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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 868-875

Clinical and angiographic predictors of success in chronic total occlusion coronary angioplasty


1 Department of Cardiology, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Cardiology, Kobry El Kobba Military Hospital, Cairo, Egypt

Date of Submission22-May-2015
Date of Acceptance10-Aug-2015
Date of Web Publication17-Oct-2019

Correspondence Address:
Ahmad M Mahmoud Elsheikh
Department of Cardiology, Kobry El Kobba Military Hospital, 14 Elobour St., Mansheyat Alsadat, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_229_15

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  Abstract 

Objective
The aim of this study was to define the preinterventional parameters for procedural success of chronic total occlusion (CTO) coronary angioplasty.
Background
CTOs are encountered in 15–30% of patients undergoing coronary angiography. Compared with failed CTO angioplasty, successful CTO angioplasty has been associated with improvement in angina and left ventricular function and increased survival. Compared with intervention of nonoccluded stenoses, the recanalization of CTOs requires expert operator skills, increased procedural time, and increased radiation exposure to the patient, physician, and catheterization laboratory staff.
Materials and methods
This prospective study was conducted from April 2014 to March 2015 in Kobry El Kobba Military Hospital and included 30 patients with CTO of more than 1-month duration having significant angina (class III/IV) or recent acceleration of previously chronic stable angina. Clinical and angiographic variants were listed, and rate of success and failure of each was calculated after CTO angioplasty trial.
Results
There were 25 successful angioplasty cases. There was no significant affection of the different clinical variants and risk factors on the success rate. On the contrary, some of the angiographic variants showed a significant affection on the success and failure rates. The criteria of failure were difficult antegrade and retrograde wiring, unhealthy donor vessel, blunt calcified distal cap, and no continuous collaterals.
Conclusion
The success rate of CTO percutaneous coronary intervention mainly depends on certain angiographic factors. The clinical factors, although not statistically significant, play a crucial role in decision planning of CTO percutaneous coronary intervention.

Keywords: angioplasty, chronic total occlusion, predictors, success


How to cite this article:
Emara AA, Hataba AEA, Elkersh AM, Mahmoud Elsheikh AM. Clinical and angiographic predictors of success in chronic total occlusion coronary angioplasty. Menoufia Med J 2019;32:868-75

How to cite this URL:
Emara AA, Hataba AEA, Elkersh AM, Mahmoud Elsheikh AM. Clinical and angiographic predictors of success in chronic total occlusion coronary angioplasty. Menoufia Med J [serial online] 2019 [cited 2019 Nov 19];32:868-75. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/868/268818




  Introduction Top


Decreasing morbidity and mortality from coronary artery disease (CAD) will necessitate the early diagnosis as well as early detection of risk factors for prevention of CAD and provision of optimal care [1].

Chronic total occlusions (CTOs) are encountered in 15–30% of patients undergoing coronary angiography [2].

Compared with failed CTO percutaneous coronary intervention (PCI), successful CTO PCI has been associated with improvement in angina and left ventricular function and increased survival [3].

Despite these benefits, CTO PCI is performed infrequently [4]. This is likely owing to historically low procedural success rates, technical complexity, high equipment use, and the potential for major periprocedural complications [5].

Compared with intervention of nonoccluded stenoses, the recanalization of CTOs requires expert operator skills, increased procedural time, and increased radiation exposure to the patient, physician, and catheterization laboratory staff.

The procedural success rate varies from physician to physician with intervention in CTOs, and a definite learning curve exists in which technical success rates for individual operators continue to improve after the performance of hundreds of CTO procedures [6].

According to the guidelines published in 2005 by the European Society of Cardiology, CTO PCI still shows the lowest technical success rates compared with other anatomical subset lesions [7].


  Patients and Methods Top


A total of 30 patients with CTO of more than 1-month duration having significant angina (class III/IV) or recent acceleration of previously chronic stable angina admitted to Kobry El Kobba Military Hospital were included in the study. The inclusion criteria were CTO of more than 1-month duration; absence of scar defined as a bright thinned-out echo-reflective area of less than 6-mm thickness, which is akinetic or dyskinetic in the entire territory of CTO; and/or absence of history of Myocardial infarction (MI)/absence of Q wave in CTO territory/positive viability test in CTO territory/significant angina (class III/IV), or recent acceleration of previously Chronic stable angina (CSA) that is not explained except by the CTO. The exclusion criteria were patients with a recent coronary occlusion, patients with presence of scar or nonviable myocardium in CTO territory, patients with uncontrolled congestive heart failure, and patients with renal impairment (creatinine >1.5).


