JACC: CARDIOVASCULAR INTERVENTIONS VOL. 2, NO.

6, 2009

2009 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 1936-8798/09/$36.00

PUBLISHED BY ELSEVIER INC. DOI: 10.1016/j.jcin.2009.04.008

Procedural and In-Hospital Outcomes After

Percutaneous Coronary Intervention for Chronic
Total Occlusions of Coronary Arteries 2002 to 2008
Impact of Novel Guidewire Techniques

Sudhir Rathore, MD, Hitoshi Matsuo, MD, Mitsuyasu Terashima, MD,

Yoshihisa Kinoshita, MD, Masashi Kimura, MD, PHD, Etsuo Tsuchikane, MD, PHD,
Kenya Nasu, MD, Mariko Ehara, MD, Yasushi Asakura, MD, Osamu Katoh, MD,
Takahiko Suzuki, MD

Toyohashi, Japan

The aim of this study was to examine the procedural success and in-hospital outcomes after percuta-
neous coronary intervention (PCI) for chronic total occlusions in the current era during contemporary
practice. The technique of PCI has improved over time with the introduction of novel equipment and
guidewire crossing techniques. However, there is limited data available from contemporary practice in
the recent years. We evaluated the procedural and in-hospital outcomes in a consecutive series of 904
procedures performed at Toyohashi Heart Center for PCI of chronic total occlusions of 3 months in
duration. Technical and procedural success was achieved in 87.5% and 86.2%, respectively. In-hospital
major adverse cardiac events occurred in only 1.9% of the patients. Single antegrade wire was the pre-
dominant strategy for guidewire crossing; however, retrograde guidewire crossing was used in 7.2% of
the cases and controlled antegrade and retrograde subintimal tracking in 9.9% of the cases as the nal
strategy. Logistic regression analysis identied severe tortuosity and moderate-to-severe calcication as
signicant predictors of procedural failure. This is the rst reported large series of patients undergoing
PCI for chronic total occlusion with improved wire crossing techniques. We have reported high success
rates in recent years and very low complication rates despite the use of more aggressive devices and
techniques. (J Am Coll Cardiol Intv 2009;2:489 97) 2009 by the American College of Cardiology
Foundation

Percutaneous coronary intervention (PCI) of failure to cross the lesion with the guidewire
chronic total occlusion (CTO) is considered a (4 11). Recent development of dedicated guide-
major frontier in interventional cardiology. Ap- wires, sophisticated technologies, and increasing
proximately one-third to one-half of patients with clinical experience and skills have improved the
significant coronary artery disease on angiography procedural outcomes with CTO-PCI. Moreover,
have at least 1 CTO (1,2). However, they account the novel methods of guidewire crossing particu-
for only 10% to 15% of all PCI activity (3), and the larly parallel wire, retrograde, and controlled ante-
majority of the patients are treated with either grade and retrograde subintimal tracking (CART)
coronary artery bypass grafting or medical therapy. techniques have given much hope for the treatment
The procedural success rate for CTO has improved of chronically occluded arteries.
over time, but is still low and is mainly due to the However, there is limited data on the procedural
success rate and procedural complications with
these techniques after PCI for CTO in contempo-
From the Department of Cardiology, Toyohashi Heart Center, Toyo- rary practice. Several previous large studies have
hashi, Japan.
shown procedural success rates and outcomes after
Manuscript received February 17, 2009; revised manuscript received
April 6, 2009, accepted April 17, 2009. CTO-PCI, but they have also included the pa-
490 Rathore et al. JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 2, NO. 6, 2009

