Browsing by Subject "Coronary Occlusion"
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Item Application of the "Hybrid Approach" to Chronic Total Occlusions in a Contemporary Multicenter US Registry(2014-02-04) Menon, Rohan; Christopoulos, Georgios; Karmpaliotis, Dimitrios; Alaswad, Khaldoon; Lombardi, William; Grantham, Aaron; Mishoe, Katrina L.; Patel, Vishal G.; Rangan, Bavana V.; Kotsia, Anna P.; Lembo, Nicholas; Kandzari, David; Lee, James; Kalynych, Anna; Carlson, Harold; Garcia, Santiago; Banerjee, Subhash; Thompson, Craig A.; Brilakis, Emmanouil S.BACKGROUND: The "hybrid" approach to coronary chronic total occlusion (CTO) crossing was developed to optimize procedural efficacy, efficiency, and safety. Current strategies of crossing CTOs include antegrade wire escalation, antegrade dissection re-entry, and the retrograde approach. The "hybrid" approach is an algorithm that, based on angiographic characteristics of the lesion, streamlines the selection of the optimal technique for crossing the CTO. The goal of this study was to analyze the impact of the "hybrid" approach to CTO percutaneous coronary intervention on procedural workflow and outcomes at five high-volume US centers. METHODS: We examined the procedural techniques and outcomes of 489 consecutive CTO cases performed using the "hybrid" approach between 2012 and 2013 at 5 US centers from cities including Appleton WI, Atlanta GA, Bellingham WA, Kansas City MO, and Dallas TX. RESULTS: Mean age was 63.8 ± 9.8 years and 86.9% of the patients were men, with high prevalence of diabetes mellitus (41.7%) and prior coronary artery bypass graft surgery (35.7%). Most target CTOs were located in the right coronary artery (61.5%), followed by the left anterior descending artery (20.9%) and left circumflex (16.8%). Dual injection was used in 73.3%. Overall, antegrade wire escalation was used in 62.8%, antegrade dissection re-entry in 38.9% and retrograde in 44.2%. Among successful cases, the final successful crossing technique was antegrade wire escalation in 40.6%, antegrade dissection and re-entry in 27.5%, and retrograde in 31.9%. The initial crossing strategy was successful in 62.0% of the patients, whereas 35.8% required an additional 1 to 4 crossing strategies. Technical success was achieved in 91.6% and major procedural complications occurred in 1.6%. Mean contrast volume, fluoroscopy time, and air kerma radiation exposure were 297.6 ± 154.7 ml, 48.9 ± 31.4 min, 4.4 ± 3.8 Gray, respectively. CONCLUSION: Application of the "hybrid" approach to CTO crossing resulted in high success and low complication rates among a varied operator group and hospital structure, further supporting the value of the "hybrid" approach in crossing these challenging coronary lesions.Item Impact of Crossing Strategy on Intermediate-Term Outcomes After Chronic Total Occlusion Percutaneous Coronary Interventions(2016-01-19) Amsavelu, Suwetha; Christakopoulos, Georgios E.; Tarar, Muhammad Nauman J.; Patel, Krishna; Rangan, Bavana V.; Stetler, Jeffrey; Roesle, Michele; Resendes, Erica; Grodin, Jerrold; Abdullah, Shuaib; Banerjee, Subhash; Brilakis, Emmanouil S.BACKGROUND: There is ongoing controversy on the optimal crossing strategy selection for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially on the relative merits of antegrade dissection/re-entry and the retrograde approach. METHODS: We retrospectively examined the clinical outcomes of 173 consecutive patients who underwent successful CTO PCI at our institution between January 2012 and March 2015. RESULTS: Mean age was 65 ± 8 years and 98% of the patients were men with high prevalence of diabetes (60%), prior coronary artery bypass graft surgery (31%) and prior PCI (54%). The successful CTO crossing strategy was antegrade wire escalation in 79 patients (45.5%), antegrade dissection/re-entry in 58 patients (33.5%), retrograde wire escalation in 11 patients (6.4%) and retrograde dissection and re-entry in 25 patients (14.5%). The retrograde approaches was more commonly used in lesions with interventional collaterals (p<0.0001), moderate/severe calcification (p=0.02), blunt stump (p=0.01) and a higher J-CTO score (p=0.0002). Specifically, the retrograde wire escalation was associated with a prior attempt to open the CTO (p=0.05), and the dissection and re-entry approaches for both antegrade and retrograde had a stronger correlation with bifurcation and the distal cap (p=0.004), higher CTO occlusion length (p<0.0001) and higher stent length (p<0.0001). Median follow-up was 11 months. The 12-month incidence of death, myocardial infarction, and acute coronary syndrome/target lesion revascularization/target vessel revascularization was 2.5%, 4.9%, and 24.4%, respectively and was similar across intimal and subintimal crossing strategies. CONCLUSION: Antegrade dissection/re-entry and retrograde approaches are frequently used during CTO PCI and were