Interv Akut Kardiol. 2019;18(1):12-17 | DOI: 10.36290/kar.2019.002

Experience with recanalization of difficult chronic total occlusions

Vojtěch Novotný, Ivo Varvařovský, Tomáš Lazarák, Jan Matějka, Vladimír Rozsíval, David Vindiš, Milan Plíva

Kardiologické centrum AGEL, a. s., Pardubice

Aim: Percutaneous coronary intervention (PCI) for coronary artery chronic total occlusion (CTO) has been a rapidly evolving branch
of interventional cardiology in recent years. The article presents our two-year experience with the development of a dedicated
CTO programme, while focusing on stratification of CTO difficulty depending on the J-CTO scoring system and the role of the
proctor in the learning curve.

Material and methods: The study cohort comprised consecutive patients who underwent PCI for CTO at our centre during the
period from 08/2016 to 10/2018. The following aspects were studied: the basic patient characteristics and technical aspects of the
procedure; the estimated difficulty depending on the J-CTO score; the proportions of various recanalization techniques; whether
or not a proctor was present during the procedure; and the rates of complications. Procedures with a J-CTO score ≥ 2 were graded
as difficult in consistency with the authors of the scoring system.

Results: The overall success rate of CTO PCI in the follow-up period was 84.4 %. The mean fluorocopic time per procedure was
30:17 minutes, the irradiation dose 2 660 mGy, and contrast medium consumption 262 ml. In successful procedures, the final
strategy that resulted in CTO recanalization was antegrade wire escalation in 65.6 %, retrograde dissection-reentry technique in
11.1 %, and retrograde wire escalation in 6.7 %. In one case, we succeeded with antegrade dissection-reentry technique. While the success rate of CTO PCI for J-CTO scores of 0-1 reached 94.9%, in difficult cases (J-CTO ≥ 2) the success rate was only
76.5%. Proctored procedures versus unproctored ones had a higher mean J-CTO score (2.3 vs. 1.7), a higher proportion of difficult
findings with a J-CTO ≥ 2 (66.7 % vs. 52.4 %), a higher percentage of retrograde procedures (55.6 % vs. 19.1 %), and a higher success
rate was achieved with them (92.6 % vs. 81.0 %).
Clinically severe complications occurred in 4.5%, and there was no periprocedural death or tamponade.

Conclusion: The present cohort represents the first two years of the CTO PCI learning curve showing that, when certain rules are
followed, it is possible to master the CTO PCI techniques and introduce them into normal operation of a catheterization room as
an effective and safe treatment method for patients with a specific, and not rare, type of coronary disease.

Keywords: CTO, chronic total occlusion, PCI, J-CTO score, proctor

Received: January 31, 2019; Accepted: February 15, 2019; Prepublished online: February 15, 2019; Published: March 8, 2019  Show citation