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PROGRESS CTO registry highlights feasibility of hybrid approach at experienced centers

SAN DIEGO — As chronic total occlusion PCI continues to evolve with new equipment and techniques, new data from the PROGRESS CTO Registry — the largest study to date on the hybrid approach — show that CTO PCI is being performed with high success and acceptable complications rates across experienced centers in the United States, Europe and Russia.

Among 3,122 CTO PCI procedures performed in 3,055 patients at 20 centers in the United States, Europe and Russia, overall technical success was 87% and procedural success was 85%.

The rate of in-hospital major complications was 3%, including MI in 1.1%, death in 0.9%, pericardial tamponade in 0.9%, stroke in 0.3%, and emergency CABG in 0.2%. Complications were less frequent in technically successful procedures (2.2% vs. 7.9%; P < .0001).

Patients in this registry had a mean age of 65 years, 85% were men and there was a high prevalence of diabetes, prior MI, prior CABG and prior PCI. The majority of patients were asymptomatic. The mean J-CTO score was 2.4 and the mean PROGRESS CTO score was 1.3.

In half of the cases, the right coronary artery was the CTO target vessel, followed by the left anterior descending artery (24%) and left circumflex coronary artery (20%).

Antegrade wire escalation was used in 75% as the initial approach, especially for patients with lower-complex CTOs, while antegrade dissection re-entry and the retrograde approach were used for more complex lesions. The initial approach was successful in 55% of patients, while 41% required further attempts to achieve a technical success rate of 79%. Antegrade wire escalation was the final successful crossing strategy in 52%, retrograde in 27.1% and antegrade dissection re-entry in 20.9%.

Radial access was used in 37% of cases; a biradial approach was utilized in 14% and in combination with a femoral approach in 20%. Use of femoral and bifemoral approaches were more frequent in patients with more complex lesions.

Median contrast volume was 270 ml and air kerma radiation dose was 2.6 Gy. Median procedure time was 123 minutes and fluoroscopy time was 47 minutes.

Procedure volume played a role in success. Procedural success was likely to be higher at centers with higher annual CTO PCI volume.

“To the best of our knowledge, this is the largest study reported to date on CTO PCI using the hybrid approach, demonstrating high technical success rate with an acceptable major complication rate. These outcomes were achieved despite high lesion complexity and relatively low success of the initially selected CTO crossing strategy,” Peter Tajti, MD, from Abbott Northwestern Hospital, Minneapolis Heart Institute, and colleagues wrote in JACC: Cardiovascular Interventions.

Gregg W. Stone, MD
Gregg W. Stone

Discussing the findings at the Society for Cardiovascular Angiography and Interventions Scientific Sessions, Tajti said these results “provide important benchmarking for discussion of the risk-benefit ratio of CTO PCI with patients and providers.”

The researchers noted that “previous smaller studies have provided similarly encouraging results.”

In an editorial published in JACC: Cardiovascular Interventions, Cardiology Today’s Intervention Editorial Board Member Gregg W. Stone, MD, professor of medicine at Columbia University Medical Center, director of cardiovascular research and education for Columbia University Medical Center/NewYork-Presbyterian Hospital, co-director of medical research and education at the Cardiovascular Research Foundation, referred to the current update as “the magnus opus of CTO PCI technique.” Looking ahead, “the focus now needs to shift to 1) appropriate patient selection and demonstration of clinical use; and 2) ensuring that most patients with CTOs who can derive benefit are provided access to expert care.”

“Bridging the gap of what is currently achieved at most centers and what can be achieved should be a major focus of upcoming research and education,” Tajti said here. – by Katie Kalvaitis

References:

Tajti P. Late Breaking Clinical Science I. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; April 25-28, 2018; San Diego.

Stone GW. JACC Cardiovasc Interv. 2018;doi:10.1016/j.jcin.2018.03.031.

Tajti P, et al. JACC Cardiovasc Interv. 2018;doi:10.1016/j.jcin.2018.02.036.

Disclosure: Tajti reports no relevant financial disclosures. Please see the full study for the other authors’ relevant financial disclosures. Stone reports he is a consultant for Matrizyme.

