Guide Catheter Extension Use in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS CTO Registry

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00117. Epub August 2, 2024.

There are limited data on the use of guide catheter extensions (GCE) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the frequency and temporal trends of GCE use in a large multicenter CTO-PCI registry and compared the clinical and angiographic characteristics and outcomes of cases with vs without GCE use. A GCE was used in 4106 of 14 521 CTO PCIs (28%) with increasing frequency from 18.8% in 2012 to 29.9% in 2023. The most used GCE size was 6 French (Fr) (45%), followed by 7 Fr (34%), and 8 Fr (21%). CTOs that required GCE use were more likely to have unfavorable lesion characteristics such as moderate-to-severe calcification (59% vs 40%, P < .0001), moderate-to-severe tortuosity (35% vs 28%, P < .0001), proximal cap ambiguity (39% vs 33%, P < .0001), and had higher J-CTO scores (2.78 ± 1.15 vs 2.20 ± 1.27, P < .0001). Advanced techniques like the retrograde approach (44% vs 24%, P < .0001) and antegrade dissection and re-entry (28% vs 17%, P < .0001) were more likely to be used in GCE cases. Technical success (86.6% vs 86.8%, P = .816) was similar between the 2 groups. However, major adverse cardiovascular events (MACE) (3.8% vs 2.4%, P < .0001) and procedural complications (11.2% vs 8.7%, P < .0001) were more frequent in the GCE group. In summary, GCE use in CTO PCI significantly increased between 2012 and 2023. Cases that required GCEs were more complex and had similar technical success, but higher incidence of MACE compared with cases that did not require GCEs.

Guide catheter extensions (GCE) can facilitate complex percutaneous coronary interventions (PCI), including chronic total occlusion (CTO) PCI. GCEs can assist with vessel engagement and equipment delivery in complex anatomies especially, such as lesions with severe calcifications and tortuosity, and in post-coronary artery bypass graft surgery (CABG) patients.¹ GCEs have multiple applications in both antegrade and retrograde techniques in CTO PCI.² We examined the frequency and temporal trends of GCE use in a large CTO-PCI registry.  

We examined the frequency and temporal trends of GCE use in CTO-PCI cases that were performed at multiple US and non-US centers participating in the PROGRESS CTO Registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; Clinicaltrials.gov identifier: NCT02061436) between 2012 and 2023. We then compared the clinical and angiographic characteristics and outcomes of cases with vs without GCE use. The study was approved by the institutional review board of each center.

A GCE was used in 4106 of 14 521 CTO PCIs (28%) performed between 2012 and 2023 at high-volume centers. GCE use increased from 18.8% in 2012 to 29.9% in 2023 (P < .0001) (Figure 1). Most guide catheter extensions (81%) were used through the antegrade guide catheter, while 19% were used in the retrograde guide catheter. The most commonly used GCE was the Trapliner (Teleflex) (46.4%), followed by the Guideliner (Teleflex) (35.2%), and the Guidezilla (Boston Scientific) (15.2%) (Figure 2). The most commonly used GCE size was 6 French (Fr) (45%), followed by 7 Fr (34%), and 8 Fr (21%) (Figure 3).

Patients with CTOs that required use of a GCE were older (66 ± 10 vs 64 ± 29, P = .0002) and had more comorbidities, such as diabetes ( 47% vs 42%, P < .0001), dyslipidemia (92% vs 82%, P < .0001), hypertension (91% vs 87%, P < .0001), prior CABG (40% vs 24%, P < .0001), and peripheral arterial disease (17% vs 13%, P < .0001) (Table 1).

The most common target CTO vessel was the right coronary artery (RCA) (63%). When compared with lesions that did not require GCE use, CTOs that required GCE use were more likely to have unfavorable anatomy, such as proximal cap ambiguity (39% vs 33%, P < .0001), moderate or severe calcification (59% vs 40%, P < .0001), moderate or severe tortuosity (35% vs 28%, P < .0001), and poor distal landing zone (36% vs 30%, P < .0001). The J-CTO score (2.78 ± 1.15 vs 2.20 ± 1.27, P < .0001) and PROGRESS-CTO score (1.28 ± 0.98 vs 1.23 ± 1.01, P < .0071) were higher in the GCE group. Femoral access was more likely to be used in GCE cases than in non-GCE cases. (81% vs 77%, P < .0001) (Table 2).