Impact of Novel Guidewire Techniques JUNE 2009:489 97

tients with recent occlusions (10) and all occlusions of more Procedure time is defined as the time difference between
than 1 months duration (3,12,13). the patients entry and exit from the catheterization room.
The aim of our study is to analyze the procedural success Fluoroscopy time and dosing data was available in only 350
rates, guidewire strategies, and in-hospital outcomes in the patients. Type 1 coronary perforation was defined as discrete
patients treated for CTO-PCI in contemporary practice. or localized extravasation of the contrast medium and Type
2 coronary perforation was defined as persistent visible
Methods extravasation of the contrast medium.
Interventional technique and guidewire crossing strategies.
Study design. Consecutive patients who underwent PCI of The operators performed the PCI procedure according to
a chronic occluded artery were identified from the dedicated their practice at that time, and most of the procedures were
database at the Toyohashi Heart Center, Toyohashi, Japan, performed via femoral route using 8-F guiding catheters.
where data was entered prospectively. All procedures per-
The technique has been modified over time by routine use
formed between January 2002 and July 2008 were included
of bilateral simultaneous coronary injections and dedicated
in this analysis. The database includes demographic, clini-
stiff wires, including Xtreme (Asahi Intecc, Aichi, Japan),
cal, angiographic, and procedural data; guidewire strategies;
Fielder and Fielder FC (Asahi Intecc), Miracle 3-12 (Asahi
and in-hospital outcomes.
Denitions. Our study defined CTO as a lesion showing
Intecc), and stiff-tapered wires (Confianza Family, Asahi
Thrombolysis In Myocardial In- Intecc). Also, the uptake of micro catheters (Finecross MG,
Abbreviations farction (TIMI) flow grades of 0 Terumo Corporation, Tokyo, Japan) and over-the-wire
and Acronyms
to 1 that were 3 months or more specialist devices has increased over time.
CABG coronary artery in duration. All patients included The guidewire strategies used were single wire technique,
bypass surgery in this analysis had at least 1 parallel (contact) wire technique, intravascular ultrasound
CART controlled occlusive lesion. Duration of oc- (IVUS)-guided wiring technique, and retrograde wiring
antegrade and retrograde
clusion was estimated on the basis through collaterals and CART technique. These techniques
tracking
of either history of angina or pre- have been described by our group in the past (14 18).
CK creatinine kinase
vious myocardial infarction (MI) The sequence of these wiring techniques and selection of
CTO chronic total the guidewire is completely dependent on the operators
in the same territory or proven by
occlusion
previous angiography. discretion and the patients coronary anatomy. Generally the
IVUS intravascular
Major adverse cardiac events antegrade approach was started with a step up to different
ultrasound
(MACE) were defined as death, wiring strategies and stiffer wires depending on the progress.
MACE major adverse
cardiac events
Q-wave MI, or urgent revascu- Briefly, parallel wire (contact wire) technique involves 2
larization during the same ad- antegrade wires in which the first wire ends up in the false
MI myocardial infarction
mission. Urgent revasculariza- lumen. The shaft of second wire remains in contact with the
PCI percutaneous
coronary intervention
tion was defined as target vessel first wire and the tip is deflected to gain entry into the true
repeat PCI within 24 h or urgent lumen.
TIMI Thrombolysis In
Myocardial Infarction
coronary artery bypass surgery Intravascular ultrasound guided wiring was used when the
(CABG). entry point of the CTO was not visible, therefore IVUS was
Q-wave MI was defined as cardiac enzymes (creatinine
used to localize the entry point. Second, IVUS was used to
kinase [CK]) elevation of more than 3 times the normal
help find the true lumen in the event of guidewire entry into
value with development of Q-wave following the PCI.
the false lumen.
NonQ-wave MI was defined as elevation of CK greater
Retrograde wiring was used when favorable collaterals
than 3 times without development of Q-wave following the
were present and this technique involves manipulating and
PCI.
Technical success was defined as successful guidewire and advancing the guidewire into CTO retrogradely to reach the
balloon crossing with residual stenosis 50% and TIMI proximal true lumen and achieve successful recanalization.
flow grade 3. Procedural success was defined as residual The CART technique involves simultaneously antegrade
stenosis 50% with TIMI flow grade 3 without MACE. and retrograde guidewire manipulation using controlled
Acute occlusion is defined as target vessel occlusion antegrade and retrograde subintimal tracking to limit the
needing repeat PCI within 24 h. Subacute occlusion is extent of dissection to the CTO site and achieve successful
defined as target vessel occlusion needing repeat PCI within recanalization.
7 days. Side branch compromise was defined as TIMI flow All patients were treated with aspirin and thienopyridine
grades 0 to 1 in the side branch of 2.0 mm in size. (ticlopidine or clopidogrel) before the procedure and re-
Access-related complications were not included in this ceived heparin to achieve activated clotting time of around
analysis. 250 s.
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 2, NO. 6, 2009 Rathore et al. 491
JUNE 2009:489 97 Impact of Novel Guidewire Techniques

