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Hybrid approach improves success of chronic total occlusion angioplasty
  1. W M Wilson1,
  2. S J Walsh2,
  3. A T Yan3,
  4. C G Hanratty2,
  5. A J Bagnall4,5,
  6. M Egred4,5,
  7. E Smith6,
  8. K G Oldroyd7,
  9. M McEntegart7,
  10. J Irving8,
  11. J Strange9,
  12. H Douglas2,
  13. J C Spratt7,10,11
  1. 1Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
  2. 2Belfast Health and Social Care Trust, Belfast, UK
  3. 3St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
  4. 4Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
  5. 5Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
  6. 6The London Chest Hospital (Barts Health Centre, Barts Health NHS Trust), London, UK
  7. 7Golden Jubilee National Hospital, Glasgow, UK
  8. 8Ninewells Hospital, Dundee, UK
  9. 9Bristol Heart Institute, Bristol, UK
  10. 10Edinburgh Heart Centre, Edinburgh, UK
  11. 11Forth Valley Acute Hospitals, Larbert, UK
  1. Correspondence to Dr J C Spratt, Forth Valley Acute Hospitals, Larbert, FK5 4WR UK; James.spratt{at}


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. Inhospital 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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