  Materials and Methods Top


All patients were investigated by (a) history taking and clinical examination (age, sex, hypertension, diabetes mellitus, smoking, Canadian Cardiovascular society (CCS) class III/IV angina, and cardiac examination to exclude signs of decompensation); (b) 12-lead ECG, with special concern for ischemic manifestations in the form of Q waves, ST, and T changes; (c) cardiac enzyme assessment before and after the procedure; (d) routine laboratory investigations, with special concern to serum creatinine, with exclusion of patients with serum creatinine more than 1.5 mg% and lipid profile (patient is considered dyslipidemic if Low-density lipoprotiens (LDL) >130 mg/dl); (e) echo Doppler study for assessment of left ventricular dimensions and left ventricular ejection fraction before the procedure; (f) in-hospital management, where all patients had received low-dose aspirin 150 mg, unfractionated Heparin, clopidogrel (300 mg as a loading dose the day before then 75 mg as a maintenance dose), and conventional treatment (β-blockers, nitrates, Angiotensin converting enzyme inhibitor (ACEI), and statins); (g) all patients were subjected to PCI for coronary CTO with documentation of number of diseased vessels, CTO vessel, length of the lesion, presence of stump and its shape, bridging collaterals and relation to stump, presence of calcification, adequacy of septal branches, antegrade or retrograde approach, guide wires that accomplished successful lesion passage, and balloons that succeeded to dilate the total occlusion; (h) success was defined as procedural success with achievement of thrombolysis in myocardial infarction (TIMI) III flow in CTO artery with no complications during hospital stay; (i) patients were evaluated for the following points: (a) angiographic: TIMI flow, which is a qualitative grading of coronary flow with four grades recognized: TIMI 0: complete occlusion with no distal run off, TIMI I: some penetration of contrast agent beyond the point of obstruction with poor distal run off, TIMI II: perfusion of the entire vessel with good but delayed distal run off, and TIMI III: full perfusion of the entire vessel with normal distal run off, (b) myocardial blush grade (MBG), which is a qualitative visual assessment of the amount of contrast medium filling the territory supplied by an epicardial coronary artery, which is graded as follows: MBG 0: no myocardial blush or contrast density, MBG I: minimal myocardial blush or contrast density, MBG II: myocardial blush or contrast density which exists to lesser extent and its clearance is diminished compared to noninfarct related coronary artery, and MBG III: normal myocardial blush or contrast density comparable with that obtained during angiography of noninfarct-related coronary artery, and (c) any angiographic complications: Major adverse cardiovascular event (MACE) (death, myocardial infarction, stroke) or other in-hospital complications; and (j) CTO opening: the plan is an antegrade approach as a first approach. If antegrade trial failed or complications developed like dissection or perforation, retrograde approach as a secondary approach was tried.

Statistical methods

Data were statistically described in terms of mean ± SD, median, or frequencies (number of cases) and percentages when appropriate. The distribution of cervical lengths was tested for normality using the Kolmogorov–Smirnov test. Unpaired Student's t-test was used to calculate the significance of differences. χ2-Test was used and Fisher's exact tests were used instead when the expected frequency is less than 5. Correlation between various variables was done using Pearson moment correlation equation for linear relation in normally distributed variables and Spearman rank correlation equation for non-normal variables. P values less than 0.05 was considered statistically significant. All statistical calculations were done using computer programs statistical package for the social sciences (SPSS, IBM, SPSS Inc, Chicago, Delaware, USA). Data were collected and tabulated according to the standard statistical methods.


  Results Top


CTOs are the most technically challenging lesion subset that interventional cardiologists might face; recanalization of these lesions will have the most effect on future PCIs success.

Our study included 30 patients, comprising 29 males and one female, who were recruited from Kobry El Kobba Military Hospital in the period from April 2014 to March 2015. The age of our study population ranged from 40 to 65 years. They presented with significant angina (class III–IV) or recent acceleration of previously chronic stable angina. Overall, 16 (53.33%) patients of our group had previous myocardial infarction, whereas 14 (46.67%) patients did not have previous myocardial infarction.

