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Association of Proximal Vessel Tortuosity with Technical Success and Clinical Outcomes: Analysis From the
Dimitrios Strepkos1, Athanasios Rempakos1, Michaella Alexandrou1
1Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.
Insights
Proximal vessel tortuosity independently lowers technical success in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). High-volume operators achieve success in tortuous vessels but face increased perforation risks.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Proximal vessel tortuosity presents challenges in delivering equipment during chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
- Understanding the impact of tortuosity on CTO PCI outcomes is crucial for procedural planning and patient management.
Purpose of the Study:
- To investigate the association between proximal vessel tortuosity and both short- and long-term clinical outcomes in patients undergoing CTO PCI.
- To evaluate the role of operator volume in managing tortuous vessels during CTO PCI.
Main Methods:
- A retrospective analysis of 14,141 patients undergoing CTO PCI across 50 international centers (2012-2024).
- Assessment of moderate or severe proximal vessel tortuosity and its correlation with patient comorbidities, angiographic characteristics, procedural metrics, and clinical outcomes.
- Multivariable analysis was used to determine independent associations, with subgroup analysis for high-volume operators.
Main Results:
- 28.1% of patients had moderate or severe proximal vessel tortuosity, associated with more comorbidities and complex lesions.
- Moderate/severe tortuosity correlated with longer procedure and fluoroscopy times, lower technical success (OR: 0.77; 95% CI: 0.67, 0.89), and similar major adverse cardiac events (MACE).
- High-volume operators (>30 cases/year) demonstrated higher technical and procedural success in tortuous lesions but had an increased risk of perforation (6.49% vs. 3.57%).
Conclusions:
- Moderate to severe proximal vessel tortuosity is an independent predictor of lower technical success in CTO PCI.
- While not associated with increased MACE, tortuosity necessitates careful consideration of procedural risks, particularly perforation in high-volume settings.
- Operator experience plays a significant role in navigating complex tortuous anatomy during CTO PCI.
Background:
Proximal vessel tortuosity can hinder wiring and equipment delivery during chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
Aims:
We sought to examine the association of proximal vessel tortuosity with the short and long-term outcomes of patients undergoing CTO PCI.
Methods:
We examined the association of proximal vessel tortuosity with clinical outcomes in patients who underwent CTO PCI at 50 US and non-US centers between 2012 and 2024.
Results:
Of 14,141 patients, 3,974 (28.1%) had moderate or severe proximal vessel tortuosity. Patients with moderate or severe proximal vessel tortuosity had more comorbidities and more complex angiographic characteristics, such as longer lesion length and higher prevalence of side branch at the proximal cap. Lesions with moderate or severe proximal tortuosity required greater procedure and fluoroscopy time. On unadjusted analyses, moderate/severe proximal vessel tortuosity was associated with lower technical success and higher incidence of major adverse cardiac events (MACE). In multivariable analysis, moderate/severe proximal vessel tortuosity was associated with lower technical success (odds ratio [OR]: 0.77; 95% confidence intervals [CI]: 0.67, 0.89) but similar MACE (OR: 1.26; 95% CI: 0.91, 1.73). Higher operator volume (≥ 30 CTO PCI cases per year) was associated with higher technical (85.2% vs. 75.6%, p < 0.001) and procedural success (83.6% vs. 74.5%, p < 0.001) but also higher risk of perforation (6.49% vs. 3.57%, p < 0.001) but not pericardiocentesis, in lesions with moderate/severe proximal vessel tortuosity.
Conclusions:
Moderate or severe proximal vessel tortuosity is independently associated with lower technical success in CTO PCI but not with MACE. High-volume operators are more likely to successfully perform CTO PCI in lesions with moderate/severe tortuosity at the cost of higher risk of perforation, without higher MACE.
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