Search Results (56)

Coronary chronic total occlusions (CTOs) are diagnosed in a significant portion of patients undergoing coronary angiography and represent one of the most complex scenarios in contemporary percutaneous coronary interventions (PCI). This review systematically examines how adjunctive imaging modalities’—intravascular ultrasound (IVUS), optical coherence tomography (OCT), and coronary computed tomography angiography (CCTA)—co-registration enhances the precision and success rates of CTO-PCI during the procedure. The strategic integration of these technologies enables the development of patient-specific intervention strategies tailored to individual vascular architecture and lesion characteristics. This personalized approach marks a transition from standardized protocols to precision interventional cardiology, potentially optimizing procedural success rates while minimizing complications. Full article

Background: Patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD) who undergo complete revascularization (CR) have a more favorable prognosis than those who receive incomplete revascularization (IR), as evidenced by recent randomized controlled trials. Despite the absence of a survival benefit associated with CR in these trials, positive outcomes were ascribed to combined endpoints, such as repeat revascularization, myocardial infarction, or ischemia-driven rehospitalization. In light of the significant burden that rehospitalization from STEMI imposes on healthcare systems, we examined the long-term effects of CR on ischemia-driven rehospitalization and cardiovascular (CV) mortality in STEMI patients with MVD. Methods: In our retrospective study, we included patients with STEMI and MVD who underwent successful primary percutaneous coronary intervention (PCI) at the University Medical Centre Ljubljana between 1 January 2009, and 11 April 2011. The combined endpoint was ischemia-driven rehospitalization and CV mortality, with a minimum follow-up period of six years. Results: We included 235 participants who underwent CR (N = 70) or IR (N = 165) at index hospitalization, with a median follow-up time of 7 years (interquartile range 6.0–8.2). The primary endpoint was significantly higher in the IR group than in the CR group (47.3% vs. 32.9%, log-rank p = 0.025), driven by CV mortality (23.6% vs. 12.9%, log-rank p = 0.047), as there was no difference in ischemia-driven rehospitalization rate (log-rank p = 0.206). Ischemia-driven rehospitalization did not influence CV mortality in the CR group (p = 0.49), while it significantly impacted CV mortality in the IR group (p = 0.03). After adjusting for confounders, there were no differences in CV mortality between CR and IR groups (p = 0.622). Predictors of the combined endpoint included age (p = 0.014), diabetes (p = 0.006), chronic kidney disease (CKD) (p = 0.001), cardiogenic shock at presentation (p = 0.003), chronic total occlusion (CTO) (p = 0.046), and ischemia-driven rehospitalization (p = 0.0001). Significant risk factors for the combined endpoint were cardiogenic shock at presentation (p < 0.001), stage 4 kidney failure (p = 0.001), age over 70 years (p = 0.004), female gender (p = 0.008), and residual SYNTAX I score > 5.5 (p = 0.017). Conclusions: Patients with STEMI and MVD who underwent CR had a lower combined endpoint of ischemia-driven rehospitalizations and CV mortality than IR patients, but after adjustments for confounders, the true determinants of the combined endpoint and risk factors for the combined endpoint were independent of the revascularization method. Full article

Background/Objectives: Data on the prognostic value of frailty in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is limited. This study aimed to evaluate the association between frailty and in-hospital complications in patients undergoing CTO-PCI. Methods: We conducted a retrospective cohort study using administrative data from the National Inpatient Sample (2016–2019). Frailty was assessed using the Hospital Frailty Risk Score (HFRS) and categorized into three groups: low risk (<5), intermediate risk (5–15), and high risk (>15). Logistic regression models were applied to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital complications. Results: A total of 46,695 patients undergoing CTO-PCI were included. In the adjusted models, patients at high risk of frailty had higher odds of in-hospital mortality (OR 9.51, 95% CI 3.49–26.00), blood transfusion (OR 4.78, 95% CI 1.72–13.20), pericardial complication (OR 16.0, 95% CI 4.85–52.90), and renal replacement therapy (OR 3.83, 95% CI 1.22–12.00) compared to the low-risk group. Intermediate-risk patients also experienced higher odds of most outcomes. Conclusions: Frailty was a significant predictor of in-hospital complications in patients undergoing PCI for CTO. Incorporating frailty assessment into routine clinical practice could enhance risk stratification and enable tailored care strategies for this high-risk population. Full article

