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Canadian Journal of Cardiology

High Stakes: CTO-PCI in the Post-CABG Patient

  • Brian J. Potter
    Correspondence
    Corresponding author: Dr Brian J. Potter, Carrefour de l'innovation et évaluation en santé (CIÉS), Centre de recherche du CHUM (CRCHUM), Cardiology & Interventional Cardiology, CHUM, Pavillon S, S03-334, 850, rue St-Denis, Montréal, Quebec H2X 0A9, Canada. Tel.: +1-514-890-8000, ext. 15471; fax: +1-514-412-7212.
    Affiliations
    Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada

    Carrefour de l'innovation et de l’évaluation en santé, Centre de Recherche du CHUM, Montréal, Quebec, Canada
    Search for articles by this author
  • Alexis Matteau
    Affiliations
    Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada

    Carrefour de l'innovation et de l’évaluation en santé, Centre de Recherche du CHUM, Montréal, Quebec, Canada
    Search for articles by this author
  • Nicolas Noiseux
    Affiliations
    Cardiac Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada

    Axe cardiométabolique, Centre de Recherche du CHUM, Montréal, Quebec, Canada
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  • Samer Mansour
    Affiliations
    Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada

    Axe cardiométabolique, Centre de Recherche du CHUM, Montréal, Quebec, Canada
    Search for articles by this author
Published:December 27, 2017DOI:https://doi.org/10.1016/j.cjca.2017.12.022
      Chronic total occlusions (CTOs) represent a technically challenging subset of obstructive coronary lesions that are found in approximately one-third of patients with atherosclerotic coronary disease.
      • Kearney K.
      • Hira R.S.
      • Riley R.F.
      • Kalyanasundaram A.
      • Lombardi W.L.
      Update on the management of chronic total occlusions in coronary artery disease.
      While CTO percutaneous coronary intervention (PCI) techniques and specialized equipment continue to evolve, the so-called “hybrid approach” algorithm has quickly gained favour, offering a success rate of more than 80%.
      • Wilson W.M.
      • Walsh S.J.
      • Yan A.T.
      • et al.
      Hybrid approach improves success of chronic total occlusion angioplasty.
      • Walsh S.J.
      • Hanratty C.G.
      • Spratt J.C.
      Optimal approach to percutaneous intervention for CTO in 2017: a hybrid strategy is now the preferred choice.
      • Pershad A.
      • Eddin M.
      • Girotra S.
      • et al.
      Validation and incremental value of the hybrid algorithm for CTO PCI.
      • Maeremans J.
      • Walsh S.
      • Knaapen P.
      • et al.
      The hybrid algorithm for treating chronic total occlusions in Europe: the RECHARGE Registry.

      Daniels DV, Banerjee S, Alaswad K, et al. Safety and efficacy of the hybrid approach in coronary chronic total occlusion percutaneous coronary intervention: The Hybrid Video Registry [e-pub ahead of print]. Catheter Cardiovasc Interv https://doi.org/10.1002/ccd.26501. Accessed January 30, 2018.

