Frequency and Outcomes of Ad Hoc Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS-CTO Registry

Abstract

BACKGROUND. Although discouraged, ad hoc chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is occasionally performed. METHODS. We examined the clinical, angiographic characteristics, and procedural outcomes of patients who underwent ad hoc CTO PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). RESULTS. Of the 10,998 patients included in the registry, 899 (8.2%) underwent ad hoc CTO PCI. The incidence of ad hoc CTO PCI decreased from 18% in 2016 to 3% in 2022. Ad hoc CTO PCI patients had a lower prevalence of comorbidities and less complex angiographic characteristics demonstrated by lower J-CTO score (1.9±1.2 vs 2.4±1.3, P<.001). In these patients, PROGRESS-CTO major adverse cardiovascular events (MACE) (1.9±1.4 vs 2.5±1.7), mortality (1.2±1.0 vs 1.6±1.1), and perforation (1.5±1.2±2.2 vs 1.5) scores were lower (P<.001). Technical success was similar between the groups (86%). MACE were lower in the ad hoc CTO PCI group (.8% vs 2.0%, P=.009). Ad hoc CTO PCI was not associated with MACE after adjusting for potential confounders, odds ratio: .69 (95% confidence interval, .30-1.57). In patients with higher J-CTO scores, planned CTO PCI was associated with higher technical success (P<.001). CONCLUSION. Approximately 8% of CTO PCI procedures are performed ad hoc, usually in less complex lesions and patients with lower complication risk. While ad hoc CTO PCI might be appropriate for carefully selected cases, a staged approach is recommended for most CTO PCI.

J INVASIVE CARDIOL 2023;35(7): E329-E340. doi: 10.25270/jic/23.00070

Key words: ad hoc, planning, chronic total occlusion, percutaneous coronary intervention

The Global Expert Consensus Document for CTO PCI discourages ad hoc CTO PCI to allow adequate time for procedural planning, preparation, and patient counseling.¹ However, ad hoc CTO PCI is occasionally performed in daily practice,² and such procedures have received limited study. We examined the frequency, clinical, angiographic, and procedural characteristics of patients who had ad hoc CTO PCI in a large international CTO PCI registry.

Methods

We examined the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO, NCT02061436) after stratifying patients based on CTO PCI planning into 2 groups: ad hoc vs planned CTO PCI. PROGRESS-CTO includes patient-level data for CTO PCI procedures performed between 2012 and 2022 at experienced CTO PCI centers from the United States, Canada, Greece, Turkey, Egypt, Russia, and Lebanon.^3,4 Study data were collected and managed using the REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the Minneapolis Heart Institute Foundation.^5,6

Definitions. CTOs were defined, according to the CTO Academic Research Consortium, as the absence of antegrade flow through the lesion with a presumed or documented duration of ≥3 months.⁷ Ad hoc CTO PCI was defined as PCI of a CTO that was discovered during the procedure (vs planned). Technical success was defined as the successful canalization of the CTO vessel with <30% residual stenosis and final Thrombolysis in Myocardial Infarction (TIMI) 3 flow.

Calcification was assessed by angiography as mild (spots), moderate (involving ≤50% of the reference lesion diameter), or severe (involving ≥50% of the reference lesion diameter).   

The Multicenter CTO Registry of Japan (J-CTO) score was calculated as described by Morino et al,⁸ the PROGRESS-CTO score as described by Christopoulos et al,⁹ the PROGRESS-CTO MACE, mortality, pericardiocentesis scores as described by Simsek et al,¹⁰ and the PROGRESS-CTO perforation score as described by Kostantinis et al.¹¹

Acute coronary syndromes (ACS) at presentation included unstable angina, non-ST-segment elevation myocardial infarction (non-STEMI), or ST-segment elevation MI (STEMI) that were defined according to the American College of Cardiology - National Cardiovascular Data Registry (NCDR) CathPCI Registry definitions.¹²

In-hospital MACE were defined as the composite of in-hospital all-cause mortality, acute myocardial infarction (MI), stroke, urgent repeat revascularization (re-PCI or surgery), or pericardiocentesis. MI was defined using the Third Universal Definition of MI.¹³ Procedural success was defined as technical success in the absence of in-hospital MACE.

Patients for whom procedural planning information (ad hoc vs planned) was not available were excluded from the analysis.

Decision-making regarding the CTO PCI procedure was made by the heart team, including patient preference. The study was approved by the institutional review board of each site.

Statistical analysis. Continuous variables were presented as mean ± standard deviation or median (interquartile range Q1-Q3) and compared using the independent t-test or Mann-Whitney U test, as appropriate. Categorical variables were presented as absolute numbers and percentages, and compared using chi-square or Fisher’s exact test, as appropriate. Statistical analyses were performed using Stata v17.0 (StataCorp).