Statistical Analysis

Continuous data was presented as mean SD and differ-

ences were compared using the Student t test. Discrete
variables were expressed as counts and percentages. These
were assessed by Fisher exact test and chi-square test
depending on the table size. All statistical tests were
2-tailed.
Logistic regression analysis was used to assess the rela-
tionship between baseline demographic, clinical, and angio-
graphic characteristics and procedural failure. All analysis
was performed using SPSS version 15 statistical software
(SPSS Inc., Chicago, Illinois).

Results

Patient population. Between January 2002 and July 2008,

665 patients had 1 CTO lesion attempted (665 lesions), 88
patients had more than 1 CTO lesion (186 lesions) at-
tempted, and 53 patients had same CTO lesion (53 lesions)
attempted more than once. Therefore, we present a consec-
utive series of 904 CTO lesions in 806 patients.
Trends in successful revascularization. Overall technical suc-
cessful revascularization was achieved in 791 (87.5%) lesions
and the remaining 113 (12.5%) were unsuccessful. Success-
ful revascularization has increased from around 80% in year
2002 up to 90% during more recent years. The procedural
success rate was achieved in 780 (86.2%) lesions.
Guidewire techniques. Yearly uptake of different novel
guidewire techniques and technical success rates are shown
in Figure 1. There is a steady yearly increase in the usage of
Figure 1. Yearly Utilization of Adjunctive Wiring Strategies and
IVUS guidance, parallel wire technique, retrograde wiring Procedural Success Rates
techniques, and CART attempts (p 0.019), and this
(A) Yearly increase in adjunctive wiring techniques (p 0.019). (B) Proce-
increase in usage was associated with a nonsignificant
dural success rates in percutaneous coronary intervention for chronic total
increase in the procedural success rates (p 0.078). occlusion (p 0.078), comparing success rates (2002 to 2004 vs. 2004 to
Baseline clinical characteristics. The baseline demographics 2008). CART controlled antegrade and retrograde tracking; IVUS intra-
for both CTO success and failure groups are shown in Table vascular ultrasound.

1. Mean age, gender frequency, and risk factors were similar

in both groups. The majority of patients had a history of the CTO site was higher in the successful group. Moderate-
previous MI (86%) and about one-quarter of the patients to-severe calcification was seen in around one-third of the
had previous PCI, which was similar in both groups. The cases with increased calcification seen in the CTO failure
CTO failure group had a higher incidence of multivessel group. The majority of the CTO lesions (86%) were
disease and prior CABG. nonostial in location and 12 (0.2%) lesions were aorto-
Angiographic and anatomical characteristics. Table 2 sum- ostially located. The location of the CTO site was similar in
marizes the angiographic and anatomical characteristics. both groups. In-stent restenosis was the cause of CTO in
The CTO vessels were predominantly the right coronary around 10% cases. The estimated CTO length was similar
arteries (38%), followed by the left anterior descending in success and failure groups.
artery (29%) and left circumflex coronary artery (22%). The Patient characteristics stratied with guidewiring techniques.
left main coronary artery was the CTO vessel in 5 cases. The As shown in Table 3, the baseline demographics and
CTO vessel was the branch artery in 8% of the procedures, angiographic features were similar in all 4 different wiring
and there was a significantly higher number of PCI proce- techniques. There were significantly more cases with severe
dures attempted on the branch artery in the CTO failure tortuosity and calcification in the single wire failure, retro-
group. Significant side branch at the CTO site was seen in grade attempt, and CART success groups. There were also
about 16% of the cases, and the incidence of side branch at significantly more cases with CTO in the right coronary
492 Rathore et al. JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 2, NO. 6, 2009