      • Christopoulos G.
      • Menon R.V.
      • Karmpaliotis D.
      • et al.
      The efficacy and safety of the “hybrid” approach to coronary chronic total occlusions: insights from a contemporary multicenter US registry and comparison with prior studies.
      • Brilakis E.S.
      • Grantham J.A.
      • Rinfret S.
      • et al.
      A percutaneous treatment algorithm for crossing coronary chronic total occlusions.
      There has been much recent interest in the literature in predicting procedural success with a view to improving patient selection and the informed consent process. Indeed, according to a quick count, no less than 5 clinical scores have been evaluated in CTOs to various extents, including patients with previous coronary artery bypass graft (CABG).
      • Morino Y.
      • Abe M.
      • Morimoto T.
      • et al.
      Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool.
      • Nombela-Franco L.
      • Urena M.
      • Jerez-Valero M.
      • et al.
      Validation of the J-chronic total occlusion score for chronic total occlusion percutaneous coronary intervention in an independent contemporary cohort.
      • Nagashima Y.
      • Iijima R.
      • Nakamura M.
      • Sugi K.
      Utility of the SYNTAX score in predicting outcomes after coronary intervention for chronic total occlusion.
      • Opolski M.P.
      • Achenbach S.
      • Schuhback A.
      • et al.
      Coronary computed tomographic prediction rule for time-efficient guidewire crossing through chronic total occlusion: insights from the CT-RECTOR multicenter registry (Computed Tomography Registry of Chronic Total Occlusion Revascularization).
      • Karatasakis A.
      • Danek B.A.
      • Karmpaliotis D.
      • et al.
      Comparison of various scores for predicting success of chronic total occlusion percutaneous coronary intervention.
      • Danek B.A.
      • Karatasakis A.
      • Karmpaliotis D.
      • et al.
      Development and validation of a scoring system for predicting periprocedural complications during percutaneous coronary interventions of chronic total occlusions: the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) Complications Score.
      • Christopoulos G.
      • Kandzari D.E.
      • Yeh R.W.
      • et al.
      Development and validation of a novel scoring system for predicting technical success of chronic total occlusion percutaneous coronary interventions: the PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Score.
      • Roller F.C.
      • Harth S.
      • Rixe J.
      • Krombach G.A.
      • Schneider C.
      Development and suggestion of a cardiac CTA scoring system for the prediction of revascularization success in chronic total occlusions (CTO) of the coronary arteries.
      • Ellis S.G.
      • Burke M.N.
      • Murad M.B.
      • et al.
      Predictors of successful hybrid-approach chronic total coronary artery occlusion stenting: an improved model with novel correlates.
      • Tan Y.
      • Zhou J.
      • Zhang W.
      • et al.
      Comparison of CT-RECTOR and J-CTO scores to predict chronic total occlusion difficulty for percutaneous coronary intervention.
      • Forouzandeh F.
      • Suh J.
      • Stahl E.
      • et al.
      Performance of J-CTO and PROGRESS CTO scores in predicting angiographic success and long-term outcomes of percutaneous coronary interventions for chronic total occlusions.
      In addition to scores on the basis of regional registries (Registry of CrossBoss and Hybrid Procedures in France, the Netherlands, Belgium and United Kingdom [RECHARGE] in Europe,

      Maeremans J, Spratt JC, Knaapen P, et al. Towards a contemporary, comprehensive scoring system for determining technical outcomes of hybrid percutaneous chronic total occlusion treatment: the RECHARGE score [e-pub ahead of print]. Catheter Cardiovasc Interv https://doi.org/10.1002/ccd.27092. Accessed January 30, 2018.

      Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS-CTO] in the United States,
      • Danek B.A.
      • Karatasakis A.
      • Karmpaliotis D.
      • et al.
      Development and validation of a scoring system for predicting periprocedural complications during percutaneous coronary interventions of chronic total occlusions: the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) Complications Score.
      • Christopoulos G.
      • Kandzari D.E.
      • Yeh R.W.
      • et al.
      Development and validation of a novel scoring system for predicting technical success of chronic total occlusion percutaneous coronary interventions: the PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Score.
      and Japanese Chronic Total Occlusion [J-CTO] score in Japan
      • Morino Y.
      • Abe M.
      • Morimoto T.
      • et al.
      Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool.
      • Nombela-Franco L.
      • Urena M.
      • Jerez-Valero M.
      • et al.
      Validation of the J-chronic total occlusion score for chronic total occlusion percutaneous coronary intervention in an independent contemporary cohort.
      • Christopoulos G.
      • Wyman R.M.
      • Alaswad K.
      • et al.
      Clinical utility of the Japan-Chronic Total Occlusion Score in coronary chronic total occlusion interventions: results from a multicenter registry.
      ), these include scores more familiar to the non-CTO operator (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery [SYNTAX] Score
      • Nagashima Y.
      • Iijima R.
      • Nakamura M.
      • Sugi K.
      Utility of the SYNTAX score in predicting outcomes after coronary intervention for chronic total occlusion.
      ) as well as scores that rely on advanced imaging techniques (Computed Tomography Registry of Chronic Total Occlusion Revascularization [CT-RECTOR]
      • Opolski M.P.
      • Achenbach S.
      • Schuhback A.
      • et al.
      Coronary computed tomographic prediction rule for time-efficient guidewire crossing through chronic total occlusion: insights from the CT-RECTOR multicenter registry (Computed Tomography Registry of Chronic Total Occlusion Revascularization).
      • Tan Y.
      • Zhou J.
      • Zhang W.
      • et al.
      Comparison of CT-RECTOR and J-CTO scores to predict chronic total occlusion difficulty for percutaneous coronary intervention.
      ). Overall, however, these scores have tended to perform modestly in external validation studies, assessed using the area under the receiver operating curve method (approximately 0.6-0.7 depending on the study and outcome of interest). Reasons for this include the evolution of PCI techniques and equipment over time, the establishment of dedicated high-volume CTO operators and centres, in addition to differences in approach to CTO PCI in different regions.
      In this issue of the Canadian Journal of Cardiology, Azzalini et al. report on the performance of the J-CTO as well as the RECHARGE scores in an international cohort representing > 7 years (2009-2017) of CTO procedures by high-volume operators.
      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      With a median clinical follow-up of 377 days, the authors were able to report on the utility of both scores with regard to predicting procedural success and complications, as well as long-term outcomes. The RECHARGE score builds on the J-CTO score by including 2 additional variables: CABG status and the quality of the “landing zone” for CTO PCI.

