Percutaneous treatment of chronic total occlusions has increase, and has become a a more habitual therapeutic challenge. However, there is limited information on distal vessel quality and its association with outcomes and techniques. This variable appears to be excluded form CTO scores, except for the RECHARGE (REgistry of CrossBoss and Hybrid procedures in FrAnce, the NetheRlands, BelGium and UnitEd Kingdom).
With this lack of information in mind, a multicenter registry was carried out to assess the association of distal vessel quality and CTO PCI outcomes.
Primary end point was inhospital major adverse cardiovascular events (MACE), which included death, acute myocardial infarction (AMI), target vessel emergency revascularization, cardiac tamponade requiring pericardiocentesis or surgery, and stroke.
Poor distal vessel quality was defined as < 2mm vessel diameter or significant diffuse atherosclerosis. A total 10,028 CTO PCI procedures between 2012 and 2022 were looked into. Patient mean age was 64, and they were mostly men. 33% of cases had poor distal vessel quality.
Patients with poor distal vessel quality more often presented prior PCI, CABG, diabetes, hypertension, dyslipidemia, AMI, cerebrovascular disease, cardiac failure and peripheral artery disease. They also showed lower ejection fraction.
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The right coronary artery was the most treated (52.8%), while the anterior descending was less prevalent in group with poor distal vessel quality (23.6% vs. 27.2%; P < 0.001). On the other hand, the circumflex was the most frequently treated among the latter (21.5% vs. 17.9%; P < 0.001).
Lesions in this group were more complex, presented higher J-CTO and PROGRESS-CTO scores, more moderate to severe calcification, proximal cap ambiguity, long occlusions and smaller target vessel proximal diameter. These lesions required more stents.
As regards procedure characteristics, the anterograde strategy was the most successful in both groups, with 60% success rate in the good quality group and 48% in poor quality patients. Lesions with poor distal vessel quality more often required retrograde access, but not anterograde dissection and reentry. Also, intravascular imaging was used in 41.8% of cases.
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Technical success, both procedural and general, was significantly lower among poor target vessel quality CTO PCIs (79.9% vs. 86.9%; P < 0.001 y 78.0% vs. 86.8%; P < 0.001, respectively). Primary end point showed higher inhospital MACE (2.5% vs. 1.7%; P = 0.01) and perforation incidence (6.4% vs. 3.7%; P < 0.01) in the group with poor distal vessel quality. Even though individual differences were not statistically significant, there was a tendency towards higher mortality (0.54% vs. 0.28%; P = 0.05) and tamponade (1.1% vs. 0.78%; P = 0.07) in the poor distal vessel quality group.
Conclusions
Poor distal vessel quality in CTO PCI is associated with more complex lesions, more use of retrograde crossing strategies, lower technical and procedural success, higher in hospital MACE and coronary perforation incidence, and higher radiation exposure. Therefore, distal vessel quality in CTO should be taken into account when planning and performing PCI.
Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.
Original Title: Distal Target Vessel Quality and Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention.
Reference: Salman S. Allana, MD et al J Am Coll Cardiol Intv 2023;16:1490–1500.
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