• PCI Shows Similar Outcomes for In-Stent and De Novo CTO Lesions

    In-stent (IS) chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with similar success and complications rates as de novo CTO PCI, according to results from the largest multicenter registry study of IS-CTO PCI to date.

    The study was presented Thursday during the Society for Cardiovascular Angiography and Interventions 2020 virtual conference and simultaneously published online in JACC: Cardiovascular Interventions.

    It is estimated that 5% to 25% of all CTO PCIs are IS, and prior studies have demonstrated lower success rates as compared to do novo lesions. Evangelia Vemmou, MD, of the Minneapolis Heart Institute Foundation, and colleagues sought to examine this further using the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Registry. They analyzed clinical, angiographic and procedural characteristics of 5,667 CTO PCI performed on 5,547 patients between 2012 and 2020 at 28 U.S. and 4 international centers.

    A total of 913 IS-CTO PCIs (16% of total CTO PCIs) were performed and these patients tended to be younger, with a higher prevalence of cardiac co-morbidities (diabetes mellitus, dyslipidemia, hypertension and prior myocardial infarction). In addition, IS-CTO PCIs had a higher mean Japanese CTO (J-CTO) score (2.6 ±1.3 vs. 2.4 ±1.3, p= 0.0002) than de novo CTO lesions.

    In terms of procedural characteristics, retrograde crossing was used less often (16% vs. 21%, p<0.0001) in the IS-CTO group. However, intravascular ultrasound (IVUS, 50% vs. 39%, p<0.0001) and optical coherence tomography (OCT, 2.4% vs. 1.3%, p=0.026) was performed more often in the IS-CTO group. Finally, the IS-CTO group had more balloon uncrossable and undilatable lesions than the de novo group, and stenting was used less often in IS-CTOs.


    In terms of outcomes, procedural and technical success and in-hospital MACE rates were similar between the two groups. Contrast volume was lower in the IS-CTO group, as was the risk of perforation, although there was no difference in pericardiocentesis rates between the two groups (0.6% for IS-CTO vs. 0.9% for de novo CTOs, p=0.2).


    This study suggests that IS-CTO PCI is feasible, with similar success rates as de novo CTO PCI.

    However, there are some limitations to this study. First, this is an observational, retrospective study with no long-term follow-up, only in-hospital outcomes. Second, intravascular imaging was used at a higher prevalence in the IS-CTO PCI cohort and may have impacted the procedural and in-hospital outcomes. Finally, and most importantly, these IS-CTO PCIs were performed at high-volume, experienced CTO PCI centers. It is well-known that the performance of CTO PCIs overall are impacted by the operator’s overall experience. Thus, in this study, the authors’ results are limited in terms of generalizability to non-CTO PCI centers.


    That being said, this study demonstrates that IS-CTOs represent about 16% of total CTO PCIs, and though more complex (higher J-CTO scores), IS-CTO PCIs have similar success rates and in-hospital complication rates as de novo CTO PCIs. These findings should be further confirmed in a prospective analysis, controlling for operator experience, intravascular imaging use and longer term follow-up.



    Vemmou E, Alaswad K, Karmpaliotis D, et al. Outcomes of Percutaneous Coronary Intervention for In-Stent Chronic Total Occlusions: Insights from the PROGRESS-CTO Registry, JACC: Cardiovasc Interv 2020 May 14. https://doi.org/10.1016/j.jcin.2020.05.003


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