Angiographic suitability for catheter revascularization of total coronary occlusions in patients from a community hospital setting

doi:10.1016/0002-8703(93)90404-W

American Heart Journal

Volume 126, Issue 3, Part 1, September 1993, Pages 561-564

https://doi.org/10.1016/0002-8703(93)90404-W Get rights and content

Abstract

To assess the frequency of totally occluded coronary arteries and their angiographic suitability for catheter-based revascularization in an unselected patient population, all coronary angiograms showing ≥50% diameter stenosis obtained from patients in a community hospital setting, were reviewed during a 1-year period. There were 112 totally occluded arteries in 101 patients (35%). Based on coronary morphologic variables previously identified as predictive of successful revascularization, 52 (46%) totally occluded arteries were judged suitable for coronary angioplasty. Totally occluded arteries with unfavorable features for coronary angioplasty were present in 29% of patients with multivessel coronary artery disease and were more commonly present in the right coronary artery. Thus totally occluded coronary arteries are found in approximately one third of patients with suspected or known coronary artery disease studied by means of coronary arteriography in a community hospital setting. Approximately one half of the total occlusions have features favoring successful coronary angioplasty.

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Chronic total occlusions (CTOs) are now an integral, albeit challenging subset of coronary disease that can benefit from revascularization. There are many unique aspects of CTOs, including the pathology and pathophysiology, the specialized equipment and techniques that are required for successful interventions, and particularly, determining why, when, and how CTO revascularization should be attempted. In this chapter, we will discuss our research in several aspects of CTOs, including the following: (1) CTO pathology, particularly the specific extracellular matrix components and expected effects on percutaneous interventions, (2) current animal models to mimic CTO disease, (3) experimental and clinical revascularization approaches based on CTO pathology, and (4) recent data to assist in CTO revascularization decision making.
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Malnutrition is associated with poor prognosis in a wide range of chronic illnesses, however, the impact of malnutrition on long-term outcomes of patients at advanced stages of atherosclerosis, coronary chronic artery occlusion (CTO), is not known.
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Average age in this study was 65.32 ± 9.97 years old. More than one-third of patients were at risk of malnutrition (moderate to severe: 10.5%; low: 29.4%; and absence of risk: 60.1%). Over a median follow-up of 33 months, compared to those with absent risk for malnutrition, moderate to severe risk was associated with significantly increased risk for the all-cause death, cardiovascular death and MACE (hazard ratio [HR]: 2.90, 95% confidence interval [CI]: 1.43 to 5.87, P for trend = 0.002; HR: 3.72, 95% CI: 1.42 to 9.77, P for trend = 0.010; HR: 1.76, 95% CI: 1.02 to 3.03, P for trend = 0.040; respectively) after adjustment for baseline variables. Moreover, addition of the GNRI score significantly raised the predictive value for the all-cause death (0.383, p = 0.004 and 0.022, p = 0.011, NRI and IDI respectively), cardiovascular death (0.488, p < 0.001 and 0.013, p = 0.014, NRI and IDI respectively) and MACE (0.368, p = 0.004 and 0.014, p = 0.008, NRI and IDI respectively) as compared to traditional factors.
Malnutrition assessed by the GNRI score on admission was an independent predictor for adverse cardiovascular events in CTO patients after PCI. Addition of the GNRI score to the existing risk prediction model significantly increased the predictive ability for cardiovascular events in CTO patients after PCI.
Association Between Revascularization and Quality of Life in Patients With Coronary Chronic Total Occlusions: A Systematic Review
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Percutaneous revascularization of coronary chronic total occlusions (CTO) has increased due to advances in technology and operator expertise. Quality of life (QoL) remains an important but understudied outcome following CTO revascularization. Our aim is to conduct a systematic review of the impact of CTO revascularization on QoL.
We searched three databases (Ovid MEDLINE, EMBASE, EBM reviews) from January 1st, 1990 to May 17th, 2020. Studies reporting on the following QoL metrics post CTO revascularization were included: QoL subscale of the Seattle Angina Questionnaire (SAQ-QoL). The ROBINS-I tool and Cochrane risk of bias tool were used to critically assess for risk of bias.
We identified 1476 articles, of which 21 articles met inclusion criteria. Three categories of studies were identified with distinct patient populations. In the first category (1 study), CTO patients treated with either PCI or CABG compared to medical therapy had a significant improvement in SAQ-QoL compared to baseline (PCI 54.2 to 74.3; CABG 56.1 to 78.0; p < 0.05). In the second category (1 study), CTO patients compared to non-CTO patients had similar improvements in SAQ-QoL post PCI (CTO baseline 53.2 to 80.3; non-CTO baseline 56.5 to 80.6; p < 0.05). Finally, a third category with only CTO patients treated with PCI to the CTO vessel included 19 studies, all of which on average showed a significant improvement in SAQ-QoL post successful PCI, compared to non-successful PCI.
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Quality of life (QoL) is an important but understudied outcome following CTO revascularization. We conducted a systematic review of the impact of CTO revascularization on QoL. Despite the limitations of a lack of enough randomized control trials and the small number of studies, our systematic review highlights a trend of improvement in QoL indices after revascularization of CTO.
Post-stEnting assessment of Re-endothelialization with optical Frequency domain imaging aftEr Chronic Total Occlusion procedure: The PERFE-CTO Study Design and Rationale
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The treatment of chronic total occlusion of coronary arteries by percutaneous coronary intervention (CTO PCI) is one of the most representative technical advances in ischemic cardiomyopathy of last decade. However, how the complex histopathological remodeling and the new techniques affect healing processes after stent implantation remains unknown.
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The PERFE-CTO study will provide essential understanding of the early history after CTO recanalization and the identification of inadequate evolution (stent thrombosis, restenosis or late delayed stent endothelization and cardiovascular outcomes) using intravascular imaging to improve long-term CTO results.
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Citation Excerpt :
These are classically defined as significantly occlusive lesions in the coronary arteries characterized by absent distal flow TIMI grade 0 and typically present for >3 months.1 The prevalence of CTO lesions among patients with significant CAD ranges from 18% to 35%.2-4 However, CTOs have been classically quite complex to treat percutaneously and pose a significant management dilemma.
The prevalence of chronic total occlusion (CTO) lesions in coronary arteries is notably high in patients with significant coronary artery disease. However, only a relatively small fraction of observed CTOs classically go for revascularization. Recent advances in techniques and equipment has greatly improved the success rates of CTO revascularization while reducing complications. There has also been an increasing body of evidence regarding clinical benefit of CTO revascularization. However, until recently majority of the evidence was observational and based on data from large multicenter registries. Recent randomized studies have reported on clinical benefits of CTO revascularization particularly with relief of angina. However, there is heterogeneity of results among different studies and the magnitude of benefit is not consistently seen in all studies. This article reviews the existing literature on the current evidence regarding clinical benefits and other rationale for CTO revascularization.
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Angiographic suitability for catheter revascularization of total coronary occlusions in patients from a community hospital setting

Abstract

J Am Coll Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol