Investment in subintimal plaque modification (SPM) with guidewire (GW) crossing – a process that plans for subsequent reattempts during an initial chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedure – is associated with a higher success rate in later reattempts, a new analysis shows.
The study, published online Monday and in the July 25 issue of JACC: Cardiovascular Interventions, noted that predictors of success in reattempted CTO PCI procedures remain obscure, mostly due to a lack of consecutive angiograms and procedural records of initial attempts in the same cohort.
Led by Xin Zhong, MD, from the Shanghai Institute of Cardiovascular Diseases, the team noted that between 15% and 25% of patients affected by coronary artery disease (CAD), undergoing coronary angiography have at least one CTO lesion.
“In recent years, the success rate of CTO PCI has improved substantially. However, reattempted CTO PCI is still common, especially in high-volume referral centers,” said the authors, noting that the lower success rates and higher incidence of complications and recanalizations of CTO lesions means CTO lesions have been seen as “the last frontier for PCI.”
“The present study identified independent predictors of success in reattempted CTO PCI procedures based on the consecutive and comprehensive review of procedural details of initial and subsequent attempts for each case,” they said.
Zhong and colleagues set out to investigate the factors predicting the success of reattempted CTO PCI procedures via a retrospective analysis of data from 208 consecutive patients who underwent a failed CTO PCI attempt and received reattempted procedure at the same cardiac center.
“By evaluating the consecutive angiographic and procedural records of initial unsuccessful attempts and analyzing the outcomes of reattempted CTO PCI procedures, this study aimed to identify the predictors of success in reattempted CTO PCI procedures and to provide more evidence for SPM,” said the team, noting an overall technical and procedural success rates of 71.2% (n = 148 for both).
In order to identify angiographic and procedural factors predicting the success of reattempted CTO PCI procedures, candidate predictor variables were initially selected by a panel of interventional physicians according to the clinical relevance, said Zhong and colleagues.
Univariate logistic regressions were then fitted for each candidate predictor, they said, adding that all predictor variables with P value <0.10 in the univariate logistic regression were then included in multivariate logistic regression.
The team reported that overall, SPM was performed in 35 (16.8%) procedures in initial attempts. For the SPM procedures with GW crossing, reasons for not achieving success in initial attempts included diffuse dissection that would have required extensive extra-plaque stenting (n = 4), diffuse dissection that would have compromised large side branches if stented (n = 10), and dissection that resulted in target vessel perforation (n = 1).
The reattempted technical success rate was 93.3% in cases in which SPM with GW crossing was achieved in the initial attempt; however, the success rate was 55.0% for procedures involving SPM without GW crossing, said Zhong and colleagues.
They reported that positive independent predictors of technical success in the subsequent reattempt were: SPM with GW crossing (odds ratio [OR]: 11.21; 95% confidence interval [CI]: 1.31-96.16; P = 0.028); referral to high-volume operators (OR: 2.38; 95% CI: 1.14-4.98; P = 0.021); and a bidirectional approach (OR: 2.31; 95% CI: 1.12-4.79; P = 0.024).
Meanwhile, the time interval for reattempt (per 90-day increment) was negatively correlated with the technical success of the reattempted procedures (OR: 0.85; 95% CI: 0.73-0.98; P = 0.030), they said.
Zhong and colleagues added that larger-scale data focusing on the SPM technique are required to confirm the results and to summarize the recanalization strategy after SPM deployment, especially in cases with vascular patent remodeling.
Previous failure does not preclude future success
Writing in an accompanying editorial, Emmanouil S. Brilakis, MD, PhD, and Salman Allana, MD, from the Minneapolis Heart Institute, noted that a repeat attempt is common in failed cases of CTO PCI – particularly in patients with greater ongoing symptoms.
The editorialists commented that the new study provides “useful insights” into the questions of when and how to reattempt CTO PCI after an initial failure – adding that a consistent finding in both the current and prior studies is that experienced operators achieve higher success in procedural reattempt.
“Reattempt CTO lesions are usually more complex and often require advanced crossing techniques, such as the retrograde approach, and may have higher risk of complications,” said Brilakis and Allana.
“CTO PCI failure does not preclude future success,” they noted.
Zhong X, Gao W, Hu T, et al. Impact of Subintimal Plaque Modification on Reattempted Chronic Total Occlusions Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2022;15:1427-1437.
Brilakis ES, Allana S. Chronic Total Occlusion Intervention Failure: When and How to Reattempt. JACC Cardiovasc Interv 2022;15:1438-1440.
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