(1) Risk factors among patients with CTO were as follows

  1. Past history of hypertension: 18 patients had Hypertension (HTN), and CTO PCI was successful in 14 (77.78%) of them [Table 1]
  2. Past history of diabetes mellitus: nine patients were diabetics, and PCI was successful among seven (77.7%) of them. CTO was more prevalent in patients who did not have past history of Diabetes Mellitus (DM) than patients who had DM, and success rate among patients without DM was higher (85.7%), with no significant difference (P = 0.593)
  3. Past history of dyslipidemia: 19 patients were dyslipidemic, with successful PCI in 15 (78.95%) of them. CTO was more prevalent in patients who had past history of dyslipidemia than patients who did not experience dyslipidemia, and success rate among patients without dyslipidemia was higher (90.9%), but there was no significant difference (P = 0.397)
  4. History of smoking: 22 patients were smokers, and successful PCI was in 19 (86.36%) of them. CTO was more prevalent among smokers, and the success rate among them was higher, with no significant difference (P = 0.460; [Table 2])
  5. Family history of CAD: 16 patients had family history of Ischemic heart disease (IHD), with successful PCI in 14 (87.5%) of them. CTO was more prevalent in patients who had family history of IHD than patients who did not have, and the success rate among these patients was higher, with no significant difference (P = 0.513; [Table 3]).
Table 1: Relation between success and failure of chronic total occlusion percutaneous coronary intervention among patients with hypertension

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Table 2: Relation between success and failure of chronic total occlusion percutaneous coronary intervention among smokers

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Table 3: Relation between success and failure of chronic total occlusion percutaneous coronary intervention among patients with positive FH of IHD

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The aforementioned data show that there is no significant affection of the different risk factors on the success of coronary CTO angioplasty.

(2) Angiographic data of patients with CTO were as follows:

  1. Success rate in patients with single lesion: 14 patients had single lesion, with successful PCI in 12 of them (success rate 85.71%). Patients who had multiple lesions were more than patients who had single lesion, and the success rate was lower among them (81.3%), without significant difference (P = 0.743)
  2. Lesion morphology: 10 patients had CTO with tapered end, and CTO PCI through antegrade approach was successful in nine of them (90% success rate), in comparison 20 patients had CTO with abrupt end; antegrade approach was successful in 10 of them (success rate 50%), whereas retrograde approach was successful in six patients of failed PCI through antegrade approach (success rate 60%). Patients whose CTO had abrupt stump were more than those who have tapered stump, but the success rate was higher among those who had tapered stump, yet was not statistically significant (P = 0.488). Retrograde approach could elevate the success rate in CTO lesions with abrupt stump from 50 to 80% [Table 4]
  3. CTO length: 17 patients had lesion length less than 15 mm, with successful PCI through antegrade approach in 13 (76.4%) of them, and by retrograde approach in two of the failed four patients (success rate 50%), in comparison with 13 patients who had CTO with lesion length of more than 15 mm, where antegrade approach was successful in six of them (success rate 46%), whereas retrograde approach could be successful in four patients of failed PCI through antegrade approach (success rate 57.1%). Patients who had lesion length of less than 15 mm in length were more than patients who had lesions longer than 15 mm, and the success rate in short lesions was higher than that in long lesions, but with no significant difference (P = 0.41). Retrograde approach could elevate the success rate in long CTO lesions from 46.1 to 76.9%
  4. Lesion angulation: 27 patients had CTO lesions with angulation degree less than 45°, with successful PCI through antegrade approach in 19 (82.6%) of them and four (17.3%) cases through retrograde approach, whereas in lesions with more than 45° angulation, retrograde approach was successful in two patients out of three, with success rate of 66.7%. Patients who had lesion angulation less than 45° were more common than those who had lesions more than 45°, and the success rate was higher in those with less angulation degree, but with no significant difference (P = 0.414). In more angulated lesions, retrograde approach raised the rate of success from 0 to 66.7%
  5. CTO calcification: 28 patients had calcific lesions by fluoroscopy with successful PCI through antegrade approach in 18 (78.2%) of them, whereas retrograde approach was successful in five (21.7%) cases. Patients who had calcified lesions were more than those without calcifications, and the success rate was higher in patients without calcifications but was not statistically significant (P = 0.694). Retrograde approach in calcified lesions raised the overall success rate from 64.2 to 82.1%
  6. Side branch origin at the site of CTO: 22 patients had side branch origin at the site of CTO with successful PCI through antegrade approach in 15 (68.1%) of them, whereas retrograde approach was successful in four (18.1%) of them, with no statistical significance (P = 0.865). Patients who had side branch origin at the site of CTO were more common than those who did not have, and the success rate was higher in those with side branch origin at the site of CTO, but with no significant difference (P = 0.414). In those with side branch origin at the site of CTO, the retrograde approach raised the rate of success from 68.1 to 86.3%
  7. Bridging collaterals at the CTO segment: 27 patients had bridging collaterals, with successful PCI through antegrade approach in 18 (78.2%) of them, whereas the retrograde approach was successful in five (21.7%) patients. Patients who had bridging collaterals at CTO were more than those who did not, and the success rate was more among them, but not statistically significant (P = 0.827). In the presence of bridging collaterals, the retrograde approach raised the overall success of the procedure from 66.7 to 85.1%.
Table 4: Relation between success and failure of chronic total occlusion percutaneous coronary intervention among patients with different lesion morphology

