Association of Prolonged Fluoroscopy Time with Procedural Success of Percutaneous Coronary Intervention for Stable Coronary Artery Disease with and without Chronic Total Occlusion

Peter Tajti, Mohamed Ayoub, Thomas Nuehrenberg, Miroslaw Ferenc, Michael Behnes, Heinz Joachim Buettner, Franz-Josef Neumann, Kambis Mashayekhi, Peter Tajti, Mohamed Ayoub, Thomas Nuehrenberg, Miroslaw Ferenc, Michael Behnes, Heinz Joachim Buettner, Franz-Josef Neumann, Kambis Mashayekhi

Abstract

Background: In percutaneous coronary interventions (PCI), the impact of prolonged fluoroscopy time (FT) on procedural outcomes is poorly studied.

Methods and results: We analyzed the outcomes of 12,538 consecutive elective PCIs. The primary endpoint was procedure failure (PF), the composite of technical failure, and adverse in-hospital events including all-cause death, myocardial infarction, stroke, and target vessel revascularization (MACCE), as well as pericardial tamponade. We stratified the procedures as PCI for chronic total occlusion (CTO, n = 2720) and PCI for non-CTO (n = 9818). Logistic regression demonstrated a significant association between fluoroscopy time and procedural failure with a significant interaction with PCI type (both p < 0.001). The odds ratios (OR) of procedural failure for a 10-min increment in FT were 1.15 (confidence interval (CI) 95% 1.12-1.18, p < 0.001) in non-CTO PCI and 1.05 (CI 95% 1.03-1.06, p < 0.001) in CTO PCI. The optimal cut-point for prediction of PF was 21.1 min in non-CTO PCI (procedural success in 98.4% versus 95.3%, adjusted OR for PF 2.79 (CI 95% 1.93-4.04), p < 0.001) and 41 min in CTO PCI (procedural success in 92.3% versus 83.8%, adjusted OR for PF 2.18 (CI 95% 1.64-2.94), p < 0.001). In CTO PCI, the increase in PF with FT was largely driven by technical failure (adjusted OR 2.25 (CI 95% 1.65-3.10), p < 0.001), whereas in non-CTO PCI, it was driven by major complications (adjusted OR 2.94 (CI 95% 1.93-4.53), p < 0.001).

Conclusions: Prolonged FT is strongly associated with procedural failure in both non-CTO and CTO PCI. In CTO PCI, this relation is shifted towards longer FT. The mechanisms of procedural failure differ between CTO and non-CTO PCI.

Keywords: chronic total occlusion; complex coronary artery disease; outcomes; percutaneous coronary intervention.

Conflict of interest statement

F.-J.N. received institutional research grants, consultancy fees and speaker honoraria from Daiichi-Sankyo, Astra Zeneca, Sanofi-Aventis, Bayer, The Medicines Company, Bristol, Novartis, Roche, Boston Scientific, Biotronik, Medtronic and Edwards. K.M. received honoraria/consulting fees from Ashai Intecc, Boston, Medtronic, Teleflex, Cardinal Health, Abboth, Biotronik, Terumo, AstraZeneca, Daiichi Sankyo. The other authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Flowchart of patient cohort selection in the current study. ACS, acute coronary syndrome; CAD, coronary artery disease; CTO, chronic total occlusion; and PCI, percutaneous coronary intervention.
Figure 2
Figure 2
Forest plot of crude (Panel A) and adjusted (Panel B) odds ratios (OR) for prediction of procedural success in nonocclusive percutaneous coronary intervention (non-CTO PCI). ACC, American College of Cardiology; AHA, American Heart Association; CABG, coronary artery bypass graft; eGFR, estimated glomerular filtration rate; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NYHA, New York Heart Association. * Indicates fluoroscopy time (min). Left ventricular function groups are indicated as follows: normal (52–100%) moderately reduced (41–51%), reduced (30–40%), and low (0–29%) in males; and normal (54–100%), moderately reduced (41–53%), reduced (30–40%), and severely reduced (0–29%) in females.
Figure 3
Figure 3
In-hospital outcomes in patients undergoing various length of percutaneous coronary interventions (PCI) targeting nonocclusive (Panel A) and chronic occlusive (Panel B) coronary lesions. CTO, chronic total occlusion, and MACCE, major adverse cardiac and cerebrovascular event.
Figure 4
Figure 4
Kaplan–Meier curves of 30-days major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing prolonged non-occlusive (non-CTO, Panel A) and chronic occlusive (CTO, Panel B) percutaneous coronary interventions (PCI).
Figure 5
Figure 5
Forest plot of crude (Panel A) and adjusted (Panel B) odds ratios (OR) for prediction of procedural success in chronic total occlusion percutaneous coronary intervention (CTO PCI). CAD, coronary artery disease; CABG, coronary artery bypass graft; CTO, chronic total occlusion; CX, circumflex artery. * Indicates fluoroscopy time (min).