Advanced techniques including the retrograde approach (44% vs 24%, P < .0001) and antegrade dissection and re-entry (ADR) (28% vs 17%, P < .0001) were more commonly used in GCE cases. Antegrade wiring was less likely to be successful in GCE cases (45% vs 61%, P < .0001) (Table 3). Technical success was similar between the 2 groups (86.6% vs 86.8, P = .816). The frequency of major adverse cardiovascular events (MACE) (3.8% vs 2.4%, P < .0001) and procedural complications (11.2% vs 8.7%, P < .0001) were higher in the GCE group (Table 3).

The main findings of our study are that (a) GCEs were used in 28% of CTO PCIs with a significant increase between 2012 and 2023, and (b) GCE cases had similar technical success but higher incidence of periprocedural complications compared with non-GCE cases.

The use of GCEs in our registry (28%) was much higher than in other European and Latin America registries (14%).^3,4 The recent increase in use might in part be explained by the FDA approval of the Trapliner in 2017 (Teleflex). The Trapliner contains a balloon proximal to the half-pipe, which gives it the ability to trap an 0.014-inch guidewire, thereby simplifying equipment exchanges during CTO PCI.

GCEs were used in more complex anatomies and in cases that required advanced techniques like ADR and the retrograde approach. As expected, most GCEs were used through the antegrade guide catheter. In the antegrade direction, GCEs can increase support to tackle uncrossable lesions and impenetrable caps. Moreover, advancing a GCE deep into the occluded vessel decreases antegrade blood flow, reducing the risk of extraplaque hematoma formation during antegrade dissection and re-entry, and hence increasing the likelihood of successful re-entry.⁵ Furthermore, a GCE through the antegrade guide can be used to perform GCE-facilitated reverse Controlled Antegrade and Retrograde Tracking (CART) when the retrograde approach is used.^4,6 GCEs inserted through the retrograde guide catheter are mainly used to increase support to aid the delivery of retrograde microcatheters or balloons through collaterals and the occluded vessel.

Femoral access was more often used in the GCE group, likely due to higher clinical and angiographic complexity. In a prior analysis of the PROGRESS CTO registry, femoral access was used in cases with a higher J-CTO score and higher use of the retrograde approach when compared with radial access.⁷ Such lesions are more likely to require a GCE to achieve success.

Despite similar success rates between the 2 groups, cases that required GCE use were longer in duration and were associated with higher MACE rate and procedural complications. This may be attributed to the more complex anatomy in the GCE group and the more frequent use of advanced CTO crossing techniques. CTO PCI in older patients with moderate-to-severe calcification, as well as the use of ADR and the retrograde approach have been associated with higher complications rates.⁸ All these variables were significantly higher in GCE group, likely explaining the higher complications rate.   

In conclusion, GCEs were used in 28% of cases performed at high-volume centers, with increasing frequency over time. GCEs are frequently used in cases with complex anatomy that require advanced techniques like the retrograde approach and ADR.

Ahmed Al-Ogaili, MD; Deniz Mutlu, MD; Michaella Alexandrou, MD; Athanasios Rempakos, MD; Bavana V. Rangan, BDS, MPH; Olga C. Mastrodemos, BA; Yader Sandoval, MD; M. Nicholas Burke, MD; Emmanouil S. Brilakis, MD, PhD

From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.

Disclosures: Dr. Sandoval receives consulting/speaker honoraria from Abbott Diagnostics, Roche Diagnostics, Zoll, Phillips; is an associate editor for JACC Advances; and hold patent 20210401347. Dr. Burke receives consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Brilakis receives consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, Teleflex, and Terumo; receives research support from Boston Scientific, GE Healthcare; is the owner of Hippocrates LLC; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407, USA. Email: esbrilakis@gmail.com; X: @esbrilakis, @AhmedAlOgaili