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Success of retrograde approach is dependent on many factors: the presence of continuous collaterals between the donor vessel and the totally occluded vessel (P = 0.00), presence of healthy donor vessel (P = 0.25), presence of tapered noncalcified distal cap of the CTO lesion (P = 0.54), and the presence of difficult antegrade wiring, which was the cause for shift of the procedure from the antegrade to the retrograde approach [Table 5].
Table 5: Factors affecting the success of retrograde approach

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From the aforementioned results, though most of them are statistically nonsignificant, we can conclude the criteria favoring antegrade or retrograde approach. Criteria favoring antegrade approach were as follows: lesion with tapered end, lesion less than 15 mm length, lesion angulation less than 45°, and presence of bridging collaterals at CTO segment. Criteria favoring retrograde approach were as follows: lesion with abrupt end, lesion more than 15 mm length, lesion angulation more than 45°, no side branch origin at CTO segment, difficult antegrade wiring, healthy donor vessel, tapered noncalcified distal cap, and continuous collaterals. Criteria of failure were as follows: difficult antegrade and retrograde wiring, unhealthy donor vessel, blunt calcified distal cap, no continuous collaterals, and retry lesions.

(3) Different wires, techniques, stents, and assisting devices used in the study:

  1. Guide wires: 94 wires were used in our study, with high success rate among stiff wires in passing CTO. First, soft wires (30 wires) were tried to pass the lesion, but all of them failed to cross, then gradual upgrading to the intermediate group of wires (31 wires were tried with only five successful wires with success rate 13.89%) was done, and then upgrading to the stiff group of wires, with the highest success rate (25 wires succeeded to pass the lesions from 28 wires used, with success rate of 89.29%; [Figure 1])
  2. Balloons: 58 balloons were used in our study with regular starting with OTW balloons or microcatheter in every case of CTO, and then after being sure that the wire was in true lumen, inflation of the balloon was done repeatedly to dilate the lesion and then upgrading to compliant balloons if the lesion was not heavily calcified, and finally, use of noncompliant balloons to overcome the heavy calcification of the lesion or to ensure proper deployment of the stent after fixation of the lesion. In three cases, noncompliant balloons failed to dilate the lesion, for which rotablator was used [Table 6]
  3. Different techniques, stents, and assisting devices used in the study.


  4. Rotablator was used in three cases to overcome heavily calcified plaques that resist ordinary ways of dilatation and progress of interventional procedure. Intravascular ultrasound (IVUS) was used in 20 cases. The decision of the operator to use IVUS was taken before or during the procedure. The main aims were to study cautiously the relationship of the CTO to major side branch and the effect of calcification on the success of the procedure. Microcatheter was used in 24 cases as assisting device in order not to miss the place of the crossing wire during different stages of the procedure.

    Only one case had perforation of Left anterior descending (LAD) with development of mild pericardial effusion which resolved spontaneously. Follow-up of serum creatinine and cardiac enzymes was done after 24 h of the procedure, with no elevation of any one of them.

  5. TIMI flow and MBG: 25 of 30 (83.33%) patients achieved TIMI III flow, with only three (10%) patients with MBG I, five (16.67%) patients with MBG II, and 17 (56.67%) patients with MBG III.
Figure 1: Success rates of different guide wires used in chronic total occlusion percutaneous coronary intervention. A total of 94 wires were used in the study. First soft wires (30 wires) were tried to pass the lesion, but all of them failed to cross (0% success rate), then gradual upgrading to the intermediate group of wires (31 wires were tried with only five successful wires with success rate 13.89%) was done, and then upgrading to the stiff group of wires, with the highest success rate (25 wires succeeded to pass the lesions from the 28 wires used, with success rate of 89.29%).