Impact of Novel Guidewire Techniques JUNE 2009:489 97

Table 1. Baseline Patient Demographics and Vessel Characteristics for CTO Success and Failure Groups

CTO Success CTO Failure

Variables (n 791) (n 113) p Value

Age, yrs 65.42 10.7 66.01 11.2 0.587

Male 654 (82.2%) 94 (83.2%) 0.837
Diabetes mellitus 318 (40.2%) 42 (37.4%) 0.473
Hypertension 488 (61.7%) 74 (65.5%) 0.334
Hyperlipidemia 312 (39.5%) 45 (39.9%) 0.936
Family history of CAD 115 (14.6%) 18 (15.7%) 0.662
Smoking 219 (27.7%) 33 (29.1%) 0.728
Previous MI 679 (85.8%) 99 (87.6%) 0.571
Previous CABG 94 (11.9%) 20 (17.7%) 0.036
Previous PCI 220 (27.9%) 27 (24.1%) 0.293
Unstable angina 60 (7.7%) 15 (12.8%) 0.026
CCS class 3 to 4 52 (6.6%) 11 (9.3%) 0.187
Vessel disease
1-vessel 102 (12.9%) 7 (6.4%) 0.005
2-vessel 258 (32.6%) 35 (31.03%) NS
3-vessel 431 (54.5%) 70 (62.5%) NS
Body weight, kg 63.50 11.8 63.69 12.1 0.873
Body surface area 1.67 0.17 1.72 0.59 0.057

Values are mean SD or n (%).

CABG coronary artery bypass surgery; CAD coronary artery disease; CCS Canadian Cardiovascular Society; CTO chronic total occlusion;
MI myocardial infarction; PCI percutaneous coronary intervention.

Table 2. Angiographic and Treatment Factors of CTO Success and Failure Groups

CTO Success CTO Failure

Variables (n 791) (n 113) p Value

Target vessel
LAD 239 (30.2%) 28 (24.6%) NS
RCA 312 (39.3%) 43 (37.9%) NS
LCX 182 (23.1%) 19 (17.2%) NS
LMT 4 (0.4%) 1 (0.4%) NS
Branch 52 (6.6%) 22 (19.7%) 0.0001
RITA 1 (0.1%) 0 NS
SVG 1 (0.1%) 0 NS
Signicant side branch at CTO site 144 (18.2%) 11 (9.8%) 0.03
Calcication
None 240 (30.1%) 37 (31.5%) NS
Mild 258 (32.3%) 32 (28.5%) NS
Moderate 214 (26.9%) 22 (19.2%) 0.001
Severe 79 (9.9%) 22 (19.2%) NS
Ostial location 0.294
Aorto-ostial 10 (1.2%) 2 (1.4%)
Nonaorto-ostial 86 (10.9%) 17 (14.7%)
Nonostial 695 (87.8%) 94 (83.7%)
Tortuosity
None 675 (85.1%) 85 (75.3%) NS
Moderate 81 (10.5%) 16 (14.3%) NS
Severe 35 (4.4%) 12 (10.3%) 0.001
In-stent restenosis 95 (12.1%) 9 (8.3%) 0.174
Lesion length 30.53 13.68 24.72 6.01 0.067

Values are mean SD or n (%).