Chronic total occlusions (CTOs), defined as complete coronary artery blockages persisting for over three months, are frequently encountered in up to 25% of coronary angiograms. Although percutaneous coronary intervention (PCI) for CTO remains technically challenging, advancements in guidewires, microcatheters, re-entry devices, and intravascular imaging, along with the expertise of specialized operators, have significantly improved procedural success rates, now exceeding 90% in expert centers. While recent evidence, such as the SYNTAX II study, emphasizes the importance of complete revascularization, over half of CTO cases continue to be managed conservatively with optimal medical therapy (OMT), partly due to the limited high-quality randomized evidence supporting revascularization. Observational studies have demonstrated that successful CTO-PCI is associated with improved angina relief, quality of life, left ventricular function, and possibly long-term survival. Extended observational follow-up, such as the Korean and Canadian registries, suggests long-term reductions in cardiac and all-cause mortality with CTO revascularization. However, randomized controlled trials (RCTs) have primarily shown symptomatic benefit, with no consistent reduction in major adverse cardiac events (MACE) or mortality, likely due to limited sample sizes, short follow-up, and treatment crossovers. Various strategies, including the hybrid algorithm, guide CTO interventions by balancing antegrade and retrograde techniques based on lesion complexity. Imaging modalities such as coronary CT angiography and intravascular ultrasound play a pivotal role in planning and optimizing these procedures. Future innovations, such as real-time fusion imaging of CCTA with coronary angiography, may enhance lesion visualization and guidewire navigation. While current guidelines recommend CTO-PCI in selected symptomatic patients with demonstrable ischemia or viable myocardium, the decision should be individualized, incorporating anatomical feasibility, comorbidities, patient preferences, and input from a multidisciplinary Heart Team. Looking ahead, adequately powered RCTs with extended follow-up are essential to determine the long-term clinical impact of CTO-PCI on hard outcomes such as mortality and myocardial infarction. Full article

Background: Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) remains a complex procedure that requires advanced operator skills and dedicated devices. Despite increased success rates in experienced centers, the in-hospital complications of CTO PCI remain notably high. Female patients undergoing CTO PCI are reported to experience higher rates of complications; however, the underlying mechanisms remain inadequately defined. Methods: We prospectively enrolled consecutive patients undergoing CTO PCI at our university-affiliated tertiary care center over 4 years (2018–2021), aiming to elucidate sex-based disparities in in-hospital complications. In addition, we investigated the impact of angiographic femoral artery metrics on in-hospital complications. Results: Among 271 patients who underwent antegrade or retrograde CTO PCI, 222 (81.9%) were men and 49 (18.9%) women. Female patients were significantly older (67 ± 11 vs. 72 ± 12 years; p = 0.005) and had a comparable lesion complexity. Women exhibited smaller femoral artery diameters, more side branches at the puncture area and higher bifurcations. In-hospital complications occurred more frequently in women compared to men (16.3% vs. 6.8%; p = 0.044). Female sex independently predicted in-hospital complications (OR = 2.92; CI 1.07 to 7.60; p = 0.024), yet lost significance after adjustment for femoral artery characteristics. Maximal femoral artery diameter (OR = 0.30, 95% CI: 0.17 to 0.50, p < 0.001) and side-branch density (OR = 2.45, 95% CI: 1.26 to 5.20, p = 0.012) independently predicted in-hospital complications. Conclusions: Female patients undergoing CTO PCI are at increased risk for procedural complications, likely driven by femoral artery anatomical differences. Detailed pre-procedural assessment of femoral artery metrics may improve patient selection, procedural planning, and outcomes, particularly among women. Full article

Although chronic total occlusions (CTO) are a common finding in patients treated with coronary artery bypass grafting (CABG), it is still not clear how their presence impacts the long-term outcomes achieved with surgery. We aimed to investigate the impact of CTO on the long-term results of patients with coronary artery disease who underwent CABG. Patients from 2005 to 2023 operated on at the University Hospital Freiburg-Bad Krozingen were analyzed. The primary outcome was all-cause mortality after 3-, 5-, and 10 years. The secondary outcome was the need for coronary reintervention in the follow-up period. Propensity score matching and multivariable Cox regression were performed, and Kaplan–Meier curves were used to graphically display the outcomes for the two groups. Of the 3424 patients included in the analysis, 1784 (52%) were categorized as CTO and 1640 (48%) were categorized as no-CTO. After propensity scoring, 1232 pairs were successfully matched. The 3-, 5-, and 10-year all-cause mortality was significantly higher in patients with CTO (p = 0.028; p < 0.001; p < 0.001). The need for coronary reintervention after 3-, 5-, and 10 years was comparable in both groups. In addition, multivariable Cox Regression showed that CTO presence (HR 1.220, 95% CI 1.047–1.420, p = 0.010) was an independent predictor of 10-year mortality. Full article

