Application and outcomes of a hybrid approach to chronic total occlusion percutaneous coronary intervention in a contemporary multicenter US registry

Abstract

Background: A hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) prioritizing and combining all available crossing techniques was developed to optimize procedural efficacy, efficiency, and safety, but there is limited published data on its outcomes.

Methods: We examined the procedural techniques and outcomes of 1036 consecutive CTO PCIs performed using a hybrid approach between 2012 and 2015 at 11 US centers.

Results: Mean age was 65 ± 10 years and 86% of the patients were men, with a high prevalence of diabetes mellitus (43%) and prior coronary artery bypass graft surgery (34%). Most target CTOs were located in the right coronary artery (59%), followed by the left anterior descending artery (23%) and the circumflex (19%). Dual injection was used in 71%. Technical success was achieved in 91% and a major procedural complication occurred in 1.7% of cases. The final successful crossing technique was antegrade wire escalation in 46%, antegrade dissection/re-entry in 26%, and retrograde in 28%. The initial crossing strategy was successful in 58% of the lesions, whereas 39% required an additional approach. Overall, antegrade wire escalation was used in 71%, antegrade dissection/re-entry in 36%, and the retrograde approach in 42% of procedures. Median contrast volume, fluoroscopy time, and air kerma radiation dose were 260 (200-360) ml, 44 (27-72) min, and 3.4 (2.0-5.4) Gray, respectively.

Conclusion: Application of a hybrid approach to CTO crossing resulted in high success and low complication rates across a varied group of operators and hospital practice structures, supporting its expanding use in CTO PCI.

Keywords: Chronic total occlusion; Outcomes; Percutaneous coronary intervention; Techniques.

Conflict of interest statement

Conflict of Interest:

Dr. Christopoulos: none

Dr. Karmpaliotis: speaker bureau, Abbott Vascular, Medtronic, and Boston Scientific

Dr. Wyman: Honoraria/consulting/speaking fees from Boston Scientific, Abbott Vascular, and Asahi.

Dr. Alaswad: consulting fees from Terumo and Boston Scientific; consultant, no financial, Abbott Laboratories.

Dr. Yeh: Career Development Award (1K23HL118138) from the National Heart, Lung, and Blood Institute.

Dr. Jaffer: consultant to Boston Scientific, Siemens, and Merck, nonfinancial research support from Abbott Vascular, research grant from National Institutes of Health (HL-R01-108229).

Dr. Lombardi: equity with Bridgepoint Medical

Mr. Menon: none

Dr. Grantham: Speaking fees, consulting, and honoraria from Boston Scientific, Asahi Intecc. Research grants from Boston Scientific, Asahi Intecc, Abbott Vascular, Medtronic.

Dr. Kandzari: research/grant support and consulting honoraria from Boston Scientific and Medtronic Cardiovascular, and research/grant support from Abbott.

Dr. Lembo: speaker bureau: Medtronic; advisory board Abbott Vascular and Medtronic.

Dr. Moses: none

Dr. Kirtane: none

Dr. Parikh: none

Dr. Green: none

Dr. Finn: none

Dr. Garcia: consulting fees from Medtronic

Dr. Doing: none

Dr. Patel: none

Dr. Bahadorani: none

Dr. Tarar: none

Dr. Christakopoulos: none

Dr. Thompson: employee of Boston Scientific

Dr. Banerjee: research grants from Gilead and the Medicines Company; consultant/speaker honoraria from Covidien and Medtronic; ownership in MDCARE Global (spouse); intellectual property in HygeiaTel.

Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Somahlution, St Jude Medical, and Terumo; research support from Guerbet and InfraRedx; spouse is employee of Medtronic.

Published by Elsevier Ireland Ltd.

Figures

Figure 1

A hybrid algorithm for CTO crossing (reproduced with permission from reference 20). The initial crossing strategy selection depends on several angiographic characteristics, such as proximal cap ambiguity, size and calcification of the distal target vessel, lesion length and presence of appropriate collaterals. Strategy switch is recommended if the initially selected strategy fails.

Figure 2

Flow chart depicting the crossing strategies utilized in the study patients.

Figure 3

Utilization of crossing strategies based on crossing sequence in all procedures (n=1,036, panel A), successful procedures (n=940, panel B), and failed procedures (n=96, panel C).

Figure 3

Utilization of crossing strategies based on crossing sequence in all procedures (n=1,036, panel A), successful procedures (n=940, panel B), and failed procedures (n=96, panel C).

Figure 3

Utilization of crossing strategies based on crossing sequence in all procedures (n=1,036, panel A), successful procedures (n=940, panel B), and failed procedures (n=96, panel C).