Predictors of successful chronic total occlusion percutaneous coronary interventions: a systematic review and meta-analysis

ObjectiveThe aim of this study was to identify positive and negative predictors of technical and clinical success for percutaneous coronary intervention (PCI) of chronic total occlusions (CTO).MethodsWe conducted a systematic review and meta-analysis of studies published between 2000 and 2016 analysing rates of CTO PCI success with respect to demographic and angiographic characteristics. Crude ORs and 95% CIs for each predictor were calculated using a random effects model. Predictors of technical and clinical success were assessed among 28 demographic and 31 angiographic variables. Clinical success was defined as technical success without major adverse cardiac events.ResultsA total of 61 studies, totalling 69 886 patients were included in this analysis. The major demographic characteristics associated with a 20% or greater reduction in the odds of technical and clinical success were a history of myocardial infarction, PCI, coronary artery bypass grafting, stroke/transient ischaemic attack and peripheral vascular disease. Angiographic factors were generally stronger predictors of reduced technical and clinical success. Those associated with >20% odds reduction included non-left anterior descending CTOs, multivessel disease, presence of bridging collaterals, moderate-to-severe calcification, >45 degree vessel bending, tortuous vessel, blunt stump and ostial lesions. Of these, novel predictors included prior PCI, prior stroke, peripheral vascular disease, presence of multivessel disease and bridging collaterals.ConclusionThe present study has identified strong negative predictors for clinical success for CTO PCI, which will aid in patient selection for this procedure.

Abstract 19665: Angiographic Predictors of Successful Guide-wire Crossing Through Infrapopliteal Chronic Total Occlusions (CTOs)

Background: No current scoring system exists to predict successful guide-wire crossing of infrapopliteal CTOs. Methods: All patients undergoing peripheral endovascular procedures from 2006 to 2014 at University of California, Davis and Denver Veterans Affairs Medical Centers were reviewed. Interventions performed on anterior tibial, peroneal, or posterior tibial artery CTOs were identified. Angiographic analysis was performed to identify stump morphology, presence of bridging collaterals and side branches near the stump, calcification at entry and within the occluded segment, and the length and the diameter of the lesion. Angiographic predictors of successful wire crossing were then identified. Results: 215 cases of infrapopliteal CTOs were performed at the two centers during the study period. Antegrade wire crossing was successful in 151 cases (70%). Failure of antegrade wire crossing was associated with a beaded stump morphology (15% of failure cases vs. 4% of successful cases, p<0.01); presence of severe calcification at the entry point (56% of failure cases vs. 34% of successful cases, p = 0.02); presence of severe calcification in the occluded route (52% of failure cases vs. 33% of successful cases, p = 0.04); an occluded segment longer than 200 mm (51% of failure cases vs. 17% of successful cases, p<0.01); and reference vessel diameter smaller than 2.5 mm (63% of failure cases vs. 37% of successful cases, p<0.01). The presence of bridging collaterals and side branches were not significantly associated with success or failure of antegrade wire crossing (Table). Conclusions: A beaded stump morphology at the proximal cap, presence of severe calcification at the entry site and in the occluded route, longer occluded segment length, and narrower reference vessel diameter are associated with greater failure of antegrade wire crossing for infrapopliteal CTOs. A scoring system will be developed to identify multivariable predictors of antegrade wire crossing.

Chronic Coronary Occlusions: Age, Morphology and Chance of Reopening

In chronic coronary occlusions the chance of successful reopening by angioplasty can be judged from the age of the occlusion. Often, however, time since occlusion cannot be accurately assessed. Therefore we determined whether the chance of reopening can be predicted from angiographic morphology. In cineangiograms from 60 consecutive patients with chronic coronary occlusions morphological details in at least two projections were evaluated in relation to the rate of success and the estimated age of occlusion. Morphological features associated with a higher rate of success (type A) were a clearcut proximal stump, absence of side branches at the site of occlusion, absence of bridging collaterals, and only slight filling of the distal part of the vessel. Features associated with a low success rate (type B) were absence of proximal stump, side branches at the site of occlusion, bridging collaterals, and rapid high-contrast filling of the distal part of the vessel. 48/60 (80%) of occlusions could be classified as type A or type B. The success rate was 17/21 (81 %) in type A versus 5/27 (18.5%) in type B (P < 0.0002). The estimated age of type B occlusions was higher than that of type A—medians 8 and 4 months (P < 0.002). Thus in chronic coronary occlusions the likelihood of successful reopening can be judged in many patients from morphological features.