      Maeremans J, Spratt JC, Knaapen P, et al. Towards a contemporary, comprehensive scoring system for determining technical outcomes of hybrid percutaneous chronic total occlusion treatment: the RECHARGE score [e-pub ahead of print]. Catheter Cardiovasc Interv https://doi.org/10.1002/ccd.27092. Accessed January 30, 2018.

      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      Like previous studies, however, the predictive performances of the scores were modest (0.62-0.67) and there was no significant improvement with use of the slightly more complex RECHARGE score. (Qualitatively, however, the RECHARGE score appeared to show a slightly better “dose-response”-type relationship with procedural success as well as complications compared with the J-CTO score.) Despite this, it was the RECHARGE score and not the J-CTO score that won out as a multivariate predictor of target vessel failure (TVF; a composite of cardiac death, target vessel myocardial infarction, and ischemia-driven target vessel revascularization) during follow-up, along with stent length and not using a drug-eluting stent.
      Why did the RECHARGE score outperform the J-CTO score as a predictor of long-term outcome when it did not in terms of earlier metrics of CTO PCI success? Although it is possible that some of the advantage resulted from the fact that the RECHARGE score was developed in a European hybrid-approach registry and most of the centres in this cohort likely use a similar algorithm, it stands to reason that 1 or both of the additional criteria in the RECHARGE score add far more incremental value with regard to long-term outcomes than upfront success. For example, the quality of the landing zone, although its consideration might correlate with procedure duration by influencing initial CTO approach, might arguably not add incremental information with regard to the ultimate likelihood of procedural success when other variables are considered. However, the quality of the landing zone might be more likely to influence an outcome such as TVF. (It should be noted that the quality of the landing zone was not included as a candidate variable in the multivariate regression by Azzalini et al.,
      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      and whether the RECHARGE score would still be an independent predictor of TVF if it had remains an open question.)
      The other additional variable in the RECHARGE score deserves more extensive discussion. CTOs are even more prevalent in CABG patients (60%-90%).
      • Azzalini L.
      • Jolicoeur E.M.
      • Pighi M.
      • et al.
      Epidemiology, management strategies, and outcomes of patients with chronic total coronary occlusion.
      • Pereg D.
      • Fefer P.
      • Samuel M.
      • et al.
      Long-term follow-up of coronary artery bypass patients with preoperative and new postoperative native coronary artery chronic total occlusion.
      Indeed, it has been suggested that CABG itself might lead to accelerated native vessel lesion progression, resulting in an increase in the rate as well as complexity of CTOs.
      • Azzalini L.
      • Jolicoeur E.M.
      • Pighi M.
      • et al.
      Epidemiology, management strategies, and outcomes of patients with chronic total coronary occlusion.
      • Pereg D.
      • Fefer P.
      • Samuel M.
      • et al.
      Long-term follow-up of coronary artery bypass patients with preoperative and new postoperative native coronary artery chronic total occlusion.
      • Sakakura K.
      • Nakano M.
      • Otsuka F.
      • et al.
      Comparison of pathology of chronic total occlusion with and without coronary artery bypass graft.
      The upshot of this would appear straightforward: increased CTO complexity would be expected to be associated with reduced procedural success and an increased complication risk. Indeed, the J-CTO score appears to perform approximately as well as the RECHARGE score in this regard, but falls short in terms of predicting long-term outcomes, suggesting that it is not just the failure to recanalize the CTO
      • Pereg D.
      • Fefer P.
      • Samuel M.
      • et al.
      Long-term follow-up of coronary artery bypass patients with preoperative and new postoperative native coronary artery chronic total occlusion.
      • Jones D.A.
      • Weerackody R.
      • Rathod K.
      • et al.
      Successful recanalization of chronic total occlusions is associated with improved long-term survival.
      that is predicting TVF. Although some of the comparative shortcomings of the J-CTO score in long-term prognostication might well be explained by consideration of landing zone quality, as discussed previously, it is possible that CABG status is itself informative with regard to the long-term risk of TVF beyond lesion complexity.
