Distal Target Vessel Quality and Outcomes of Chronic Total Occlusion PCI

Jun 26, 2023
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Authors:
Allana SS, Kostantinis S, Simsek B, et al.
Citation:
Distal Target Vessel Quality and Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023;16:1490-1500.
Summary By:
Bina Ahmed, MD, FACC

Quick Takes

  • Findings from this international, retrospective analysis spanning a decade suggest that poor-quality distal vessel defined as size <2 mm in diameter or with significant diffuse atherosclerotic disease is seen in one third of chronic total occlusion (CTO) patients.
  • The presence of a poor distal target was associated with the worst outcomes (lower technical and procedural success rate, higher rates of perforations), use of a retrograde approach, and longer procedure times.
  • Findings support the assessment of the quality of distal vessel target when planning CTO PCI.

Study Questions:

What is the association of distal vessel quality with the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)?

Methods:

The authors examined the clinical and angiographic characteristics and procedural outcomes of 10,028 CTO PCIs performed at 39 US and non-US centers between 2012 and 2022. A poor-quality distal vessel was defined as <2 mm diameter or with significant diffuse atherosclerotic disease. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction (MI), urgent repeat target-vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke.

Results:

Thirty-three percent of all CTO lesions had a poor-quality distal vessel. When compared with good-quality distal vessels, CTO lesions with a poor-quality distal vessel had higher J-CTO (Japanese chronic total occlusion) scores (2.7 ± 1.1 vs. 2.2 ± 1.3; p < 0.01), lower technical (79.9% vs. 86.93%; p < 0.01) and procedural (78.0% vs. 86.8.1%; p < 0.01) success, and higher incidence of MACE (2.5% vs. 1.7%; p < 0.01) and perforation (6.4% vs. 3.7%; p < 0.01). Poor-quality distal vessel was independently associated with technical failure and MACE. Poor-quality distal vessels were associated with higher use of the retrograde approach (25.2% vs. 14.9%; p < 0.01) and higher air-kerma radiation dose (2.4, interquartile range [IQR] 1.3, 4.0 vs. 2.0 IQR 1.1, 3.5 Gray; p < 0.01).

Conclusions:

A poor-quality distal vessel in CTO lesions is associated with higher lesion complexity, higher need for retrograde crossing, lower technical and procedural success, higher incidence of MACE and coronary perforation, and higher radiation dose.

Perspective:

Findings from this international, retrospective analysis spanning a decade suggest that a poor-quality distal vessel defined as size <2 mm in diameter or with significant diffuse atherosclerotic disease is seen in one third of CTO patients. The presence of a poor distal target was associated with the worst outcomes (lower technical and procedural success rate, higher rates of perforations), use of retrograde approach, and longer procedure times. Findings support the assessment of the quality of distal vessel target when planning CTO PCI.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease, Aortic Surgery

Keywords: Atherosclerosis, Cardiac Tamponade, Coronary Occlusion, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Pericardiocentesis, Quality Assurance, Health Care, Stroke


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