CTO chronic total occlusion; LAD left anterior descending artery; LCX left circumflex artery; LMT left main trunk; RCA right coronary
artery; RITA right internal thoracic artery; SVG saphenous vein graft.
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 2, NO. 6, 2009 Rathore et al. 493
JUNE 2009:489 97 Impact of Novel Guidewire Techniques

Table 3. Patients Baseline, Procedural Characteristics, and Outcomes Comparing Different Wiring Strategies

Single Wire Parallel Wire Retrograde Attempt CART

Success Failure Success Failure Success Failure Success Failure

(n 510) (n 380) (n 150) (n 125) (n 57) (n 80) (n 78) (n 5) p Value*

Variables
Age, yrs 66.2 10.7 64.9 10.9 64.7 9.8 64.3 12.1 63.0 10.6 65.6 10.6 64.4 11.3 71.6 6.8 NS
Diabetes 40.8 38.2 42.2 31.9 42.9 33.3 40.2 42.9 NS
Male 79.5 85.2 84.5 87.4 84.1 82.2 83.9 71.4 NS
Hypertension 62.4 59.5 59.6 62.2 71.4 65.6 67.8 71.4 NS
Hyperlipidemia 37.8 41.8 40.4 41.5 42.9 42.2 47.1 28.6 NS
Smoking 24.9 31.7 31.1 33.3 28.6 28.9 32.2 20.0 NS
Previous MI 83.3 89.1 88.8 88.9 95.2 94.4 93.1 100 0.005
Previous CABG 10.1 15.8 12.4 13.3 19.0 21.1 18.4 40 0.041
Unstable angina 8.5 9.1 6.2 9.6 9.5 6.7 9.2 0 NS
Vessel
LAD 29.8 31.9 32.9 32.6 30.2 37.8 23 42.9 NS
RCA 35.9 43.4 38.5 48.9 50.8 51.1 65.5 51.1 0.0001
LCX 26.6 19.0 22.4 13.3 14.3 10.0 9.2 0 0.003
Branch 7.2 5.5 5.6 5.2 1.1 1.6 0 0 0.024
LMT 0.4 0.3 0.6 0 1.6 0 2.3 0 NS
Others 0.2 0 0 0 1.6 0 0 0 NS
Previous PCI 25.8 29.6 23.6 30.4 44.4 21.0 39.1 42.9 0.001
ISR 14.8 8.3 6.8 8.1 11.1 7.8 8.0 0 0.028
Side branch 18.6 14.5 19.9 11.9 20.6 15.6 14.9 0 NS
Tortuosity
Moderate 7.8 12.7 9.9 12.6 19.0 24.4 20.7 28.6 0.018
Severe 2.5 9.1 6.8 10.4 11.1 14.4 12.7 14.3 0.0001
Calcication
Moderate 24.3 27.8 33.5 23.7 19.0 32.2 34.5 14.3 0.0186
Severe 9.7 13.5 11.2 17.8 17.5 23.3 9.2 28.6
CTO length 31.1 13.7 27.8 12.46 26.4 13.4 36.5 15.0 34.6 14.5 27.3 5.06 31.4 11.8 N/A NS
Outcomes
Success rate 57.3% 54.5% 61.4% NS
Dissection 10.9 10.9 17.3 13.6 3.1 10 7.6 20 0.0183
Perforation
Type I 3.2 16.1 9.9 20.7
7.9 30.0 12.6 25 0.001
Type II 2 (0.4) 1 (0.3) 0 0 1 (1.6) 0 1 (1.1) 0
NonQ-wave MI 11 (2.1) 11 (2.9) 5 (3.1) 3 (1.9) 1 (1.6) 0 3 (3.4) 1 NS
Q-wave MI 1 (0.2) 4 (1.0) 2 (1.2) 1 (0.7) 0 0 0 0 NS
Cardiac tamponade 1 (0.2) 5 (1.3) 3 (1.9) 1 (0.7) 0 1 (1.1) 1 (1.1) 0 NS
Emergency CABG 1 (0.2) 1 (0.3) 0 0 0 1 (1.1) 0 0 NS
Death 2 (0.4) 3 (1.0) 0 3 (2.2) 0 0 0 0 NS
Procedure time, hh:mm 2.13 2.09 3.14 2.41 3.07 1.12 3.32 2.59 3.24 3.04 3.45 2.38 3.56 1.30 4.34 1.21 0.0001
Fluoroscopy time, mm:ss 59.57 34.40 100.00 49.03 80.16 40.32 114.00 53.50 101.60 48.10 112.40 48.71 112.96 52.29 135.32 26.29 0.0001
(n 350)
Fluoroscopy dose 7.65 5.31 11.81 8.39 10.17 6.92 13.05 10.84 12.25 6.67 14.50 8.55 12.65 6.19 13.21 15.23 0.0001
(frontal), Gy
(n 350)

