Procedural and Long-Term Outcomes of Percutaneous Coronary Intervention for In-Stent Chronic Total Occlusion

• Published in: JACC. Cardiovascular interventions 2017-05, Vol.10 (9), p.892-902
• Main Authors: Azzalini, Lorenzo, MD, PhD, MSc, Dautov, Rustem, MD, PhD, Ojeda, Soledad, MD, PhD, Benincasa, Susanna, MD, Bellini, Barbara, MD, Giannini, Francesco, MD, Chavarría, Jorge, MD, Pan, Manuel, MD, PhD, Carlino, Mauro, MD, Colombo, Antonio, MD, Rinfret, Stéphane, MD, SM
• Format: Article
• Language: English
• Subjects: Aged; Cardiovascular; Chronic Disease; chronic total occlusion; Coronary Angiography; Coronary Occlusion - diagnostic imaging; Coronary Occlusion - etiology; Coronary Occlusion - mortality; Coronary Occlusion - therapy; Disease-Free Survival; Female; Humans; in-stent restenosis; Italy; Male; Middle Aged; Multivariate Analysis; percutaneous coronary intervention; Percutaneous Coronary Intervention - adverse effects; Percutaneous Coronary Intervention - instrumentation; Percutaneous Coronary Intervention - mortality; Proportional Hazards Models; Quebec; Registries; Risk Factors; Spain; Stents; Time Factors; Treatment Outcome
• ISSN: 1936-8798; 1876-7605
• DOI: 10.1016/j.jcin.2017.01.047

Abstract Objectives The study sought to investigate the long-term outcomes and predictors of adverse events of percutaneous coronary intervention (PCI) for in-stent chronic total occlusion (IS-CTO). Background IS-CTO PCI has traditionally been associated with suboptimal success rates. Methods We performed a multicenter registry of consecutive patients undergoing CTO PCI at 3 specialized centers. Patients were divided in IS-CTO and de novo CTO. The primary endpoint (major adverse cardiac events [MACE]) was a composite of cardiac death, target-vessel myocardial infarction, and ischemia-driven target-vessel revascularization (TVR) on follow-up. Independent predictors of MACE were sought with Cox regression. Results We included 899 patients (n = 111 IS-CTO, n = 788 de novo CTO). Baseline clinical and angiographic characteristics were balanced between the 2 groups. Overall mean J-CTO (Japanese-CTO) score was 1.88 ± 1.24 and mean PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention-CTO) score was 1.04 ± 0.88. Antegrade wire escalation was used in 59.0% of IS-CTO and 48.1% of de novo CTO patients (p = 0.08). Procedural success was achieved in 86.5% in both groups (p = 0.99). After a median follow-up of 471 (interquartile range: 354 to 872) days, MACE were observed in 20.8% versus 13.9% in IS-CTO versus de novo CTO (p = 0.07), driven by TVR (16.7% vs. 9.4%; p = 0.03). IS-CTO was an independent predictor of MACE (hazard ratio: 2.16; 95% confidence interval: 1.18 to 3.95; p = 0.01), together with prior surgical revascularization and renal function, CTO PCI indicated for acute coronary syndrome, number of diseased vessels, and PROGRESS-CTO score. Conclusions Procedural success was high and similar in patients with IS-CTO, as compared with de novo CTO. However, IS-CTO was independently associated with MACE (driven by TVR) on follow-up.