Burke, M. Nicholas

Background: Predicting technical failure in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can assist with decision making and planning of the procedure. Methods: We analyzed 6,946 CTO PCIs performed between 2016 and June 2022 at 36 international centers in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) and created a score for risk of technical failure. Logistic regression prediction modeling was used to identify independently associated variables with technical failure and model were internally validated with bootstrapping. Results: Mean patient age was 64.0±10 years, 82% were men and technical success was 86%. The following variables were independently associated with technical failure and were included in the final model: age (odds ratio [OR]: 1.08, 95% Confidence Intervals [CI]: [1.00-1.15], p=0.039; age≥ 65 years; 1 point), CTO length (OR: 1.13, 95% CI [1.10, 1.17]; length≥ 20 mm; 1 point), moderate/severe calcification (OR: 1.35, 95% CI [1.17, 1.56]; 1 point), proximal cap ambiguity (OR: 2.25, 95% CI [1.95, 2.59]; 2 points), lack of interventional collaterals (OR: 1.60, 95% CI [1.39, 1.84]; 1 point), and lack of good distal landing zone (OR: 1.51, 95% CI [1.31, 1.75]; 1 point). The resulting score showed acceptable performance on receiver-operating characteristic (ROC) curve, AUC: 0.68 (95% CI [0.67-0.71]). Internal validation with bootstrapping of 1000 samples demonstrated a good agreement with the model, observed AUC: 0.68, (95% bias corrected CI [0.67, 0.70]). PROGRESS-CTO technical failure score and corresponding risk percentage and the percentage of patients in the respective risk group within the PROGRESS-CTO registry are represented in Figure 1. Conclusion: The updated PROGRESS CTO score may be useful for assessing the likelihood of technical failure success in CTO PCI.

Introduction: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with increased risk of periprocedural complications. Estimating the risk of complications facilitates risk-benefit assessment and procedural planning. Methods: We analyzed the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO, NCT02061436) and created a risk score for in-hospital all-cause mortality. Logistic regression prediction modeling was used to identify independently associated variables and the model was internally validated with bootstrapping. Results: Of the 10,480 CTO PCI cases performed between 2012-2022 at 40 US and non-US centers, in-hospital mortality occurred in 47 (0.45%). The final prediction model identified 4 independent predictors of mortality: Age ≥65 years, Odds Ratio [OR]: 2.83 (95% confidence interval [CI], 1.30-6.16), 1-point; Left ventricular ejection fraction ≤45%, OR: 2.13 (95% CI, 1.14-3.98), 1-point; Moderate-severe calcification, OR: 2.45 (95% CI, 1.18-5.08), 1-point; and Antegrade dissection re-entry, OR: 2.81 (95% CI, 1.06-7.43), 1-point; or Retrograde strategy, OR: 3.51 (95% CI, 1.67-7.37), 1-point; with a bootstrap corrected c-statistics of 0.71 (95% confidence interval: 0.63-0.81). The calculated risk percentages for mortality based on the PROGRESS-CTO mortality score ranged from 0.05-2.42% for mortality, and 63% of patients in the PROGRESS-CTO cohort had PROGRESS-CTO mortality score of 1 or 2, corresponding to a mortality risk of 0.1-0.5% (Figure 1). Conclusions: The PROGRESS-CTO in-hospital mortality risk score can facilitate risk-benefit assessment and procedural planning in patients undergoing CTO PCI.

AbstractBackgroundThe use of intravascular lithotripsy (IVL) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.MethodsWe analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 82 CTO PCIs that required IVL at 14 centers between 2020 and 2022.ResultsDuring the study period, IVL was used in 82 of 3301 (2.5%) CTO PCI procedures (0.4% in 2020 and 7% in 2022; p for trend < 0.001). Mean patient age was 69 ± 11 years and 79% were men. The prevalence of hypertension (95%), diabetes mellitus (62%), and prior PCI (61%) was high. The most common target vessel was the right coronary artery (54%), followed by the left circumflex (23%). The mean J‐CTO and PROGRESS‐CTO scores were 2.8 ± 1.1 and 1.3 ± 1.0, respectively. Antegrade wiring was the final successful crossing strategy in 65% and the retrograde approach was used in 22%. IVL was used in 10% of all heavily calcified lesions and 11% of all balloon undilatable lesions. The 3.5 mm lithotripsy balloon was the most commonly used balloon (28%). The mean number of pulses per lithotripsy run was 33 ± 32 and the median duration of lithotripsy was 80 (interquartile range: 40−103) seconds. Technical and procedural success was achieved in 77 (94%) and 74 (90%) cases, respectively. Two (2.4%) Ellis Class 2 perforations occurred after IVL use and were managed conservatively.ConclusionIVL is increasingly being used in CTO PCI with encouraging outcomes.