The impact of atrial fibrillation (AF) on patients with chronic total occlusions (CTOs) at the national level remains unclear. In this study, we conducted a retrospective analysis of data from the National Inpatient Sample to assess the characteristics and in-hospital outcomes of patients with CTO based on the presence or absence of AF. Multiple logistic and linear regressions examined factors associated with AF and evaluated its impact on length of stay (LoS), cost, and mortality. The analysis included 480,180 patients diagnosed with CTO, with AF present in 28.0% of cases. Patients with CTOs and AF were older (median age 73 vs. 66 years, p < 0.001) and exhibited lower female representation (25.0% vs. 27.9%, p < 0.001). Factors most strongly associated with AF included previous heart failure (OR 1.98, 95% CI 1.92–2.05, p < 0.001), liver disease (OR 1.37, 95% CI 1.27–1.48, p < 0.001), and obesity (OR 1.25, 95% CI 1.20–1.30, p < 0.001). AF correlated with increased in-hospital mortality (OR 1.29, 95% CI 1.18–1.40, p < 0.001), ischemic stroke (OR 1.27, 95% CI 1.13–1.42, p < 0.001), and major bleeding (OR 1.38, 95% CI 1.30–1.46). Moreover, AF was associated with a longer LoS (coef 1.58, 95% CI 1.50 to 1.67, p < 0.001) and higher in-hospital costs (coef 6.22, 95% CI 5.81 to 6.63, p < 0.001). Patients with CTOs and AF were older and had more underlying health problems compared to patients without AF. The patients with AF have worse outcomes in terms of mortality, ischemic stroke, major bleeding, length of stay, and costs. Full article

Coronary chronic total occlusions (CTOs) have been a point of interest of the medical community for the last decade. The natural history of CTOs was for a long time unknown, as the presence of a single CTO was the most frequent cause for the exclusion of patients from randomized controlled trials (RCTs). Recent CTO RCTs have failed to show any benefit in terms of hard endpoints as major adverse cardiovascular events, but have shown a significant improvement in quality of life, as well in the frequency of angina; however, these studies are characterized by the limitation of the short duration of their follow-up period. Real-world data from observational studies indicate a significant improvement in cardiovascular death and overall mortality, suggesting that the results depend on the duration of the follow-up, and not on the procedure per se. The aim of the current review is to summarize all the existing RCTs, and to analyze the most important registries, as well as to present the current development of techniques to boost the successful interventional treatment of CTOs. Full article

The diagnosis of chronic total occlusion (CTO), characterized by the complete obstruction of a coronary artery for at least three months, remains challenging and can be entirely asymptomatic. Since the indications for performing a recanalization procedure for CTO do not originate from randomized controlled trials, this study aimed to assess the indications, management, and procedural outcomes of patients undergoing percutaneous revascularization (PCI) for a CTO, ensuring that the population was as uniform as possible regarding technologies and methodological approaches. Forty-one consecutive patients who underwent PCI for CTO recanalization were enrolled from January 2021 to 2024. Additional outcomes included mortality, major adverse cardiovascular events, and the presence of residual cardiac symptoms, with a median follow-up of 449 days and an interquartile range of 230–643 days. Our real-life study confirmed that PCI for CTO has a high success rate and a low incidence of major complications. Full article