Results

Clinical and angiographic characteristics. Of the 10,988 patients that underwent CTO PCI, 899 (8.2%) had ad hoc CTO PCI. The incidence of ad hoc CTO PCI decreased from 18% in 2016 to 3% in 2022 (Figure 1). Non-US centers (mainly Russia and Turkey) were less likely to perform ad hoc CTO PCI (5.8% vs 9.0%, P<.001).

The main reason for ad hoc CTO PCI was achieving complete revascularization (63%), followed by alleviation of symptoms (27%), out-of-town patient (5%), complete revascularization in the setting of ventricular arrhythmia (3%), unable to PCI the culprit lesion in ACS (1.5%), and pre-transcatheter aortic valve replacement (1%). Patients who had ad hoc CTO PCI were less likely to have comorbidities compared with patients who underwent planned CTO PCI, including prior MI (36% vs 46%, P<.001), prior PCI (49% vs 62%, P<.001), and prior coronary artery bypass graft surgery (23% vs 28%, P<.001); they had higher left ventricular ejection fraction (52±12 vs 50±13%, P=.014) (Table 1). Ad hoc CTO PCI was less frequently performed for stable angina (49% vs 68%) and more commonly performed in patients who presented with non-STEMI (13% vs 7%) and unstable angina (30% vs 15%) overall (P<.001), compared with planned CTO PCI.

In the ad hoc group, the CTO vessel was more often the left anterior descending (LAD) (30% vs 26%, P=.025) or the left circumflex (23% vs 19%, P=.012) and less often the right coronary artery (RCA) (48% vs 55%, P<.001).

The CTO angiographic characteristics of the ad hoc group were more favorable, with lower prevalence of proximal cap ambiguity (23% vs 35%, P<.001), moderate/severe proximal tortuosity (22% vs 30%, P<.001), and moderate/severe calcification (35% vs 45%, P<.001) (Table 2). In the ad hoc group, the J-CTO score was lower (1.9±1.2 vs 2.4±1.3, P<.001), and PROGRESS-CTO score tended to be lower (1.2±1.0 vs 1.3±1.0, P=.072).

In the ad hoc group, the PROGRESS-CTO MACE (1.9±1.4 vs 2.5±1.7, P<.001), mortality (1.2±1.0 vs 1.6±1.1, P<.001), pericardiocentesis (1.3±1.1 vs 1.9±1.3, P<.001), and perforation (1.5±1.2 vs 2.2±1.5, P<.001) scores were lower.

In the ad hoc group, non-CTO lesions were more often treated (38% vs 22%, P<.001), a dual injection was less frequently performed (26% vs 71%, P<.001), and the first crossing strategy was more often the antegrade wiring (93% vs 83%) and less frequently the retrograde strategy (3.4% vs 12%), overall P<.001. The successful crossing strategy was also more often the antegrade wiring (72% vs 55%) and less often the retrograde strategy (5.8% vs 18%), overall P<.001 (Table 2).

In the ad hoc group, procedures were shorter (81 [57-116] vs 114 [76-167] min, P<.001) with less fluoroscopy time (27 [18-41] vs 43 [26-68] min, P<.001). However, more contrast was used in the ad hoc group (225 [160-300] vs 200 [150-300] ml, P<.001).

Procedural and in-hospital outcomes. In patients with low J-CTO scores, technical success was similar between the ad hoc vs planned CTO PCI groups. In patients with higher J-CTO scores, planned CTO PCI was associated with higher technical success (P<.001) (Figure 2).

MACE were lower in the ad hoc CTO PCI group (.8% vs 2.0%, P=.009) (Table 3); however, after adjusting for potential confounders, ad hoc CTO PCI was not associated with different MACE odds ratio: .69 (95% confidence interval, .30-1.57) (Figure 3).

Discussion

The main findings of our study are:

1. 8.2% of patients had ad hoc CTO PCI with a decreasing incidence (Figure 1);
2. Patients had lower comorbidities and angiographically less complex features (Table 2);
3. In patients with higher angiographic complexity, planned CTO PCI was associated with higher technical success (Figure 2).

CTO PCI success rate has been increasing with the introduction of new equipment and techniques.^3,14 In our study, the incidence of ad hoc CTO PCI decreased the last 5 years (Figure 1). Increased experience of operators and expert recommendations against ad hoc CTO PCI might have contributed to decreasing ad hoc CTO PCI rates.¹

Planned CTO PCI has benefits over ad hoc CTO PCI:^1,15-18

1. Provides time for thorough risk/benefit and goals discussion
2. The heart team may evaluate the patient
3. Additional evaluation (such as myocardial viability) may be performed
4. Could help minimize contrast use, radiation dose, and reduce operator and patient fatigue
5. May improve catheterization laboratory efficiency (eg, CTO days)

A retrospective study of 512 patients from Taiwan compared the outcomes between ad hoc vs planned CTO PCI and found similar technical success and complication rates.¹⁹ In our study, patients with lower angiographic complexity had similar technical success and MACE compared with planned CTO PCI. While this may support the feasibility of ad hoc CTO PCI in select patients when performed by experienced operators, the value of meticulous planning in CTO PCI is demonstrated with higher success rates in patients with higher angiographic complexity (Figure 2).

