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Procedural Success and Long-Term Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion in Small
Gal Sella1, Chloe Kharsa1, Yasser M Sammour1
1Department of Cardiology Houston Methodist DeBakey Heart & Vascular Center Houston Texas USA.
Insights
Percutaneous coronary intervention for chronic total occlusions in small vessels has lower procedural success but similar long-term outcomes. Small vessel size significantly impacts guidewire crossing success.
Area of Science:
- Interventional Cardiology
- Cardiovascular Research
- Vascular Medicine
Background:
- Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in small vessels (<3.0 mm) presents unique technical challenges.
- These challenges can impact both the success of the procedure and the patient's long-term health outcomes.
- Understanding these challenges is crucial for improving patient care in interventional cardiology.
Purpose of the Study:
- To compare procedural success and long-term outcomes of CTO PCI in small versus large coronary vessels.
- To identify factors influencing procedural difficulty, particularly guidewire crossing, in small vessel CTOs.
- To evaluate the utility of vessel size in existing complexity scoring systems for CTO PCI.
Main Methods:
- Analysis of 507 consecutive CTO PCI procedures (January 2018-December 2023) in 456 patients.
- Patients were categorized into small vessel (n=178) and large vessel (n=329) groups based on reference diameter.
- Primary endpoint: composite of target lesion revascularization, heart failure hospitalization, myocardial infarction, and stroke at median 704-day follow-up.
Main Results:
- Small vessel CTOs were more prevalent in women and associated with higher rates of diabetes and chronic kidney disease.
- Technical and procedural success rates were significantly lower in small vessels (66.3% and 65.7%) compared to large vessels (88.5% and 88.2%).
- Small vessel size was a strong predictor of guidewire crossing failure (OR 0.31) and did not independently predict worse long-term composite outcomes.
Conclusions:
- CTO PCI in small vessels demonstrates significantly lower procedural success but comparable long-term outcomes to large vessels.
- Vessel size is a critical determinant of procedural difficulty, impacting guidewire crossing.
- Current complexity scoring systems may underestimate small vessel CTO complexity, necessitating further validation and refined techniques.
Background:
Chronic total occlusion (CTO) percutaneous coronary intervention in small vessels (<3.0 mm) poses distinct technical challenges that may affect procedural success and long-term outcomes.
Methods:
We analyzed 507 consecutive CTO percutaneous coronary intervention procedures in 456 patients (January 2018-December 2023), categorized as small vessel (n=178, 35.1%) or large vessel (n=329, 64.9%) by reference vessel diameter. The primary end point was a composite of target lesion revascularization, heart failure hospitalization, myocardial infarction, and stroke at median 704-day follow-up.
Results:
Small vessel CTOs were more frequent in women (27.5% versus 17.3%, P=0.007) and associated with higher rates of diabetes (57.9% versus 45.3%, P=0.007) and chronic kidney disease (42.7% versus 31.0%, P=0.008). Technical success (66.3% versus 88.5%, P<0.001) and procedural success (65.7% versus 88.2%, P<0.001) were lower in small vessels. Composite end point rates were similar at follow-up (19.1% versus 12.4%, P=0.058); large vessel size was not independently protective (hazard ratio, 0.60 [95% CI, 0.34-1.07]). Small vessel size strongly predicted guidewire crossing failure (odds ratio, 0.31 [95% CI, 0.18-0.55], P<0.001). Adding vessel size to Japan CTO score improved discrimination (area under the curve, 0.66 versus 0.60) but yielded unfavorable reclassification.
Conclusions:
CTO percutaneous coronary intervention in small vessels is associated with significantly lower procedural success but comparable long-term outcomes. Vessel size is a strong determinant of procedural difficulty; routine incorporation into complexity scoring requires multicenter validation. Current scoring systems may underestimate the complexity of small vessel CTOs, underscoring the need for refined techniques and careful patient selection.