      CABG patients are typically older with more comorbidities than CABG-naive patients, even among patients with CTOs.
      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      • Pereg D.
      • Fefer P.
      • Samuel M.
      • et al.
      Long-term follow-up of coronary artery bypass patients with preoperative and new postoperative native coronary artery chronic total occlusion.
      • Brilakis E.S.
      • O'Donnell C.I.
      • Penny W.
      • et al.
      Percutaneous coronary intervention in native coronary arteries versus bypass grafts in patients with prior coronary artery bypass graft surgery: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.
      • Dautov R.
      • Manh Nguyen C.
      • Altisent O.
      • Gibrat C.
      • Rinfret S.
      Recanalization of chronic total occlusions in patients with previous coronary bypass surgery and consideration of retrograde access via saphenous vein grafts.
      CABG status might therefore be a marker of increased mortality and morbidity risk not captured in other elements of the RECHARGE or J-CTO scores. Moreover, although rare, perforation requiring intervention is definitely not unheard of in post-CABG patients,
      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      • Kinnaird T.
      • Anderson R.
      • Ossei-Gerning N.
      • et al.
      Coronary perforation complicating percutaneous coronary intervention in patients with a history of coronary artery bypass surgery: an analysis of 309 perforation cases from the British Cardiovascular Intervention Society Database.
      • Danek B.A.
      • Karatasakis A.
      • Tajti P.
      • et al.
      Incidence, treatment, and outcomes of coronary perforation during chronic total occlusion percutaneous coronary intervention.
      and there is the suggestion of a so-called “legacy effect” of CTO PCI complications on outcomes out to 1 year.
      • Kinnaird T.
      • Anderson R.
      • Ossei-Gerning N.
      • et al.
      Coronary perforation complicating percutaneous coronary intervention in patients with a history of coronary artery bypass surgery: an analysis of 309 perforation cases from the British Cardiovascular Intervention Society Database.
      • Kinnaird T.
      • Anderson R.
      • Ossei-Gerning N.
      • et al.
      Legacy effect of coronary perforation complicating percutaneous coronary intervention for chronic total occlusive disease: an analysis of 26 807 cases from the British Cardiovascular Intervention Society Database.
      (It is not clear if this legacy effect is partly due to a lower rate of successful recanalization because of aborted PCI.) Despite this, there is a not uncommon false assumption among some operators that post-CABG patients are (at least relatively) protected from such complications. It is therefore at least plausible that some operators in the cohort reported by Azzalini et al.
      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      were more willing to engage in more advanced, aggressive recanalization techniques in post-CABG patients with an associated increased risk of early complications and later TVF. CABG status might therefore also be a surrogate marker of increased inherent risk of the revascularization technique above and beyond coronary anatomic considerations. (It should also be noted that previous CABG surgery precludes rapid, safe sternotomy in the case of a PCI complication.)
      Would RECHARGE have been an independent predictor of long-term events if procedural complications were part of the multivariate model? Perhaps not, but this does not diminish the importance of the results of this report to our mind. First, procedural complications are arguably a step in the causal pathway between CABG status and TVF and, therefore, should be excluded from the model. In addition, the multivariate model reported by Azzalini et al. includes only those clinical and procedural characteristics that are, to a large extent, knowable before the procedure.
      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      Total stent length can be reasonably predicted from diagnostic angiography and using a drug-eluting stent is a simple clinical choice that can be easily decided ahead of time, whereas the occurrence of a complication such as tamponade cannot be so precisely predicted. As such, acknowledging that a drug-eluting stent is now the default stent in nearly all cases, a combination of the RECHARGE score and predicted total stent length would seem to the best predictor of the risk of TVF during follow-up that is available at the time of informed consent before the CTO PCI procedure.
