Chronic total occlusion (CTO) recanalization remains one of the most challenging procedures in interventional cardiology, and the inability to cross the lesion with a guidewire is the most common cause of CTO percutaneous coronary intervention (PCI) failure. While the current standard lesion evaluation is mostly based on anatomical complexity scores, a global comprehensive approach could help guiding the clinical decision and allow predicting CTO-PCI success. In this study, we aimed to evaluate angiographic predictors of procedural success.
Methods and Results
This single-centre prospective observational study was conducted in an academic tertiary care medical center and patients were recruited between January 2014 and March 2020. CTO was defined as 99-100% occlusions with Thrombolysis in Myocardial Infarction (TIMI) 0 flow with at least 3-month duration. The primary inclusion criteria were the presence of refractory ischemic symptoms despite optimal medical therapy and non-invasive imaging demonstrating reversible ischemia. A total of 255 patients were consecutively enrolled in this registry. Average age was 65±10 and 75% were males. Hypertension and diabetes were present in 73% and 27% of patients respectively. The left ventricular ejection fraction (LVEF) was above 50% in 73% of patients. The mean SYNTAX and J-CTO scores were 19.3±8.6 and 2.26±1.11 respectively. The overall CTO-PCI success rate was 86.4%. Univariate analysis showed that a high J-CTO score >1 predicted decreased CTO PCI success in 83.5% vs 94.1%, p=0.038. In addition, patients with procedural success had a lower percentage of history with bypass graft (73.8% vs. 88.8%, p = 0.004), significant left main stenosis (61.9% vs. 88.9%; p=0.003), reference vessel diameter < 3mm (82.7% vs. 96.9%, P=0.003). Finally, a lower median Syntax score was a predictor of procedural success (17 IQR 12-24 vs. 20.5 IQR 15-29.5, p=0.036).
Beyond the J-CTO score, several angiographic parameters related to the CTO lesion complexity and the coronary atherosclerotic burden predict the risk of CTO PCI failure. This hypothesis-generating analysis needs to be validated in future large-scale studies as it could improve patient selection and refine decision making for such a complex coronary intervention.
© 2022 Published by Elsevier Inc.