SAN DIEGO — As chronic total occlusion PCI continues to evolve with new equipment and techniques, new data from the PROGRESS CTO Registry — the largest study to date on the hybrid approach — show that CTO PCI is being performed with high success and acceptable complications rates across experienced centers in the United States, Europe and Russia.

Among 3,122 CTO PCI procedures performed in 3,055 patients at 20 centers in the United States, Europe and Russia, overall technical success was 87% and procedural success was 85%.

The rate of in-hospital major complications was 3%, including MI in 1.1%, death in 0.9%, pericardial tamponade in 0.9%, stroke in 0.3%, and emergency CABG in 0.2%. Complications were less frequent in technically successful procedures (2.2% vs. 7.9%; P < .0001).

Patients in this registry had a mean age of 65 years, 85% were men and there was a high prevalence of diabetes, prior MI, prior CABG and prior PCI. The majority of patients were asymptomatic. The mean J-CTO score was 2.4 and the mean PROGRESS CTO score was 1.3.

In half of the cases, the right coronary artery was the CTO target vessel, followed by the left anterior descending artery (24%) and left circumflex coronary artery (20%).

Antegrade wire escalation was used in 75% as the initial approach, especially for patients with lower-complex CTOs, while antegrade dissection re-entry and the retrograde approach were used for more complex lesions. The initial approach was successful in 55% of patients, while 41% required further attempts to achieve a technical success rate of 79%. Antegrade wire escalation was the final successful crossing strategy in 52%, retrograde in 27.1% and antegrade dissection re-entry in 20.9%.

Radial access was used in 37% of cases; a biradial approach was utilized in 14% and in combination with a femoral approach in 20%. Use of femoral and bifemoral approaches were more frequent in patients with more complex lesions.

Median contrast volume was 270 ml and air kerma radiation dose was 2.6 Gy. Median procedure time was 123 minutes and fluoroscopy time was 47 minutes.

Procedure volume played a role in success. Procedural success was likely to be higher at centers with higher annual CTO PCI volume.

“To the best of our knowledge, this is the largest study reported to date on CTO PCI using the hybrid approach, demonstrating high technical success rate with an acceptable major complication rate. These outcomes were achieved despite high lesion complexity and relatively low success of the initially selected CTO crossing strategy,” Peter Tajti, MD, from Abbott Northwestern Hospital, Minneapolis Heart Institute, and colleagues wrote in JACC: Cardiovascular Interventions.

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Gregg W. Stone, MD
Gregg W. Stone

Discussing the findings at the Society for Cardiovascular Angiography and Interventions Scientific Sessions, Tajti said these results “provide important benchmarking for discussion of the risk-benefit ratio of CTO PCI with patients and providers.”

The researchers noted that “previous smaller studies have provided similarly encouraging results.”

In an editorial published in JACC: Cardiovascular Interventions, Cardiology Today’s Intervention Editorial Board Member Gregg W. Stone, MD, professor of medicine at Columbia University Medical Center, director of cardiovascular research and education for Columbia University Medical Center/NewYork-Presbyterian Hospital, co-director of medical research and education at the Cardiovascular Research Foundation, referred to the current update as “the magnus opus of CTO PCI technique.” Looking ahead, “the focus now needs to shift to 1) appropriate patient selection and demonstration of clinical use; and 2) ensuring that most patients with CTOs who can derive benefit are provided access to expert care.”

“Bridging the gap of what is currently achieved at most centers and what can be achieved should be a major focus of upcoming research and education,” Tajti said here. – by Katie Kalvaitis

References:

Tajti P. Late Breaking Clinical Science I. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; April 25-28, 2018; San Diego.

Stone GW. JACC Cardiovasc Interv. 2018;doi:10.1016/j.jcin.2018.03.031.

Tajti P, et al. JACC Cardiovasc Interv. 2018;doi:10.1016/j.jcin.2018.02.036.

Disclosure: Tajti reports no relevant financial disclosures. Please see the full study for the other authors’ relevant financial disclosures. Stone reports he is a consultant for Matrizyme.

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