Faculty Bibliography

BACKGROUND: A hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) prioritizing and combining all available crossing techniques was developed to optimize procedural efficacy, efficiency, and safety, but there is limited published data on its outcomes. METHODS: We examined the procedural techniques and outcomes of 1036 consecutive CTO PCIs performed using a hybrid approach between 2012 and 2015 at 11 US centers. RESULTS: Mean age was 65+/-10years and 86% of the patients were men, with a high prevalence of diabetes mellitus (43%) and prior coronary artery bypass graft surgery (34%). Most target CTOs were located in the right coronary artery (59%), followed by the left anterior descending artery (23%) and the circumflex (19%). Dual injection was used in 71%. Technical success was achieved in 91% and a major procedural complication occurred in 1.7% of cases. The final successful crossing technique was antegrade wire escalation in 46%, antegrade dissection/re-entry in 26%, and retrograde in 28%. The initial crossing strategy was successful in 58% of the lesions, whereas 39% required an additional approach. Overall, antegrade wire escalation was used in 71%, antegrade dissection/re-entry in 36%, and the retrograde approach in 42% of procedures. Median contrast volume, fluoroscopy time, and air kerma radiation dose were 260 (200-360) ml, 44 (27-72) min, and 3.4 (2.0-5.4) Gray, respectively. CONCLUSION: Application of a hybrid approach to CTO crossing resulted in high success and low complication rates across a varied group of operators and hospital practice structures, supporting its expanding use in CTO PCI.

Canine non-Hodgkin's lymphoma (NHL) is a heterogeneous group of cancers representing approximately 15% of all canine cancers. Further, canine NHL mimics human disease in regards to histopathology and clinical behavior and could function as a comparative model. Diagnosis is currently performed by histopathological evaluation of surgical biopsy specimens and fine needle aspirate (FNA) cytology, an alternative and less invasive method for diagnosis. Desorption electrospray ionization - mass spectrometry (DESI-MS) imaging was performed on tissue sections of surgical biopsies and FNA smears. Mass spectra acquired from normal lymph nodes and NHL tumors were explored using multivariate statistics (e.g. principal component analysis). Tissue sections yielded a predicted sensitivity of 100% for normal and 93.1% for tumor. Further, preliminary results suggest B-cell and T-cell lymphoma can be discriminated (CV sensitivity of 95.5% and 85.7%, respectively). Normal and B-cell NHL FNA samples analyzed by DESI produced spectra that were similar to spectra obtained from surgical biopsies. FNA samples were evaluated using a PCA-LDA classification system built using tissue section data, exploring if the chemical information obtained from the different sample types is similar and whether DESI-MS performed on FNA samples is of diagnostic value. FNA prediction rate for normal (85.7%) and B-cell NHL (89.3%) indicated that DESI-MS analysis of FNA, not previously explored, could provide rapid preliminary diagnosis. Certainly, MS provides complementary molecular information to be used in conjunction with histopathology/cytology, potentially improving diagnostic confidence. The methodology outlined here is applicable to canine NHL, further supports canine models of human NHL, and translation to humans is envisioned.

BACKGROUND:The performance of the Japan-chronic total occlusion (J-CTO) score in predicting success and efficiency of CTO percutaneous coronary intervention has received limited study. METHODS AND RESULTS/RESULTS:We examined the records of 650 consecutive patients who underwent CTO percutaneous coronary intervention between 2011 and 2014 at 6 experienced centers in the United States. Six hundred and fifty-seven lesions were classified as easy (J-CTO=0), intermediate (J-CTO=1), difficult (J-CTO=2), and very difficult (J-CTO≥3). The impact of the J-CTO score on technical success and procedure time was evaluated with univariable logistic and linear regression, respectively. The performance of the logistic regression model was assessed with the Hosmer-Lemeshow statistic and receiver operator characteristic curves. Antegrade wiring techniques were used more frequently in easy lesions (97%) than very difficult lesions (58%), whereas the retrograde approach became more frequent with increased lesion difficulty (41% for very difficult lesions versus 13% for easy lesions). The logistic regression model for technical success demonstrated satisfactory calibration and discrimination (P for Hosmer-Lemeshow =0.743 and area under curve =0.705). The J-CTO score was associated with a 2-fold increase in the odds of technical failure (odds ratio 2.04, 95% confidence interval 1.52-2.80, P<0.001). Procedure time increased by ≈20 minutes for every 1-point increase of the J-CTO score (regression coefficient 22.33, 95% confidence interval 17.45-27.22, P<0.001). CONCLUSIONS:J-CTO score was strongly associated with final success and efficiency in this study, supporting its expanded use in CTO interventions. CLINICAL TRIAL REGISTRATION/BACKGROUND:URL: http://www.clinicaltrials.gov. Unique identifier: NCT02061436.