Introduction: The number of chronic total occlusion (CTO) revascularization procedures has continuously increased, obtaining better results in recent years. However, there are few data regarding long-term outcomes and no comparisons to planned complex non-CTO percutaneous coronary intervention (PCI). Methods: We included all patients undergoing planned complex PCI. Our main objective was to compare a combined endpoint of all-cause death, myocardial infarction, and target vessel revascularization at the long-term follow-up of CTO PCI versus planned complex non-CTO PCI. We compared the groups using multivariable Cox regression and performed a propensity score matching analysis to control the baseline characteristics. We repeated the analysis for the separate components of the primary endpoint. Results: From January 2018 to June 2023, 1394 complex coronary PCIs were performed at our center. After excluding 393 non-planned cases, 201 CTO PCIs and 800 non-CTO PCIs were included. The mean follow-up was 2.5 ± 1.5 years. The composite endpoint occurred in 23 (11.6%) CTO PCIs and 219 (28.2%) planned non-CTO PCIs. The multivariable Cox regression using the CTO group as the reference showed a lower risk for the primary outcome (HR: 0.59; 95% CI 0.37–0.95; p = 0.031). After matching, a total of 195 adequately balanced pairs were obtained. The CTO group presented a lower risk for the primary combined outcome (HR: 0.46; 95% CI 0.27–0.76; p = 0.003). Conclusions: In patients undergoing planned complex PCI, those in the CTO group presented a reduced risk of all-cause death, myocardial infarction, and target vessel revascularization at the end of the follow-up. Full article

Introduction: Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) requires advanced techniques and prolonged procedural efforts, often necessitating high contrast volumes, which may increase the risk of contrast-associated acute kidney injury (CA-AKI). However, evidence suggests that factors beyond contrast exposure contribute to CA-AKI, though data specific to CTO PCI remain limited. Methods: Patients undergoing contemporary CTO PCI at our university-affiliated tertiary care center were enrolled. CA-AKI was defined according to KDIGO criteria, and patients were stratified based on the presence of postprocedural CA-AKI. Baseline and procedural characteristics, including osmotic factors, were compared between the groups. The primary outcome was all-cause mortality at one year, and the secondary outcome was all-cause mortality at three years. Results: A total of 145 patients were enrolled, with a mean age of 67 years, and 75% were male. Baseline creatinine levels, electrolytes, and osmotic factors did not differ significantly between groups. Lesion parameters and J-CTO scores were also comparable. The contrast volume and procedural duration were numerically higher in patients who developed CA-AKI. Patients with CA-AKI received a higher radiation dose (22.1 vs. 13.2 Gy·cm², p = 0.041). CA-AKI emerged as an independent predictor of all-cause mortality at one year (adjusted HR 5.3, CI [1.52–18.51], p = 0.009) but not at three years. Conclusions: In this retrospective analysis, CA-AKI was an independent predictor of all-cause mortality at one year following CTO PCI but lost predictive value at three years. Baseline renal function and contrast volume alone did not predict CA-AKI. Instead, procedural complexity, reflected by higher radiation exposure, was associated with an elevated risk of CA-AKI. Full article

Background and aim: Patients with non-infarct-related artery chronic total occlusion (non-IRA CTO) found during percutaneous coronary intervention (PCI) in acute coronary syndromes (ACSs) are not rare and have worse clinical outcomes. We aimed to analyze their long-term clinical outcomes in regard to clinical characteristics, revascularization strategies, and adherence to medical therapy. Patients and methods: The dual-center ACS registry of patients treated from Jan 2017 to May 2023 was used to identify 1950 patients with timely PCI in ACS who survived to discharge with documented adequate demographic, clinical, and angiographic characteristics, treatment strategies, and medical therapy adherence during a median follow-up time of 49 months. Results: There were 171 (9%) patients with non-IRA CTO. In comparison to patients without non-IRA CTO, they were older, with more diabetes mellitus (DM), higher Syntax scores (median 27.5 vs. 11.5), and lower left ventricular ejection fraction (LVEF) at discharge (median LVEF 50% vs. 55%). There was also a lower proportion of patients with high adherence to medical therapy (32% vs. 46%). Patients with non-IRA CTO had significantly higher cardiovascular mortality during follow-up (18% vs. 8%, RR 1.87, 95% CI 1.27–2.75). After adjusting for relevant clinical and treatment characteristics in a multivariate Cox regression analysis, only lower LVEF, worse renal function, the presence of DM, and lower adherence to medical therapy were independently associated with higher cardiovascular mortality during follow-up, with low adherence to medical therapy as the strongest predictor (RR 3.18, 95% CI 1.76–5.75). Time to cardiovascular death was significantly lower in patients who did not receive non-IRA CTO revascularization, although CTO revascularization did not show independent association with survival in the multivariate analysis. Conclusions: Patients with non-IRA CTO found during ACS treatment have more unfavorable clinical characteristics, worse adherence to medical therapy, and higher cardiovascular mortality. They need a more scrutinized approach during follow-up to increase adherence to optimal medical therapy and to receive revascularization of the non-IRA CTO whenever it is clinically indicated and reasonably achievable without excess risks. Full article