associated with similarly favorable intermediate-term outcomes as antegrade wire escalation.Item Impact of Sex on Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention: Insights from a Multicenter US Registry(2017-01-17) Alame, Aya J.; Karmpaliotis, Dimitri; Alaswad, Khaldoon; Jaffer, Farouc A.; Yeh, Robert W.; Wyman, R. Michael; Patel, Mitul; Bahadorani, John; Lombardi, William; Grantham, J. Aaron; Kandzari, David; Lembo, Nicholas; Moses, Jeffrey W.; Kirtane, Ajay; Toma, Catalin; Doing, Anthony; Choi, James; Uretsky, Barry; Karacsonyi, Judit; Resendes, Erica; Karatasakis, Aris; Danek, Barbara A.; Rangan, Bavana V.; Thompson, Craig A.; Banerjee, Subhash; Brilakis, Emmanouil S.INTRODUCTION: The effect of sex on in-hospital outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: Using data collected from 14 experienced U.S. centers between 2012 and 2016, we compared the clinical, angiographic, and procedural characteristics of 1,753 CTO PCIs performed in 1,718 patients by sex. RESULTS: Most patients were men (84.7%) with a mean age of 65.3±10 years. As compared with women, men presented for CTO PCI at a younger age (65.0±10 vs. 66.8±11 years, p=0.022), had higher J-CTO (2.54±1.23 vs. 2.35±1.28, p=0.045) and Progress-CTO (1.05±1.0 vs. 0.875±0.94, p=0.005) scores, longer lesions [30.0 (20.0, 50.0) mm vs. 28.0 (15.0, 40.0) mm, p=0.034] and more moderate to severe tortuosity (36.9% vs. 28.8%, p=0.016). They were also more likely to have had prior coronary artery bypass graft surgery (36.4% vs. 30.0%, p=0.046) and to undergo CTO PCI using the retrograde approach (41.0% vs. 32.6%, p=0.010). The final successful crossing strategy was more likely to be antegrade wire escalation in women (40.8% vs. 54.4%, p<0.001). Technical success was lower in men (88.0% vs. 92.6%, p=0.034), whereas procedural success (86.6% vs. 89.4%, p=0.232) and major adverse cardiovascular events (2.42% vs. 3.41%, p=0.348) were similar (Figure 1). CTO PCI in men was associated with longer procedural time, fluoroscopy time, increased use of contrast, and higher air kerma radiation dose. CONCLUSIONS: As compared with women, CTO PCI in men is associated with higher lesion complexity and lower technical success, but similar procedural success and similar incidence of major adverse cardiovascular events.Item Intravascular Ultrasonography Analysis of the Everolimus-Eluting Stent in Coronary Chronic Total Occlusions(2013-01-22) Navara, Rachita; Brilakis, Emmanouil S.; Rangan, BavanaPURPOSE: Coronary artery disease (CAD) is consistently the number one cause of death for both men and women worldwide. Of the millions of patients diagnosed with CAD, approximately 1 in 5 is found to have a coronary artery that has been 100% blocked for three months or longer, representing the most formidable subset of atherosclerosis: chronic total occlusion (CTO). While drug-eluting stents have demonstrated success in patients with less severe coronary atherosclerosis, little is known about their efficacy in CTOs, which are currently managed by bare metal stents associated with high rates of restenosis. The present study aims to evaluate the effectiveness of the novel Everolimus-Eluting Stent (EES) in CTOs, using intravascular ultrasonography (IVUS) to assess restenosis. METHODS: One hundred consecutive CTO patients who were successfully treated using EES at the Dallas VAMC between 2009-2012 were enrolled in the AngiographiC Evaluation of the Everolimus-Eluting Stent in Chronic Total Occlusions (ACE-CTO trial: NCT01012869). Patients underwent follow-up angiography and IVUS imaging at 8 months and clinical follow-up for up to 12 months. The primary endpoint of this study, binary angiographic restenosis, was defined as >50% minimum lumen diameter stenosis, as assessed by 8-month follow-up quantitative coronary angiography in the treated coronary segment. The primary endpoint of the IVUS analysis was 8-month in-stent neointimal hyperplasia (NIH) volume, defined as the difference between stent and lumen volume. RESULTS: Of the 226 patients who underwent CTO percutaneous coronary intervention (PCI) during the enrollment period, 129 were eligible and 100 agreed to participate. Mean age was 64±7 years, and 99% of the patients were men. Patients had high prevalence of hypertension (91%), hyperlipidemia (90%), diabetes (47%), prior myocardial infarction (51%), and prior PCI (21%). The CTO target vessel was the right coronary artery (70%), left anterior descending artery (16%), circumflex (13%), or left main (1%). The mean number of implanted stents was 3.3±1.3, mean stent diameter was 2.8±1.1 mm, mean stent length was 85±34 mm, and 94 patients had overlapping stents. Binary angiographic restenosis was 45%. Follow-up IVUS analysis of 55 patients revealed low median minimum lumen area (3.3 mm2) and high NIH volume (103.6 mm3). CONCLUSIONS: Everolimus-eluting stent implantation in CTOs is associated with