References

    1. Kirtane A.J., Doshi D., Leon M.B., Lasala J.M., Magnus Ohman E., O’Neill W.W., Shroff A., Cohen M.G., Palacios I.F., Beohar N., et al. Treatment of Higher-Risk Patients with an Indication for Revascularization: Evolution Within the Field of Contemporary Percutaneous Coronary Intervention. Circulation. 2016;134:422–431. doi: 10.1161/CIRCULATIONAHA.116.022061.
    1. Nikolsky E., Pucelikova T., Mehran R., Balter S., Kaufman L., Fahy M., Lansky A.J., Leon M.B., Moses J.W., Stone G.W., et al. An evaluation of fluoroscopy time and correlation with outcomes after percutaneous coronary intervention. J. Invasive Cardiol. 2007;19:208–213.
    1. Thygesen K., Alpert J.S., Jaffe A.S., Chaitman B.R., Bax J.J., Morrow D.A., White H.D., Mickley H., Crea F., Van De Werf F., et al. Fourth Universal Definition of Myocardial Infarction. J. Am. Coll. Cardiol. 2018;72:2231–2264. doi: 10.1016/j.jacc.2018.08.1038.
    1. Moussa I.D., Klein L.W., Shah B., Mehran R., Mack M.J., Brilakis E.S., Reilly J.P., Zoghbi G., Holper E., Stone G.W. Consideration of a new definition of clinically relevant myocardial infarction after coronary revascularization: An expert consensus document from the society for cardiovascular angiography and interventions (SCAI) Catheter. Cardiovasc. Interv. 2013;83:27–36. doi: 10.1002/ccd.25135.
    1. Ryan T.J., Faxon D.P., Gunnar R.M., Kennedy J.W., King S.B., Loop F.D., Peterson K.L., Reeves T.J., Williams D.O., Winters W.L. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty) Circulation. 1988;78:486–502.
    1. Galassi A.R., Werner G.S., Boukhris M., Azzalini L., Mashayekhi K., Carlino M., Avran A., Konstantinidis N.V., Grancini L., Bryniarski L., et al. Percutaneous recanalisation of chronic total occlusions: 2019 consensus document from the EuroCTO Club. EuroIntervention. 2019;15:198–208. doi: 10.4244/EIJ-D-18-00826.
    1. Michael T.T., Karmpaliotis D., Brilakis E.S., AlOmar M., Abdullah S.M., Kirkland B.L., Mishoe K.L., Lembo N., Kalynych A., Carlson H., et al. Temporal trends of fluoroscopy time and contrast utilization in coronary chronic total occlusion revascularization: Insights from a multicenter united states registry. Catheter. Cardiovasc. Interv. 2015;85:393–399. doi: 10.1002/ccd.25359.
    1. Fazel R., Curtis J., Wang Y., Curtis J., Wang Y., Einstein A.J., Smith-Bindman R., Tsai T.T., Chen J., Shah N.D., et al. Determinants of fluoroscopy time for invasive coronary angiography and percutaneous coronary intervention: Insights from the NCDR((R)) Catheter. Cardiovasc. Interv. 2013;82:1091–1105. doi: 10.1002/ccd.24996.
    1. Cho M.S., Ahn J.-M., Lee C.-H., Kang D.-Y., Lee J.-B., Lee P.H., Kang S.-J., Lee S.-W., Kim Y.-H., Park S.-W., et al. Differential Rates and Clinical Significance of Periprocedural Myocardial Infarction After Stenting or Bypass Surgery for Multivessel Coronary Disease According to Various Definitions. JACC Cardiovasc. Interv. 2017;10:1498–1507. doi: 10.1016/j.jcin.2017.05.051.

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