Although coronary artery occlusion can have a negative effect on the myocardium, chronic total occlusion (CTO) exhibits different clinical features from those of acute myocardial infarction (AMI). In this study, we identify the differential associations of exosomal miRNAs with CTO and AMI. Exosomes were isolated from the plasma obtained from coronary arteries of patients undergoing percutaneous coronary intervention to treat CTO (n = 29) and AMI (n = 24), followed by small RNA sequencing, target gene predictions, and functional enrichment analyses. Promising miRNA markers were validated using real-time PCR in 35 CTO, 35 AMI, and 10 normal subjects. A total of 205 miRNAs were detected in all subjects, and 20 and 12 miRNAs were upregulated and downregulated in CTO compared to AMI patients, respectively (|fold change| > 4, FDR q < 0.05). The target genes of miRNAs that were higher in CTO patients were associated with “regulation of cell cycle phase transition”, “cell growth”, and “apoptosis”. The target genes of miRNAs that were lower in CTO patients were enriched in terms such as “muscle cell differentiation”, “response to oxygen levels”, and “artery morphogenesis”. On qRT-PCR analysis, the expression levels of miR-9-5p and miR-127-3p were significantly different between CTO and AMI patients. The miRNA expression levels accurately distinguished CTO from AMI patients with 79% specificity and 97% sensitivity. The miRNA contents of plasma exosomes were significantly different between CTO and AMI patients. The miRNAs may play important roles in CTO and AMI. Full article

Chronic total occlusions (CTOs) represent a challenging scenario in coronary artery disease (CAD). The prevalence of CTOS in patients undergoing coronary angiography underscores the need for effective diagnostic and therapeutic strategies. Coronary angiography, while essential, offers limited insights into lesion morphology, vessel course, and myocardial viability. In contrast, coronary imaging techniques—including optical coherence tomography (OCT), intravascular ultrasound (IVUS), and coronary computed tomography angiography (CCTA)—provide comprehensive insights for each stage of CTO percutaneous coronary intervention (PCI). OCT facilitates the assessment of plaque morphology and stent optimization, despite low evidence and several limitations in CTO-PCI. IVUS offers deeper penetration, allowing managing proximal cap scenarios and guiding subintimal navigation. CCTA provides a non-invasive, three-dimensional view of coronary anatomy, enabling the precise evaluation of myocardial mass at risk and detailed procedural planning. Despite their individual limitations, these imaging modalities have enhanced the success rates of CTO-PCI, thus reducing procedural and long-term complications and improving patient outcomes. The future of CTO management lies in further technological advancements, including hybrid imaging, artificial intelligence (AI) integration, and improved fusion imaging. These innovations promise to refine procedural precision and personalize interventions, ultimately improving the care of patients with complex coronary artery disease. Full article

Percutaneous coronary intervention (PCI) to chronic total occlusion (CTO) is still a subject of debate. The primary goal of revascularization is to provide symptomatic relief and enhance left ventricular (LV) functions. Global longitudinal strain (GLS) is proven to be more sensitive than the ejection fraction (EF), especially for subtle ischemic changes. The purpose of this study was to investigate the improvement in LV GLS after revascularization of symptomatic stable coronary patients with single-vessel CTO, categorized according to their collateral supply grades. Sixty-nine patients with successful CTO-PCI were grouped, according to their collateral supply grades, as well-developed (WD) and poor collateral groups and followed-up for 3 months. Basal characteristics were similar for both groups, except for a lower EF (p = 0.04) and impaired GLS (p < 0.0001) in the poor collateral group. At the end of 3 months follow-up, symptomatic relief was similar in both groups (p = 0.101). GLS improvement reached statistical significance only for the poor collateral, not for the WD group (p < 0.0001 and p = 0.054, respectively). The EF did not change significantly in both groups. Poorly collateralized CTO lesions may not only result in baseline LV dysfunction, but also appear to carry potential for recovery after revascularization. This may not be the case for WD collaterals. Full article