Study Questions:

What are the techniques and outcomes of hybrid chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a diverse group of patients and operators on two continents?


The investigators examined contemporary outcomes of CTO PCI by analyzing the clinical, angiographic, and procedural characteristics of 3,122 CTO interventions performed in 3,055 patients at 20 centers in the United States, Europe, and Russia. Technical success was defined as successful CTO revascularization with achievement of <30% residual diameter stenosis within the treated segment and restoration of TIMI antegrade flow grade 3. In-hospital major adverse cardiac events (MACE) included any of the following adverse events before hospital discharge: death, myocardial infarction, recurrent symptoms requiring urgent repeat target vessel revascularization with PCI or coronary artery bypass grafting (CABG), tamponade requiring either pericardiocentesis or surgery, and stroke. Multivariate logistic regression with stepwise backward elimination was performed to examine the independent association between annual CTO PCI volume and procedural outcomes (procedural success and in-hospital MACE).


The mean age was 65 ± 10 years, and 85% of the patients were men, with high prevalence of diabetes (43%), prior myocardial infarction (46%), prior CABG (33%), and prior PCI (65%). The CTO target vessels were the right coronary artery (55%), left anterior descending coronary artery (24%), and left circumflex coronary artery (20%). The mean J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores were 2.4 ± 1.3 and 1.3 ± 1.0, respectively. The overall technical and procedural success rate was 87% and 85%, respectively, and the rate of in-hospital major complications was 3.0%. The final successful crossing strategy was antegrade wire escalation in 52.0%, retrograde in 27.1%, and antegrade dissection re-entry in 20.9%; >1 crossing strategy was required in 40.9%. Median contrast volume, air kerma radiation dose, and procedure and fluoroscopy time were 270 ml (interquartile range [IQR], 200-360 ml), 2.9 Gy (IQR, 1.7-4.7 Gy), 123 minutes (IQR, 81-188 minutes), and 47 minutes (IQR, 29-77 minutes), respectively.


The authors concluded that CTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the United States, Europe, and Russia.


This study reports a high technical success rate (88%) with an acceptable major complication rate (3.0%) using the hybrid approach (i.e., use of all crossing strategies: antegrade wire escalation, antegrade dissection re-entry, and the retrograde approach) for CTO PCI. Furthermore, these outcomes were achieved despite high lesion complexity and relatively low success of the initially selected CTO crossing strategy (55%). However, it should be noted that the procedures were performed at dedicated, high-volume CTO centers by experienced operators, thus limiting the extrapolation to less experienced operators at low-volume centers. Despite the encouraging findings of this study and other contemporary registries, the success rates of CTO interventions in unselected patient cohorts remain low. Hence, CTO PCI should be performed by experienced operators at dedicated centers to achieve optimal results.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Aortic Surgery, Interventions and Imaging, Nuclear Imaging

Keywords: Cardiac Surgical Procedures, Constriction, Pathologic, Coronary Artery Bypass, Coronary Occlusion, Diabetes Mellitus, Experimental, Fluoroscopy, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Pericardiocentesis, Radiation Dosage, Stroke

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