Hybrid approach improves success of chronic total occlusion angioplasty

W. M. Wilson, S. J. Walsh, A. T. Yan, C. G. Hanratty, A. J. Bagnall, M. Egred, E. Smith, K. G. Oldroyd, M. McEntegart, J. Irving, J. Strange, H. Douglas, J. C. Spratt (Lead / Corresponding author)

    Research output: Contribution to journalArticle

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    Abstract

    Objectives: Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques.

    Methods: Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan ( J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30% residual stenosis, subclassified as at first attempt or overall. In hospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded.

    Results: 1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79% (first attempt) and 90% (overall) with 30-day MACE of 1.6%. AWE was highly effective in less complex lesions ( J-CTO ≤1 94% success vs 79% in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions ( J-CTO≤1 15% vs J-CTO ≥2 56%). Need for multiple approaches during each attempt increased with lesion complexity (17% J-CTO ≤1 vs 48% J-CTO ≥2). Lesion modification (‘investment procedures’) at the end of unsuccessful first attempts increased the chance of subsequent success (96% vs 71%).

    Conclusions: Hybrid-trained operators can achieve overall success rates of 90% in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.

    Original languageEnglish
    Pages (from-to)1486-1493
    Number of pages8
    JournalHeart
    Volume102
    Issue number18
    Early online date10 May 2016
    DOIs
    Publication statusPublished - Sep 2016

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    Percutaneous Coronary Intervention
    Angioplasty
    Dissection
    Registries
    Japan
    Pathologic Constriction
    Myocardial Infarction
    Therapeutics

    Cite this

    Wilson, W. M., Walsh, S. J., Yan, A. T., Hanratty, C. G., Bagnall, A. J., Egred, M., ... Spratt, J. C. (2016). Hybrid approach improves success of chronic total occlusion angioplasty. Heart, 102(18), 1486-1493. https://doi.org/10.1136/heartjnl-2015-308891
    Wilson, W. M. ; Walsh, S. J. ; Yan, A. T. ; Hanratty, C. G. ; Bagnall, A. J. ; Egred, M. ; Smith, E. ; Oldroyd, K. G. ; McEntegart, M. ; Irving, J. ; Strange, J. ; Douglas, H. ; Spratt, J. C. / Hybrid approach improves success of chronic total occlusion angioplasty. In: Heart. 2016 ; Vol. 102, No. 18. pp. 1486-1493.
    @article{efa367931a484ad7aabfc9fb9b16e283,
    title = "Hybrid approach improves success of chronic total occlusion angioplasty",
    abstract = "Objectives: Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques.Methods: Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan ( J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30{\%} residual stenosis, subclassified as at first attempt or overall. In hospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded.Results: 1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79{\%} (first attempt) and 90{\%} (overall) with 30-day MACE of 1.6{\%}. AWE was highly effective in less complex lesions ( J-CTO ≤1 94{\%} success vs 79{\%} in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions ( J-CTO≤1 15{\%} vs J-CTO ≥2 56{\%}). Need for multiple approaches during each attempt increased with lesion complexity (17{\%} J-CTO ≤1 vs 48{\%} J-CTO ≥2). Lesion modification (‘investment procedures’) at the end of unsuccessful first attempts increased the chance of subsequent success (96{\%} vs 71{\%}).Conclusions: Hybrid-trained operators can achieve overall success rates of 90{\%} in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.",
    author = "Wilson, {W. M.} and Walsh, {S. J.} and Yan, {A. T.} and Hanratty, {C. G.} and Bagnall, {A. J.} and M. Egred and E. Smith and Oldroyd, {K. G.} and M. McEntegart and J. Irving and J. Strange and H. Douglas and Spratt, {J. C.}",
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    Wilson, WM, Walsh, SJ, Yan, AT, Hanratty, CG, Bagnall, AJ, Egred, M, Smith, E, Oldroyd, KG, McEntegart, M, Irving, J, Strange, J, Douglas, H & Spratt, JC 2016, 'Hybrid approach improves success of chronic total occlusion angioplasty', Heart, vol. 102, no. 18, pp. 1486-1493. https://doi.org/10.1136/heartjnl-2015-308891

    Hybrid approach improves success of chronic total occlusion angioplasty. / Wilson, W. M.; Walsh, S. J.; Yan, A. T.; Hanratty, C. G.; Bagnall, A. J.; Egred, M.; Smith, E.; Oldroyd, K. G.; McEntegart, M.; Irving, J.; Strange, J.; Douglas, H.; Spratt, J. C. (Lead / Corresponding author).

    In: Heart, Vol. 102, No. 18, 09.2016, p. 1486-1493.

    Research output: Contribution to journalArticle

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    AU - Wilson, W. M.

    AU - Walsh, S. J.

    AU - Yan, A. T.

    AU - Hanratty, C. G.

    AU - Bagnall, A. J.

    AU - Egred, M.

    AU - Smith, E.

    AU - Oldroyd, K. G.

    AU - McEntegart, M.

    AU - Irving, J.

    AU - Strange, J.

    AU - Douglas, H.

    AU - Spratt, J. C.

    PY - 2016/9

    Y1 - 2016/9

    N2 - Objectives: Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques.Methods: Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan ( J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30% residual stenosis, subclassified as at first attempt or overall. In hospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded.Results: 1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79% (first attempt) and 90% (overall) with 30-day MACE of 1.6%. AWE was highly effective in less complex lesions ( J-CTO ≤1 94% success vs 79% in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions ( J-CTO≤1 15% vs J-CTO ≥2 56%). Need for multiple approaches during each attempt increased with lesion complexity (17% J-CTO ≤1 vs 48% J-CTO ≥2). Lesion modification (‘investment procedures’) at the end of unsuccessful first attempts increased the chance of subsequent success (96% vs 71%).Conclusions: Hybrid-trained operators can achieve overall success rates of 90% in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.

    AB - Objectives: Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques.Methods: Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan ( J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30% residual stenosis, subclassified as at first attempt or overall. In hospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded.Results: 1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79% (first attempt) and 90% (overall) with 30-day MACE of 1.6%. AWE was highly effective in less complex lesions ( J-CTO ≤1 94% success vs 79% in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions ( J-CTO≤1 15% vs J-CTO ≥2 56%). Need for multiple approaches during each attempt increased with lesion complexity (17% J-CTO ≤1 vs 48% J-CTO ≥2). Lesion modification (‘investment procedures’) at the end of unsuccessful first attempts increased the chance of subsequent success (96% vs 71%).Conclusions: Hybrid-trained operators can achieve overall success rates of 90% in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.

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    Wilson WM, Walsh SJ, Yan AT, Hanratty CG, Bagnall AJ, Egred M et al. Hybrid approach improves success of chronic total occlusion angioplasty. Heart. 2016 Sep;102(18):1486-1493. https://doi.org/10.1136/heartjnl-2015-308891