Coronary CTA Before Chronic Total Occlusion PCI

Quick Takes

  • In this South Korean study of predominantly young men, performing a detailed coronary CTA rendering of a chronic total occlusion (CTO) before PCI resulted in higher success rates with less complications compared to patients who underwent angiography-only guided CTO PCI.
  • Benefit of pre-procedural coronary CTA was greatest among patients with more complex CTO anatomy (higher J-CTO score).
  • Clinical outcomes at 1 year did not differ in the two groups.

Study Questions:

Does pre-procedural coronary computed tomography angiography (CTA) increase rates of successful percutaneous coronary intervention (PCI) for chronic total occlusion (CTO)?

Methods:

This was a multicenter randomized trial of 400 patients with CTO who were randomized to receive PCI with pre-procedural coronary CTA (coronary CTA–guided group; n = 200) or without coronary CTA (angiography-guided group; n = 200) between January 2014–September 2019. The primary endpoint was the successful recanalization rate, a final TIMI (Thrombolysis In Myocardial Infarction) grade ≥2, and ≤30% residual stenosis on the final angiogram.

Results:

A total of 10 operators performed PCI. Successful recanalization was achieved in 187 patients (93.5%) in the coronary CTA–guided group and in 168 patients (84.0%) in the angiography-guided group (absolute difference, 9.5% [95% confidence interval, 3.4%-15.6%]; p = 0.003). When comparing the success rates according to the Multicenter CTO Registry of Japan score (J-CTO), the coronary CTA guidance was favored over the angiography-guidance in the subset of J-CTO ≥2 versus in the subset of J-CTO <2 (pinteraction = 0.035). Coronary perforations occurred in two (1%) and eight patients (4%) in the coronary CTA- and angiography-guided groups, respectively (p = 0.055). Periprocedural myocardial infarction was not observed in the coronary CTA–guided group, whereas it occurred in four patients (2%) in the angiography-guided group (p = 0.123). Total procedure and fluoroscopic times were not different. There were no differences between the groups in the occurrences of cardiac death, target vessel–related myocardial infarction, or target vessel revascularization at 1 year.

Conclusions:

Pre-procedural coronary CTA-guidance for CTO resulted in higher success rates with numerically fewer immediate periprocedural complications such as coronary perforations or periprocedural myocardial infarction than angiography guidance. Higher success rates were more prominently observed in patients with CTO who had a high J-CTO score than those who did not.

Perspective:

This is the first randomized trial assessing pre-procedural planning using coronary CTA to guide CTO PCI. In this South Korean study of predominantly young men, performing a detailed coronary CTA rendering of a CTO before PCI resulted in higher success rates with less complications compared to patients who underwent angiography-only guided CTO PCI. Benefit of coronary CTA was greatest among patients with more complex CTO anatomy (higher J-CTO score). The strategy of using coronary CTA to attempt and predict a successful CTO PCI was not evaluated in this study and remains to be determined. However, for patients undergoing PCI of a CTO, the addition of coronary CTA imaging improved successful revascularization rate.

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

Keywords: Computed Tomography Angiography, Constriction, Pathologic, Coronary Angiography, Coronary Occlusion, Coronary Vessels, Diagnostic Imaging, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Thrombolytic Therapy, Tomography, X-Ray Computed


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