BACKGROUND:The hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly increased procedural success rates, yet some cases still fail. We sought to evaluate the causes of failure in a contemporary CTO PCI registry. METHODS:We examined 380 consecutive patients who underwent CTO-PCI at 4 high volume CTO PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, complication, and efficiency outcomes were compared between successful and failed cases. Failed cases were individually reviewed by an independent reviewer to determine the cause of failure. RESULTS:Procedural success was 91.3%. Compared with patients in whom CTO PCI was successful, those in whom CTO PCI failed had similar baseline clinical characteristics, but were more likely to have longer occlusion length, more tortuosity, more proximal cap ambiguity and blunt stump, and higher mean J-CTO scores (2.8 ± 1.1 vs. 3.5 ± 1.0, P < 0.001), and less likely to have collaterals suitable for the retrograde approach (66% vs. 45%, P = 0.021). Failure was due to a complication in 10 cases (30%). In the remaining 23 cases (70%) failure was due to inability to wire the lesion (n = 21, 4 of which were CTOs due to in-stent restenosis), or poor antegrade flow after PCI (n = 5). CONCLUSIONS:Compared with successful cases, failed CTO-PCI cases are more likely to have higher J-CTO scores, longer occlusion length, ambiguous proximal cap and no appropriate collaterals for retrograde crossing. Development of novel CTO crossing techniques is needed to further increase CTO PCI success rates.

OBJECTIVES/OBJECTIVE:To examine the impact of transradial access on the procedural outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI). BACKGROUND:The efficacy and safety of transradial access in CTO PCI has received limited study. METHODS:We compared the technique and outcomes of transradial vs. transfemoral access among 650 CTO PCI cases performed between January 2012 and March 2014 at 6 US centers. RESULTS:Most patients were men (87%) with high frequency of diabetes mellitus (42%) and prior coronary artery bypass graft surgery (36%). The CTO target vessel was the right coronary (59%), left anterior descending (20%), or circumflex (17%) artery. TR access was used in 110 (17%) of the 650 cases, as follows: bilateral radial access (63%); bilateral radial access plus unilateral or bilateral femoral access (7%); unilateral radial access plus unilateral or bilateral femoral access (26%); and unilateral radial access (4%). Six and eight French guide catheters were used through the radial and femoral artery, respectively. Compared to transfemoral, transradial cases had similar technical (92.6% vs. 93.0%, P = 0.87) and procedural (91.1% vs. 90.0%, P = 0.95) success and major complication rates (1.7% vs 1.8%, P = 0.99). However, transradial access was associated with higher mean procedure (142 ± 83 vs. 120 ± 60 min, P = 0.008) and fluoroscopy (58 ± 40 vs. 49 ± 31 min, P <0.026) time, and number of crossing approach changes (0.7 ± 1.0 vs. 0.5 ± 0.7, P = 0.008). CONCLUSION/CONCLUSIONS:Transradial CTO PCI can be performed with similar success and complication rates with transfemoral CTO PCI, but is associated with longer procedural and fluoroscopy times. © 2015 Wiley Periodicals, Inc.

There is substantial evidence that recanalization of a chronic total occlusion is beneficial; nonetheless, it is generally underutilized in clinical practice. We consider the Aesop's fable of the "Fox and the Grapes" as analogous to the current situation in interventional cardiology. The technical challenges in achieving CTO recanalization has led interventionalists, clinical cardiologists, and sometimes even patients to believe that CTO recanalization is not effective, and, therefore, not needed. This perspective reviews available data regarding efficacy and safety of CTO percutaneous coronary intervention (PCI) in the current drug-eluting stent era, discusses areas where more studies are required, and encourages the interventional community to utilize CTO PCI where appropriate based on current evidence.

BACKGROUND The J-CTO (Multicenter Chronic Total Occlusion [CTO] Registry in Japan) score was developed to predict the probability of successful guidewire crossing within 30 minutes. However, guidewire crossing alone does not ensure final success of CTO PCI. We therefore sought to develop a novel parsimonious scoring system to estimate the likelihood of technical success. METHODS We examined 781 CTO percutaneous coronary interventions (PCI) performed using the "hybrid" approach and included in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO). To develop the "PROGRESS CTO" score we analyzed clinical and angiographic parameters using a derivation and validation cohort (2:1 sampling ratio). Variables with strong association with technical failure in multivariable analysis were assigned 1 point and a 4-point score was developed from summing all points. The PROGRESS CTO score was subsequently compared with the J-CTO score in the validation cohort. RESULTS Technical success was achieved in 726 lesions (92.9%). Factors associated with technical success on multivariable analysis included proximal cap ambiguity (beta coefficient b=0.88), moderate/ severe tortuosity (b=1.18), left circumflex artery CTO PCI (b=0.99), and absence of "interventional" collaterals (b=0.88). The resulting PROGRESS CTO score demonstrated good calibration and discriminatory capacity in the derivation (Hosmer-Lemeshow chi²=2.633, p=0.268 and receiver operator characteristic [ROC] area=0.778) and validation subset (Hosmer-Lemeshow chi²=5.333, p=0.070 and ROC area=0.720). In the validation cohort, the PROGRESS CTO and J-CTO performed similarly in predicting final procedural success and guidewire crossing at 30 minutes, respectively (ROC area 0.720 vs. 0.746, area under the curve AUC difference=0.026, 95% confidence interval=-0.093 to 0.144). CONCLUSIONS The PROGRESS CTO score is a novel useful tool for estimating technical success in CTO PCI performed using the hybrid approach. (Table Presented)