Related Experiment Videos
The hybrid algorithm in treatment of coronary chronic total occlusions - MSWiA Lublin CTO 5-year registry
Drozd Jakub1, Marcin Kowalski1, Tomasz Wołyniak1
1Department of Cardiology, SP ZOZ MSWiA, Lublin, Poland.
Insights
The hybrid algorithm for percutaneous coronary intervention (PCI) in chronic total occlusions (CTO) demonstrates high success rates and low complications. This strategy facilitates wider adoption of CTO PCI, especially for complex cases.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Treatment of coronary artery chronic total occlusions (CTO) remains challenging, often limited to specialized centers.
- The hybrid algorithm offers a structured approach to improve procedural success and accessibility of CTO percutaneous coronary intervention (PCI).
Purpose of the Study:
- To evaluate the efficacy and safety of the hybrid algorithm for CTO PCI in a consecutive patient series.
- To analyze procedural outcomes based on lesion complexity using the J-CTO score.
Main Methods:
- A prospective registry collected data on 266 patients undergoing 285 CTO PCI procedures between January 2015 and September 2019.
- Lesion complexity was assessed using the J-CTO score, and strategies included antegrade and retrograde approaches.
- Angiographic success was defined as <30% residual stenosis with TIMI 3 flow; complications were systematically recorded.
Main Results:
- An overall procedural success rate of 87.7% was achieved, with patient-based success at 92.5%.
- Higher J-CTO scores correlated with increased use of complex strategies and a trend towards lower success rates (83.4% for J-CTO ≥ 3).
- In-hospital Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) rate was 3.5%, including one death, myocardial infarction in 3.2%, and coronary perforations in 2.5%.
Conclusions:
- The hybrid algorithm is effective for CTO PCI, yielding good early outcomes and manageable complication rates.
- While successful, complex CTOs necessitate more intricate procedural strategies and are associated with reduced success rates.
Introduction:
Treatment of chronic total occlusions (CTO) despite improvement in techniques and results over the last years still seems to be limited to a small number of centres and operators. Application of the hybrid strategy may support further spread of CTO percutaneous coronary intervention (PCI) and increase procedural success rates.
Aim:
Our single-centre prospective ongoing registry aims to provide details and results of recanalizations of coronary CTO performed according to the hybrid algorithm in a series of consecutive patients.
Material And Methods:
Between January 2015 and September 2019 the clinical and procedural data of CTO PCI procedures on consecutive patients were collected. Lesion complexity was assessed according to the Multicenter CTO Registry of Japan (J-CTO) score: 0 - easy, 1 - intermediate, 2 - difficult, ≥ 3 - very difficult and PROGRESS score. Strategies applied were classified as: antegrade wire escalation (AWE), antegrade dissection and re-entry (ADR), retrograde wire escalation (RWE) and retrograde dissection and re-entry (RDR). Angiographic success was defined as < 30% residual stenosis with TIMI 3 flow. Angiographic and clinical complications were reported.
Results:
Two hundred sixty-six patients were included and 285 procedures were performed in total. Success rate was 87.7% (calculated per procedure) and 92.5% (calculated per patient). Four patients underwent successful staged double CTO recanalization. Fifteen patients out of 31 primary failures underwent a second attempt with a 73% success rate (11/15). Fifty-two patients (18.2%) were referred for a second attempt from other institutions. Mean J-CTO score was 2.6 (13 cases with J-CTO of 0, 41 cases with J-CTO of 1, 80 cases with J-CTO of 2, and 151 cases with J-CTO ≥ 3) and the success rate was respectively 92.3%, 95.1%, 91.3% and 83.4%. Higher complexity of occlusion required a higher number of applied strategies including retrograde access in over a quarter of cases. Complete revascularization was achieved in 215 (75.4%) cases. In-hospital MACCE rate was 3.5% - 1 patient died due to acute kidney injury complications, 9 (3.2%) patients sustained myocardial infarction (1 STEMI due to side branch occlusion). All 7 (2.5%) coronary perforations (Ellis 1 and Ellis 2) were treated conservatively and we recognised 10 (3.5%) cases of acute kidney injury (one dialysis).
Conclusions:
The hybrid algorithm in CTO PCI can be successfully applied with good early results and low complication rates. Higher complexity CTOs require more procedural strategies with a significantly lower success rate in very difficult cases.