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Hybrid approach to CTO PCI yields high success rates

Elvira Manzano
28 May 2018

The hybrid approach to percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) yielded good success rates in the hands of experienced operators, the PROGRESS CTO* Registry study has shown, offering important benchmarking for discussion of the risk-benefit ratio of CTO PCI.

Among 3,122 CTO PCI procedures performed in 3,055 patients, overall technical success rate was 87 percent under the hybrid approach. When in-hospital complications were taken into account, procedural success rate slightly went down to 85 percent, said Dr Peter Tajti of the Minneapolis Heart Institute, Minnesota, US who presented the results at SCAI 2018.  Overall, success was achieved despite high lesion complexity and low success of the initial CTO crossing strategy. [SCAI 2018, abstract II-04; JACC Cardiovasc Interv 2018;doi:10.1016/j.jcin.2018.02.036]

This suggests that CTO PCI using the hybrid approach is now being performed “with high success and acceptable complication rates” in experienced centres in the US and Europe, Tajti said.

Patients in the registry had a mean age of 65 years and 85 percent were men. There was a high prevalence of diabetes, prior myocardial infarction (MI), prior coronary artery bypass graft (CABG), and prior PCI. Majority of the patients were asymptomatic, with a mean J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) score of 2.4 and mean PROGRESS CTO score of 1.3.

The right coronary artery was the CTO target vessel in half of the cases, the left anterior descending artery in 24 percent, and the left circumflex coronary artery in 20 percent of cases.

The rate of in-hospital major complications was 3 percent, including MI in 1.1 percent, death in 0.9 percent, pericardial tamponade in 0.9 percent, stroke in 0.3 percent, and emergency CABG in 0.2 percent. Complications were less frequent in technically successful procedures (2.2 percent vs. 7.9 percent; p<0 .0001).

The initial approach (antegrade wire escalation in 75 percent of patients particularly those with lower-complex CTOs, antegrade dissection re-entry and retrograde approach in more complex lesions) was successful in 55 percent of patients. Further attempts were required in 41 percent of patients to achieve a technical success rate of 79 percent. Antegrade wire escalation was the final successful crossing strategy in 52 percent, retrograde in 27.1 percent, and antegrade dissection re-entry in 20.9 percent of cases.

Radial access was utilized in 37 percent of cases, biradial approach in 14 percent, and biradial- femoral combination in 20 percent. Combined femoral and bifemoral approaches were more frequent in those with more complex lesions. Median procedure time was 123 minutes. Fluoroscopy time was 47 minutes.

In an accompanying editorial, Dr Gregg W. Stone, director of cardiovascular research and education, Columbia University Medical Center/New York-Presbyterian Hospital, described the hybrid approach as “the magnus opus of CTO PCI technique.” However, he cautioned that appropriate patient selection and patient access to expert care are warranted. [JACC Cardiovasc Interv 2018;doi:10.1016/j.jcin.2018.03.031]

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