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Table 6: Different balloons used in chronic total occlusion percutaneous coronary intervention

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  Discussion Top


Despite remarkable advances in the procedural and clinical outcomes of percutaneous revascularization, CTO remains the unresolved dilemma in interventional cardiology [8].

Our study showed that the success rate of coronary CTO PCI was 83.3%, which was consistent with the study published by Han et al. [9], who reported that the overall success rate was 88.9%.

The results showed that the different clinical risk factors had no influence on the success of coronary CTO angioplasty. This was partially consistent with Mashallah et al. [10], who studied the effect of clinical and coronary angiographic data of patients with CTO and showed that there was no significant correlation between the success rate of PCI and the patient's age, sex, clinical risk factors, or history of recent MI.

On the contrary, the criteria favoring success by antegrade approach were as follows: lesions with tapered end, lesions less than 15 mm length, lesion angulation less than 45°, and presence of bridging collaterals at CTO segment. However, the criteria favoring success by retrograde approach were lesion with abrupt end, lesion more than 15 mm length, lesion angulation more than 45°, no side branch origin at CTO segment, difficult antegrade wiring, healthy donor vessel, tapered noncalcified distal cap, and presence of continuous collaterals.

Criteria of failure of CTO PCI were absence of criteria favoring antegrade and retrograde wiring, unhealthy donor vessel, blunt calcified distal cap, and absence of continuous collaterals.

This was partially consistent with the study published by Han et al. [9], who showed that the success rate of PCI declined with longer duration of occlusion, bridging collaterals, at least 15 mm in occluded length, moderate to severe calcification or tortuosity, and ostial or distal location of CTO lesions. Procedural failure was caused by impossibility of guide wire (81.0%) or balloon (19.0%) to cross the occlusion.

However, Mashallah et al. [10] studied the effect of clinical and coronary angiographic data of patients with CTO and showed that the success rate was not affected by target vessel, location of lesion, presence of side branch at the site of occlusion, and TIMI flow of artery, yet they found that the success rate of PCI was decreased with increase in the length of occlusion and presence of bridging collaterals.

Our results were also partially consistent with Maiello et al. [11] (Catherization Laboratory, Centro Cuore Columbus, Milano, Italy). They studied the influence of 27 clinical, morphologic, and procedural variables as possible predictors of successful outcomes. Success rate was shown to be significantly influenced by the following: (a) duration of occlusion: 89% if up to 1 month, 87% if it ranges from 1 to 3 months, 45% if more than 3 months; and 60% in CTOs with unknown age; (b) morphology of occlusion: 83% in tapered lesions and 51% in abrupt lesions; (c) length of occlusion: 71% in lesions less than 15 mm and 60% in lesions more than 15 mm; and (d) bridging collaterals: 29% if present, and 67% if absent.

None of the other clinical, angiographic, or procedural variables correlated with the success rate of coronary angioplasty.

The results of this study support a previous study by Olivari et al. [12], which investigated the success rate of PCI for CTO. They identified the following factors as significant predictors of PCI failure: CTO length more than 15 mm or not measurable, moderate to severe calcifications, duration of at least 180 days, and multivessel disease.

Similarly, Tomasello et al. [13] agreed that duration of occlusion had no influence on procedural outcome. However, predictors of angiographic failure were vessel diameter less than 2.5 mm, CTO length more than 20 mm, and severe calcification.

Dong et al. [14] also showed that blunt morphology, at least 45° of angulations of the target artery, and length of occlusion more than 15 mm were statistically significant independent predictors of procedural failure.

In this study, the success rate was higher in cases with bridging collaterals through antegrade approach. This was consistent with the results obtained by Kinoshita et al. [15] who showed that coronary angioplasty can open CTOs, with or without bridging collateral channels, safely and effectively without major complications. This might be explained by the fact that bridging collaterals may be confused with micro channels in CTO body, which facilitates wire passage through the CTO.

Addressing this particular point, Stone et al. [6] reported that in the past, the presence of bridging collaterals was repeatedly found to be the strongest determinant of failed CTO angioplasty. However, in more recent experiences, the success rates have no longer been inversely correlated to the presence of bridging collaterals.