An analysis of the German ALKK registry had 714 CTO PCIs, of which 74.2% were performed ad hoc in 2006.²⁰ In our registry, non-US centers (mainly Russia and Turkey) were less likely to perform ad hoc CTO PCI compared with US centers (5.8% vs 9.0%, P<.001).

Ad hoc CTO PCI may reduce costs and hospital stays.¹⁹ In our study, when the operators were asked why they chose to perform ad hoc CTO PCI, the leading response was the goal of achieving complete revascularization in the setting of an “easy” CTO lesion (63%). This is in line with the lower J-CTO and PROGRESS-CTO complication scores seen in these patients and the less frequent use of retrograde strategy in ad hoc CTO PCI (5.8% vs 18%, P<.001). Patients who underwent ad hoc CTO PCI were also more likely to have presented with non-stable angina symptoms (eg, ACS) and more often underwent non-CTO PCI.

Procedures were shorter, and the fluoroscopy dose was less in ad hoc CTO PCI, but more contrast was used in ad hoc CTO PCI. This finding might be explained by higher rates of concomitant non-CTO PCI, contrast use during diagnostic angiography in ad hoc CTO PCI, and less complex CTO cases in ad hoc CTO PCI.

Despite the feasibility of ad hoc CTO PCI in select cases by experienced operators, meticulous planning and thorough risk/benefit discussion with the patients are essential to optimize outcomes in CTO PCI.   

Limitations. First, the PROGRESS-CTO registry is observational. Second, clinical events and angiographic images were reported by the attending interventional cardiologists and not adjudicated by an independent committee and a core laboratory, respectively. Third, the PROGRESS-CTO operators are experienced in CTO PCI, which could limit external validity.

Conclusion

Approximately 8% of CTO PCI procedures are performed ad hoc, usually in patients with lower complication risk. The incidence of ad hoc CTO PCI decreased from 18% in 2016 to 3% in 2022. In patients with higher angiographic complexity, planned CTO PCI was associated with higher technical success. While ad hoc CTO PCI is occasionally performed in carefully selected cases, a staged procedure is recommended for most CTO PCIs.

Affiliations and Disclosures

From the ¹Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota; ²Division of Cardiology, Emory University, Atlanta, Georgia; ³Department of Cardiology, Biruni University School of Medicine, Kocaeli, Turkey; ⁴Division of Cardiology, Henry Ford Hospital, Detroit, Michigan; ⁵Cleveland Clinic Foundation, Cleveland, Ohio; ⁶University Hospitals, Case Western Reserve University, Cleveland, Ohio; ⁷Department of Cardiology, Selcuk University, Konya, Turkey; ⁸Department of Invasive Cardiology, Meshalkin National Medical Research Center, Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation; ⁹Department of Cardiology, Central Arkansas Veterans Health System, and University of Arkansas for Medical Sciences, Little Rock, Arkansas; ¹⁰Department of Cardiology, Memorial Bahcelievler Hospital, Istanbul, Turkey; ¹¹UC Health Medical Center of the Rockies, Loveland, Colorado; ¹²Department of Cardiology, Baylor Scott & White Health, Dallas, Texas.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors reporting as follows: Dr Rinfret is a consultant for Boston Scientific, Teleflex, Abbott Vascular, Biotronik, and SoundBite Medical; Dr Jaber received institutional funds and is on the advisory board for Medtronic; and has received proctorship fees from Abbott Vascular; Dr Nicholson is a proctor and on the speakers' bureau and the advisory board for Abbott Vascular, Boston Scientific, and Asahi Intecc Co., Ltd.; he reports intellectual property with Vascular Solutions; Dr. Alaswad is a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI; Dr. Khatri receives personal honoraria for proctoring and speaking from Abbott Vascular, Asahi Intecc, Terumo, and Boston Scientific; Dr. Potluri is a speaker, advisory board member, and a proctor for Boston Scientific, Medtronic, Abbott, Terumo, Shockwave; Dr. Al-Azizi is a consultant for Philips, Medtronic, Shockwave, and Boston Scientific; Dr. Burke is a shareholder, Egg Medical and MHI Ventures; 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), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; research support: Boston Scientific, GE Healthcare; he is an owner of Hippocrates LLC, and a shareholder of MHI Ventures, Cleerly Health, and Stallion Medical.

Manuscript accepted April 12, 2023.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Center for Complex Coronary Interventions, Minneapolis Heart Institute, Center for Coronary Artery Disease at the Minneapolis Heart Institute Foundation, 920 E 28th Street #300, Minneapolis, Minnesota, 55407. Email: esbrilakis@gmail.com

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