Elsevier

International Journal of Cardiology

Volume 367, 15 November 2022, Pages 20-25
International Journal of Cardiology

Preprocedural coronary computed tomography angiography in chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry

https://doi.org/10.1016/j.ijcard.2022.08.027Get rights and content

Highlights

  • Of the 7,034 CTO PCI procedures performed between 2012-2022, preprocedural CCTA was used in 375 (5.3%).

  • CCTA helped resolve proximal cap ambiguity in 27%, identified calcium in 18%, and changed the estimated CTO length in 10%.

  • On multivariable analysis preprocedural CCTA was not associated with technical success or major adverse cardiovascular events.

Abstract

Background

Preprocedural coronary computed tomography angiography (CCTA) can be useful in procedural planning for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Methods

We examined the clinical, angiographic and procedural characteristics and outcomes of cases with vs. without preprocedural CCTA in PROGRESS-CTO (NCT02061436). Multivariable logistic regression was used to adjust for confounding factors.

Results

Of 7034 CTO PCI cases, preprocedural CCTA was used in 375 (5.3%) with increasing frequency over time. Patients with preprocedural CCTA had a higher prevalence of prior coronary artery bypass graft surgery (39% vs. 27%, p < 0.001) and angiographically unfavorable characteristics including higher prevalence of proximal cap ambiguity (52% vs. 33%, p < 0.001) and moderate/severe calcification (59% vs. 41%, p < 0.001) compared with those without CCTA. CCTA helped resolve proximal cap ambiguity in 27%, identified significant calcium not seen on diagnostic angiography in 18%, changed estimated CTO length by >5 mm in 10%, and was performed as part of initial coronary artery disease work up in 19%. CCTA cases had higher J-CTO (2.6 ± 1.2 vs. 2.3 ± 1.3, p < 0.001) and PROGRESS-CTO (1.3 ± 1.0 vs. 1.2 ± 1.0 p = 0.027) scores. After adjusting for potential confounders, cases with preprocedural CCTA had similar technical success (odds ratio [OR]: 1.18, 95% confidence interval [CI], 0.83–1.67) and incidence of major adverse cardiovascular events (OR: 1.47, 95% CI, 0.72–3.00).

Conclusion

Preprocedural CCTA was used in ~5% of CTO PCI cases. While CCTA may help with procedural planning, especially in complex cases, technical success and MACE were similar with or without CCTA.

Introduction

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can be challenging to perform, especially in the presence of certain anatomic characteristics such as proximal cap ambiguity, tortuosity, calcification and severely diseased distal vessel. Preprocedural coronary computed tomography (CCTA) can provide accurate assessment of coronary anatomy that could help plan and overcome challenges in CTO PCI [1]. A recent randomized controlled trial demonstrated higher technical success in patients who had preprocedural CCTA guided CTO PCI [2]. However, whether preprocedural CCTA has an impact on CTO PCI outcomes in daily practice has received limited study. We, therefore, evaluated the clinical and angiographic characteristics, contemporary outcomes and the contribution of preprocedural CCTA to procedural planning in a large multicenter CTO PCI registry.

Section snippets

Methods

We compared the clinical and angiographic characteristics, in-hospital procedural outcomes, and the contribution of preprocedural CCTA to procedural planning in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO registry, NCT02061436). PROGRESS-CTO includes patient level data for CTO PCI procedures performed between 2012 and 2022 at experienced CTO PCI centers from the United States, Canada, Greece, Turkey, Egypt, Russia, and Lebanon. All

Results

Of the 7034 CTO PCI procedures performed between 2012 and 2022, preprocedural CCTA was used in 375 (5.3%), with increasing use over time (Fig. 1).

Discussion

The main findings of our study are that preprocedural CCTA was used in ~5% of CTO PCI cases with increasing frequency over time, especially in cases with higher angiographic complexity, and was mainly helpful in resolving proximal cap ambiguity (27%), identifying calcium not seen on angiogram (18%), and changing CTO lesion length (10%) (Fig. 2).

Conclusion

CCTA was used in approximately 5% of CTO PCIs and was most often useful in resolving proximal cap ambiguity followed by identification calcium not seen by conventional angiography. CCTA may facilitate risk/benefit calculation and guide intraprocedural strategy, but was not associated with higher success rates in the present study.

Declaration of Competing Interest

Dr. Jaffer: Sponsored research: Canon, Siemens, Shockwave, Teleflex, Mercator, Boston Scientific; Consultant: Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, Intravascular Imaging. Equity interest – Intravascular Imaging Inc., DurVena. Massachusetts General Hospital – licensing arrangements: Terumo, Canon, Spectrawave, for which FAJ has right to receive royalties.

Dr. Doshi: speaker's bureau for Abbott Vascular, Boston Scientific, and Medtronic and research

Acknowledgements

The authors are grateful for the philanthropic support of our generous anonymous donors, and the philanthropic support of Drs. Mary Ann and Donald A Sens; Mrs. Diane and Dr. Cline Hickok; Mrs. Wilma and Mr. Dale Johnson; Mrs. Charlotte and Mr. Jerry Golinvaux Family Fund; the Roehl Family Foundation; the Joseph Durda Foundation. The generous gifts of these donors to the Minneapolis Heart Institute Foundation's Science Center for Coronary Artery Disease (CCAD) helped support this research

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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation

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