      Although questions remain and the generalizability of the performance of this predictive model to populations treated by less experienced CTO operators is unknown, a few conclusions appear clear. First, post-CABG patients are a high-risk CTO population, in terms of procedural complications as well as long-term event-free survival.
      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      • Brilakis E.S.
      • O'Donnell C.I.
      • Penny W.
      • et al.
      Percutaneous coronary intervention in native coronary arteries versus bypass grafts in patients with prior coronary artery bypass graft surgery: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.
      • Dautov R.
      • Manh Nguyen C.
      • Altisent O.
      • Gibrat C.
      • Rinfret S.
      Recanalization of chronic total occlusions in patients with previous coronary bypass surgery and consideration of retrograde access via saphenous vein grafts.
      Second, major complications, including perforation and tamponade, can occur in a postcardiotomy patient and the ready availability of experienced teams able to rapidly intervene in such cases is critical.
      • Azzalini L.
      • Ojeda S.
      • Karatasakis A.
      • et al.
      Long-term outcomes of chronic total occlusion percutaneous coronary intervention in patients with vs without prior coronary artery bypass graft.
      • Kinnaird T.
      • Anderson R.
      • Ossei-Gerning N.
      • et al.
      Coronary perforation complicating percutaneous coronary intervention in patients with a history of coronary artery bypass surgery: an analysis of 309 perforation cases from the British Cardiovascular Intervention Society Database.
      • Danek B.A.
      • Karatasakis A.
      • Tajti P.
      • et al.
      Incidence, treatment, and outcomes of coronary perforation during chronic total occlusion percutaneous coronary intervention.
      • Kinnaird T.
      • Anderson R.
      • Ossei-Gerning N.
      • et al.
      Legacy effect of coronary perforation complicating percutaneous coronary intervention for chronic total occlusive disease: an analysis of 26 807 cases from the British Cardiovascular Intervention Society Database.
      For these reasons, it would appear reasonable to recommend that CTO PCI for post-CABG patients be preferentially performed in highly experienced centres, particularly if advanced techniques are required, such as a retrograde approach.
      As a final thought, because of the complexity and risk of intervening on CTOs in CABG patients, the day might well come when the decision to refer patients with multivessel disease for surgery—including CTOs—will not be as straightforward as it once was.
      • Azzalini L.
      • Torregrossa G.
      • Puskas J.D.
      • et al.
      Percutaneous revascularization of chronic total occlusions: rationale, indications, techniques, and the cardiac surgeon's point of view.
      Although interventionalists now by and large accept that intermediate SYNTAX score
      • Serruys P.W.
      • Morice M.C.
      • Kappetein A.P.
      • et al.
      Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
      multivessel anatomy might be appropriate for PCI, many will still more readily consult cardiac surgery than consider a referral to a CTO operator if a CTO is present. Although some of this tendency might be driven by what services are available locally, with our current understanding of the evolution of critical lesions (CTOs as well as non-CTOs) after bypass,
      • Pereg D.
      • Fefer P.
      • Samuel M.
      • et al.
      Long-term follow-up of coronary artery bypass patients with preoperative and new postoperative native coronary artery chronic total occlusion.
      • Sakakura K.
      • Nakano M.
      • Otsuka F.
      • et al.
      Comparison of pathology of chronic total occlusion with and without coronary artery bypass graft.
      the optimal time for an attempt at CTO PCI is likely before CABG, not after, particularly if the SYNTAX score is not high or if the proportion of the SYNTAX score attributable to the CTO is elevated (> 0.5).
      • Azzalini L.
      • Jolicoeur E.M.
      • Pighi M.
      • et al.
      Epidemiology, management strategies, and outcomes of patients with chronic total coronary occlusion.
      Because of the complexity of clinical decision-making in patients who present with CTOs, referral of such patients to formalized complex PCI programs with a heart team approach is likely to be beneficial.

      Disclosures

      The authors have no conflicts of interest to disclose.

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