Journal Article

Hybrid approach improves success of chronic total occlusion angioplasty

Hanratty, C G, Douglas, H, Oldroyd, K G, Smith, E, McEntegart, M, Yan, A T, Walsh, S J, Egred, M, Irving, J, Strange, J, Wilson, W M, Bagnall, A J, Spratt, J C

2016

Overview

Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques. Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan (J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30% residual stenosis, subclassified as at first attempt or overall. Inhospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded. 1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79% (first attempt) and 90% (overall) with 30-day MACE of 1.6%. AWE was highly effective in less complex lesions (J-CTO ≤1 94% success vs 79% in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions (J-CTO≤1 15% vs J-CTO ≥2 56%). Need for multiple approaches during each attempt increased with lesion complexity (17% J-CTO ≤1 vs 48% J-CTO ≥2). Lesion modification ('investment procedures') at the end of unsuccessful first attempts increased the chance of subsequent success (96% vs 71%). Hybrid-trained operators can achieve overall success rates of 90% in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.

• Subject: Aged / Chronic Disease / Collateral Circulation / Coronary Angiography / Coronary Circulation / Coronary Occlusion - diagnostic imaging / Coronary Occlusion - mortality / Coronary Occlusion - physiopathology / Coronary Occlusion - therapy / Female / Humans / Male / Middle Aged / Percutaneous Coronary Intervention - adverse effects / Percutaneous Coronary Intervention - methods / Percutaneous Coronary Intervention - mortality / Registries / Risk Factors / Time Factors / Treatment Outcome / United Kingdom / Vascular Patency