Angiographic Features and Clinical Outcomes of Balloon Uncrossable Lesions during Chronic Total Occlusion
Judit Karacsonyi1, Spyridon Kostantinis1, Bahadir Simsek1
1Center for Coronary Artery Disease, Abbott Northwestern Hospital, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN 55407, USA.
Insights
Balloon uncrossable lesions, defined as those impassable by balloon post-guidewire crossing, occurred in 9.2% of chronic total occlusion interventions. These lesions were linked to lower success rates and increased complications.
Area of Science:
- Cardiovascular Medicine and Interventional Cardiology
- Medical Device Technology in Interventional Procedures
Background:
- Balloon uncrossable lesions present a significant challenge in percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs).
- These lesions are defined as those that cannot be crossed with a balloon catheter even after successful guidewire traversal.
Purpose of the Study:
- To investigate the prevalence and procedural outcomes associated with balloon uncrossable lesions during CTO PCI.
- To identify patient and lesion characteristics that predict the occurrence of balloon uncrossable lesions.
- To assess the impact of balloon uncrossable lesions on technical success, procedural success, and major adverse cardiac events (MACE).
Main Methods:
- Analysis of a large multicenter registry including 8671 CTO PCI procedures performed between 2012 and 2022.
- Comparison of procedural outcomes, patient demographics, and lesion characteristics between balloon uncrossable and balloon crossable lesions.
- Statistical analysis to determine the association between balloon uncrossable lesions and procedural success rates and MACE.
Main Results:
- Balloon uncrossable lesions were identified in 9.2% of successfully crossed CTOs.
- These lesions were associated with older patients, higher rates of prior coronary artery bypass graft surgery, diabetes, in-stent restenosis, calcification, and tortuosity.
- Procedures involving balloon uncrossable lesions had longer procedure times, higher radiation doses, lower technical and procedural success rates, and increased MACE.
Conclusions:
- A significant proportion of CTOs present with initially balloon uncrossable lesions, necessitating advanced techniques.
- Balloon uncrossable lesions are independently associated with poorer procedural outcomes and a higher risk of complications.
- Identifying and managing balloon uncrossable lesions is crucial for optimizing CTO PCI success and patient safety.
Abstract:
Background: Balloon uncrossable lesions are defined as lesions that cannot be crossed with a balloon after successful guidewire crossing. Methods: We analyzed the association between balloon uncrossable lesions and procedural outcomes of 8671 chronic total occlusions (CTOs) percutaneous coronary interventions (PCIs) performed between 2012 and 2022 at 41 centers. Results: The prevalence of balloon uncrossable lesions was 9.2%. The mean patient age was 64.2 ± 10 years and 80% were men. Patients with balloon uncrossable lesions were older (67.3 ± 9 vs. 63.9 ± 10, p < 0.001) and more likely to have prior coronary artery bypass graft surgery (40% vs. 25%, p < 0.001) and diabetes mellitus (50% vs. 42%, p < 0.001) compared with patients who had balloon crossable lesions. In-stent restenosis (23% vs. 16%. p < 0.001), moderate/severe calcification (68% vs. 40%, p < 0.001), and moderate/severe proximal vessel tortuosity (36% vs. 25%, p < 0.001) were more common in balloon uncrossable lesions. Procedure time (132 (90, 197) vs. 109 (71, 160) min, p < 0.001) was longer and the air kerma radiation dose (2.55 (1.41, 4.23) vs. 1.97 (1.10, 3.40) min, p < 0.001) was higher in balloon uncrossable lesions, while these lesions displayed lower technical (91% vs. 99%, p < 0.001) and procedural (88% vs. 96%, p < 0.001) success rates and higher major adverse cardiac event (MACE) rates (3.14% vs. 1.49%, p < 0.001). Several techniques were required for balloon uncrossable lesions. Conclusion: In a contemporary, multicenter registry, 9.2% of the successfully crossed CTOs were initially balloon uncrossable. Balloon uncrossable lesions exhibited lower technical and procedural success rates and a higher risk of complications compared with balloon crossable lesions.
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