high rates of angiographic restenosis and high NIH volume, suggesting the need for novel therapeutic strategies to improve outcomes in this complex and challenging lesion subgroup.Item Intravascular Ultrasonography Analysis of the Everolimus-Eluting Stent in Coronary Chronic Total Occlusions(2014-02-04) Navara, Rachita; Michael, Tesfaldet; Papayannis, Aristotelis; Patel, Vishal; Fuh, Eric; Alomar, Mohammed; Moin, Danyaal; Brayton, Kimberly; Mogabgab, Owen; Shorrock, Deborah; Tran, Daniel; Roesle, Michele; Rangan, Bavana; Haagen, Donald; Makke, Loren; Abdullah, Shuaib; Luna, Michael; Addo, Tayo; Banerjee, Subhash; Brilakis, Emmanouil S.PURPOSE: Chronic total coronary occlusions (CTOs) are challenging to treat in part due to high rates of restenosis after stenting. Drug-eluting stents improve outcomes compared to bare metal stents. The goal of the present study was to evaluate the angiographic, intravascular ultrasonography (IVUS) and clinical outcomes after implantation of the Everolimus-Eluting Stent (EES) in CTOs. METHODS: One hundred consecutive CTO patients who were successfully treated using EES at the Dallas VAMC between 2009-2012 were enrolled in the AngiographiC Evaluation of the Everolimus-Eluting Stent in Chronic Total Occlusions (ACE-CTO trial: NCT01012869). Patients underwent follow-up angiography and IVUS imaging at 8 months and clinical follow-up at 12 months. The primary endpoint of this study, binary angiographic restenosis, was defined as >50% minimum lumen diameter stenosis at 8-month follow-up quantitative coronary angiography. The primary endpoint of the IVUS analysis was 8-month in-stent neointimal hyperplasia (NIH) volume (stent volume-lumen volume). RESULTS: Patients had high prevalence of hypertension (91%), hyperlipidemia (90%), diabetes (47%), prior MI (51%), and prior PCI (21%). Of the 89 patients who underwent follow-up angiography, binary in-stent angiographic restenosis occurred in 41 patients (46%), and IVUS analysis was performed in 61 patients. IVUS was not performed in 24 patients (8 of whom had occlusive in-stent restenosis), and suboptimal image quality precluded analysis in 4 patients. Mean and median neointimal hyperplasia volume were 68 ±100 and 26 (0, 91) mm3, respectively. This corresponded to a mean and median percent volume obstruction of 12% ± 15% and 5% (0%, 24%), respectively. No NIH could be detected in 33% of patients. CONCLUSIONS: EES implantation in CTO patients is associated with high rates of angiographic restenosis as well as revascularization, yet most patients derived significant symptomatic improvement despite focal NIH formation.Item Technical Success Rates of Endovascular Treatment of Femoropopliteal Chronic Total Occlusions(2016-01-19) Das, Thomas M.; Kocak, Denizen; Planchard, Kyle; Mohammad, Atif; Brilakis, Emmanouil S.; Banerjee, SubhashBACKGROUND: There is limited data on immediate and longerterm outcomes of crossing femoropopliteal (FP) chronic total occlusions (CTO). METHODS: Consecutive patients between January 2006 and March 2015 undergoing endovascular revascularization for symptomatic peripheral artery disease with FP CTO were analyzed as part of the Excellence in Peripheral Artery Disease (XLPAD) registry. Procedural success was defined as restoration of flow through the lesion with ≤30% residual stenosis. Procedural failures included technical failures (defined as failure to cross the CTO or failure to renter the true lumen from the subintimal space) and treatment failures (defined as >30% residual stenosis after successful crossing). One year outcomes were analyzed. RESULTS: A total of 1100 CTO lesions from 948 patients were included in the analysis. Procedural success was achieved in 989 (89.9%) CTO, while procedural failure occurred in 111 (10.1%). Treatment failures comprised 23 (2.1%) and technical failures 88 (8.0%), with 59 (5.4%) intraluminal failures to cross and 29 (2.6%) failures to re-enter from subintimal space. There were significantly more surgical revascularizations following failed procedures compared to successful (13.5% vs. 3.9%;p<0.01), although with a lower need for repeat revascularization procedures (6.3% vs. 20.5%; p<0.01). Need for amputations were similar for patients with failed or successful procedures (5.4% vs. 3.3%; p=.26). Multivariable analysis showed lesion calcification to be an independent predictor of procedural success (p=.03) and multilevel FP disease an independent predictor of procedural failure (p=.03). CONCLUSION: Patients experiencing procedural failures undergo significantly higher rates of surgical revascularization, albeit with lower need for repeat revascularization. Multilevel disease and lesion calcification should both be considered when planning procedural strategy in crossing FP CTO. Further analysis will explore a link between procedural success in calcified lesions and the use of dedicated CTO crossing devices.