Chronic total occlusion (CTO) affect up to 20% of patients undergoing angiographic diagnostic tests. During the last two decades, recanalization technique refinement, the development of specific devices and operator skill improvement have elevated procedural success rate up to 90%. However, there are still particular complications such as collateral perforation and access site complications. This is why the adequate assessment of risk and benefits on a case by case basis is key.
The aim of this retrospective study was to report the success and complications rate from the European Registry of Chronic Total Occlusions (ERCTO).
Procedural success was defined as technical success without major adverse cardio and cerebrovascular events (MACCE) during hospitalization. MACCE was defined as a combination of death, myocardial infarction (AMI), stroke, emergency revascularization (repeat PCI or CABG) and emergency pericardiocentesis.
8673 CTO cases were looked at, included in the registry from January 2021 to October 2022. Mean patient age was 65, and most were men (82%). About 20% of patients presented stable angina (CF > 2), and 52% presented dyspnea according to the New York Heart Association (NYHA) classification, with functional class (FC) higher than 1.
As regards ventricular function, only 7.6 had severely reduced ejection fraction (<35%), while 52% presented done mobility segment abnormality in CTO territory. The most treated artery was the right coronary (55%), followed by the anterior descending (26%) and the circumflex (14%). Average J-CTO was 2.2. As regards the use of specific devices, intravascular ultrasound (IVUS) was use in 21% of cases, guiding catheter extension was used in 18%, dual lumen microcatheter was used in 11%, while rotational atherectomy was used in 3% of cases.
Of the total procedures, 73% were antegrade, while the remaining 27% were retrograde. Technical success rate resulted 89%, which was significantly higher in the anterograde arm vs. the retrograde (92.8% vs. 79.3%; p < 0.001). When comparing these techniques, the retrograde approach presented more complex lesions with 3.0 ± 1.0 J-CTO score vs. 1.9 ± 1.2 (p < 0.001), higher intraprocedural and inhospital MACCE rate (3.1% vs. 1.2%; p < 0.018) and higher perforation rate, with and without cardiac tamponade (1.5% vs. 0.4% and 8.3% vs. 2.1%, respectively; p < 0.001).
When looking at operator experience, those with high CTO volume presented higher success rate for both antegrade and retrograde procedures (93.4% vs. 91.2% and 81.5% vs. 69.0%, respectively; p < 0.001), and lower MACCE rate (1.47% vs. 2.41%; p < 0.001) despite greater lesion complexity (J-CTO score: 2.42 ± 1.28 vs. 2.15 ± 1.27; p < 0.001).
Conclusion
The ERCTO registry has achieve high procedural success rate and low complications rate even in patients with complex lesions. Several patient and procedure related factors increase complications risk. Operator experience is key to achieving the desired success rate.
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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