Background: Radial access (RA) is increasingly used in chronic total occlusion (CTO) percutaneous coronary intervention with encouraging results. However, there are concerns about its safety and efficacy because of higher complexity and the need for strong guide catheter support. Methods and Results: We performed a systematic review and meta-analysis of all studies published through November 2018 reporting the outcomes of RA versus femoral access in CTO percutaneous coronary intervention. Outcomes included major bleeding, access-site complications, in-hospital major adverse events, and technical success. Nine observational studies with 10 590 patients (10 617 lesions) were included in the meta-analysis. CTO lesions attempted using RA had lower Japan-CTO score (2.3±1.2 versus 2.5±1.3; P <0.001). Use of RA was associated with similar technical success (78.7% versus 78.5%; odds ratio, 1.11; 95% CI, 0.94–1.31; P =0.24; I 2 =23%), lower risk of access-site complications (0.73% versus 1.79%; odds ratio, 0.34; 95% CI, 0.22–0.51; P <0.001; I 2 =0%) and major bleeding (0.18% versus 0.9%; odds ratio, 0.22; 95% CI, 0.10–0.45; P <0.001; I 2 =0%), and similar risk of in-hospital adverse events and in-hospital mortality (odds ratio, 0.36; 95% CI, 0.12–1.07; P =0.07; I 2 =0%) as compared to femoral access. Results were similar when analyzing radial-only versus any femoral access and when excluding the largest study. Conclusions: As compared with femoral access, RA is used in CTO percutaneous coronary intervention of less complex lesions and is associated with fewer access-site complications and major bleeding and comparable technical success.

AbstractObjectivesWe examined the contemporary incidence, types, predictors, angiographic characteristics, management and outcomes of coronary perforation.BackgroundCoronary perforation is a rare, but important, complication of percutaneous coronary intervention (PCI). There is lack of data on perforations stratified as large and distal vessel perforations.MethodsRetrospective, observational cohort study of all patients who underwent PCI at a high volume, tertiary hospital between the years 2009 and 2016. Angiograms of all coronary perforation cases were reviewed to determine the mechanism, type, and management of perforation. Risk‐adjusted periprocedural complication rates were compared between patients with and without coronary perforation. One‐year mortality outcomes of patients with large vessel vs. distal vessel perforation were also examined.ResultsCoronary perforation occurred in 68 of 13,339 PCIs (0.51%) performed during the study period: 51 (75%) were large vessel perforations and 17 (25%) distal vessel perforations. Most (67%) large vessel perforations were due to balloon/stent inflation, whereas most (94%) distal vessel perforations were due to guidewire exit. Patients with coronary perforations had significantly higher risk for periprocedural complications (adjusted odds ratio 7.57; 95% CI: 4.22–13.50; P < 0.001). Only one patient with large vessel perforation required emergency cardiac surgery, yet in‐hospital mortality was high with both large vessel (7.8%) and distal vessel (11.8%) perforations.ConclusionsCoronary perforation is an infrequent, but potentially severe PCI complication. Most coronary perforations are large vessel perforations. Although coronary perforations rarely lead to emergency cardiac surgery, both distal vessel and large vessel perforations are associated with high in‐hospital mortality, highlighting the importance of prevention.

AbstractObjectivesThis study sought to compare the clinical outcomes of percutaneous coronary interventions (PCIs) performed by sleep deprived and non‐sleep deprived operators.BackgroundInterventional cardiologists are at risk for sleep deprivation as they often have to perform emergent procedures at night, but the effects of sleep deprivation on clinical outcomes have received limited study.MethodsWe examined the frequency, clinical characteristics, and outcomes of daytime PCIs performed by sleep deprived and non‐sleep deprived operators at a tertiary medical center. Operators were considered sleep deprived when performing a daytime (7 am–11:59 pm) procedure preceded by a nighttime (12 am–6:59 am) procedure on the same date.ResultsOf the 12,680 daytime PCIs performed from 6/29/09 to 12/30/2016, 367 (2.9%) were performed by sleep deprived operators. Patients undergoing PCI performed by a sleep deprived operator were more likely to be younger, white, and to present with ST‐elevation acute myocardial infarction (STEMI). The incidence of in‐hospital death (1.1% vs. 1.3%, P = 1.0) and bleeding within 72 hr (3.9% vs. 2.9%, P = 0.29) were similar for procedures performed by sleep‐deprived and non‐sleep deprived operators. When the sleep deprived group was further stratified based on degree of sleep deprivation or length of sleep interruption, differences in mortality and total bleeding remained non‐significant.ConclusionsIn this large single center study, operator sleep deprivation did not appear to adversely impact PCI outcomes.