary intervention (PCI).
Background:
Acute occlusions due to plaque rupture tend to cluster within the proximal third of the coronary artery.
Methods:
We examined the clinical and procedural characteristics of 1,348 patients according to lesion location within the coronary tree.
Results:
A total of 1,369 lesions in 1,348 patients (mean age 66 ± 10 years, 85% male) were included. CTO PCI of proximal segments (n = 633, 46%) was more common than of mid (n = 557, 41%) and distal segments (n = 179, 13%). Patients undergoing CTO PCI of proximal segments were more likely to be smokers (P < 0.01), have prior coronary artery bypass graft surgery (P = 0.03) and lower ejection fraction (P = 0.04). CTOs occurring in proximal segments had longer length (P <0.01), proximal cap ambiguity (P < 0.01), and moderate/severe calcification (P < 0.01) compared to mid or distally located CTOs. Interventional collaterals were more often present in CTO PCI of proximal segments (64%, 53%, 56%, P < 0.01) consistent with the higher use of retrograde approach (47%, 33%, 37%, P < 0.01) relative to antegrade wire escalation (67%, 82%, 82%, P < 0.01). Procedural complexity was higher in CTO PCI of proximal segments (vs. mid and distal): contrast volume= 275 ml (200-375), 260 ml (200-350), 250 ml (175-350), P = 0.01; fluoroscopy time 53 minutes (32-83), 39 minutes (24-65), 40 minutes (22-72), P < 0.01. However, procedural success (87%, 90%, 85%, P = 0.1), technical success (89%, 91%, 88%, P = 0.24), and complications rates (2.8%, 2.5%, 2.2%, P = 0.88) were not different.
Conclusions:
The most common target vessel location for CTO PCI is the proximal coronary segment. PCI of proximal occlusions is associated with adverse clinical and angiographic characteristics and often requires use of the retrograde approach, but can be accomplished with high procedural and technical success and low complication rates. © 2016 Wiley Periodicals, Inc.
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