Thus, this study results showed that success of coronary CTO angioplasty (by antegrade approach 19 of 25 and by retrograde 6 of 25) was more common in short (<15 mm), noncalcified lesions with tapered end, on side branch, with less than 45° angulation, and with bridging collaterals. These results contradict those of Rastegari et al. [16] who showed that predictors of an unsuccessful result of coronary CTO angioplasty were the presence bridging collaterals or presence of a side branch 2 mm or less from the occlusion point.

We may argue that a side branch might be useful to advance a wire or a wire and balloon to get more anchor and support for the guiding catheter. This was consistent with the study done by Fujita S et al. [17], who confirmed getting a superior guiding catheter support by inflating a balloon in a nontarget vessel and holding its shaft with backward force while advancing another balloon. The anchor effect for the guiding catheter could thus be offered by the side branch, and it appeared to be helpful for a balloon or a stent to cross the target lesion.

In agreement, Rathore et al. [18] also published that the procedure was successful by retrograde approach in 65.6% of cases. Continuous thread-like connection, collateral tortuosity less than 90°, and angle with recipient vessel less than 90° were significant predictors of success. Absence of continuous connection, corkscrew channel, angle with recipient vessel more than 90°, and nonvisibility of connection with recipient vessel were found to be significant predictors of procedural failure.

Addressing stiff wires, they were shown here to have the greatest opportunity to pass the CTO. This result is in agreement with the study done by Fujita S et al. [17], who showed that except for the use of stiff guide wires, there were no significant differences in clinical or lesion characteristics as a success predictor.

In this study, IVUS was used in 20 cases. The decision of the operator to use IVUS was taken before or during the procedure. The main aims were to study cautiously the relationship of the CTO with the major side branch and the effect of calcification on the success of the procedure. This was consistent with the study published by Mohandes et al. [19], who showed the benefit of IVUS in showing calcium in CTO segment, finding wire penetration in subintimal space in part of CTO segment, wire position verification, and more precise vessel measurement.

Moreover, rotablator was used in three cases to overcome heavily calcified plaques that resist ordinary ways of dilatation and progress of interventional procedure. This was consistent with the study done by Bittl et al. [20], who confirmed that the rotablator rotational atherectomy device is intended for plaque modification, especially in resistant, elastic, or calcific lesions. The rotablator can facilitate the procedure and can increase the overall PCI success rates, especially difficult CTOs.

Follow-up of serum creatinine in this study was done after 24 h of the procedure, with no elevation in any patient. This is not consistent with the data registry of the Mayo clinic, which reported that the overall incidence of Contrast induced nephropathy (CIN) in the general population is 1.2–1.6%. However, it is known that the peak incidence of CIN is on 2–3 days after exposure to contrast medium, which was, however, not done in the current series [21].

Only one case had perforation of LAD with development of mild pericardial effusion which resolved spontaneously but without development of MACE. This is consistent with the results published by Ellis et al. [22], who showed that the incidence of coronary perforation is less than 1%.

Assessment of cardiac enzymes was done before and every 4 h after the procedure during the first 24 h and then daily during hospital stay. We did not have any case with elevated cardiac enzymes after the procedure. This was not consistent with the study published by Bahrmann et al. [23], who reported CK-MB elevation after recanalization of CTOs was observed in only 6% of patients with CTOs.


  Conclusion Top


First of all, attempt CTO PCI only if supported by a careful revision of clinical data relating to the patient risk profile evaluation, renal impairment, life expectancy, comorbidities, and assessment of viability/ischemia in the territory of the occluded artery.

The criteria favoring success by antegrade approach were as follows: lesions with tapered end, lesions less than 15 mm length, lesion angulation less than 45°, and presence of bridging collaterals at CTO segment. However, criteria favoring success by retrograde approach were lesion with abrupt end, lesion more than 15 mm length, lesion angulation more than 45°, no side branch origin at CTO segment, difficult antegrade wiring, healthy donor vessel, tapered noncalcified distal cap, and presence of continuous collaterals.

Criteria of failure of CTO PCI were absence of criteria favoring antegrade and retrograde wiring, unhealthy donor vessel, blunt calcified distal cap, and absence of continuous collaterals.

Limitations

Important limitations to our study were as follows: (a) small sample number limited only to a single center, (b) contrast medium and radiation dose were not calculated, and (c) serum creatinine was measured only during the 24 h after the procedure, probably missing some cases of CIN.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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