Chronic total occlusions (CTO) occur in up to 20% of patients undergoing diagnostic angiographic studies. Over the past two decades, the optimization of recanalization techniques, the development of new specialized devices, and improvement in operator skill have contributed to an increased procedural success rate, reaching 90%. However, specific complications such as collateral perforation and access site complications persist. For this reason, a thorough patient-specific risk-and-benefit assessment is essential.
The objective of this retrospective study was to report the success rate and complications in the European Registry of Chronic Total Occlusion (ERCTO).
Procedural success was defined as technical achievement without in-hospital major adverse cardiac and cerebrovascular events (MACCE). MACCE was defined as a composite of events including death, myocardial infarction (MI), stroke, urgent repeat revascularization (percutaneous coronary intervention [PCI] or surgery), and urgent pericardiocentesis.
Researchers analyzed a total of 8673 CTO cases included in the registry from January 2021 to October 2022. The average age was 65 years, and most patients were men (82%). Approximately 20% of patients had stable angina (CCS >2), and 52% had dyspnea New York Heart Association (NYHA) grade >1. Regarding ventricular function, only 7.6% had severely reduced ejection fraction (EF <35%), while 52% showed segmental motility abnormalities where the CTO was located. The most treated coronary artery was the right coronary artery (55%), followed by the left anterior descending artery (26%), and the circumflex artery (14%). The average J-CTO score was 2.2.
Regarding the use of dedicated devices, the utilization rate of intravascular ultrasound (IVUS) was 21%, guiding catheter extension was 18%, and dual-lumen microcatheter was 11%, and rotational atherectomy was applied in 3% of patients.
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Of all procedures, 73% were performed via antegrade approach, while the remaining 27% were carried out via retrograde approach. The technical success rate was 89%, and it was significantly higher for the antegrade strategy compared with the retrograde approach (92.8% vs. 79.3%; p<0.001). Compared with antegrade procedures, the retrograde approach presented higher lesion complexity, with a J-CTO score of 3.0±1.0 vs. 1.9±1.2 (p<0.001), a higher rate of intraprocedural and in-hospital MACCE (3.1% vs. 1.2%; p<0.018), and a higher rate of perforation with and without cardiac tamponade (1.5% vs. 0.4% and 8.3% vs. 2.1%, respectively; p<0.001).
When analyzed according to operator experience, those with a high CTO volume had a higher success rate with both antegrade and retrograde approaches (93.4% vs. 91.2% and 81.5% vs. 69.0%, respectively; p<0.001), and a lower MACCE rate (1.47% vs. 2.41%; p<0.001), despite higher lesion complexity (J-CTO score: 2.42±1.28 vs. 2.15±1.27; p<0.001).
Conclusion
The ERCTO registry has achieved a high procedural success rate and a low complications rate even in patients with complex lesions. Various factors related to the patient and the procedure increase the risks of complications, and operator experience is a crucial factor in achieving procedural success.
Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.
Original Title: Contemporary outcomes of chronic total occlusion percutaneous coronary intervention in Europe: the ERCTO registry.
Reference: Giuseppe Vadalà MD et al EuroIntervention 2024;20:e185-e197.
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