Values are mean SD or %. Categorical variables presented as n (%) frequencies and continuous variables as mean SD. *p value compared between success in different groups; NS 0.05 (chi-square and
1-way analysis of variance). p 0.05 intragroup.
ISR in-stent restenosis; other abbreviations as in Tables 1 and 2.

artery in the retrograde technique success groups. However, patients. Single wire usage was the predominant strategy
the success rate with each wiring technique is similar, but used in 510 (64%) cases followed by parallel wire technique
overall, this increases the success rates cumulatively in some in 150 (19%) cases, retrograde guidewire crossing in 57 cases
494 Rathore et al. JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 2, NO. 6, 2009

Impact of Novel Guidewire Techniques JUNE 2009:489 97

Table 4. In-Hospital Complications for CTO Success and Failure Groups

Major side branch compromise was noted in 36 patients
(3.9%), predominantly in the successful recanalization
CTO Success CTO Failure
Variables (n 791) (n 113) p Value
group. We identified 135 (14.9%) cases with different
degrees of vessel dissection and that were similar in both
Death 2 (0.25) 3 (2.6) NS
groups. There were 98 patients (9.3%) identified with Type
Q-wave MI 4 (0.50) 1 (0.88) NS
1 coronary perforation, and the number was significantly
NonQ-wave MI 20 (2.5) 2 (1.76) NS
higher in the failure group (19.2% vs. 7.0%; p 0.01). Type
Urgent CABG 1 (0.10) 1 (0.88) NS
MACE 12 (1.5) 5 (4.4) 0.027
2 coronary perforations were seen in 5 cases (0.5%) and were
Aortic dissection 1 (0.10) 1 (0.88) NS similar in both groups.
Arrhythmias 3 (0.40) 1 (0.88) NS Table 3 also shows stratification of in-hospital complica-
Delayed tamponade 5 (0.6) 1 (0.88) NS tions and MACE events according to the different wiring
Acute vessel occlusion 5 (0.6) 0 (0) 0.058 techniques utilized with the success and failure groups.
Subacute occlusion 2 (0.23) 0 (0) 1.00 There was no difference noted in the in-hospital MACE
Distal embolization 24 (3.0) 0 (0) 0.008 events in all groups; however, there were more Type 1
Spasm 2 (0.23) 0 (0) 1.00 perforations seen in patients with single wire failure, parallel
Side branch compromise 35 (4.4) 1 (0.88) 0.008
wire, and retrograde attempts. Procedure duration, fluoros-
Any dissection 110 (13.9) 25 (22) 0.006
copy time, and fluoroscopy dose increased with more
Type 1 perforation 59 (7.0) 39 (19.2) 0.01
complex wiring techniques.
Type 2 perforation 3 (0.4) 2 (1.0) 0.240
Determinants of procedural success. Results of the logistic
Values are n (%).
MACE major adverse cardiovascular events; other abbreviations as in Table 1.
regression model are shown in Table 5. There were no
significant differences in the age, sex, history of hyperten-
(7.2%), and CART wire crossing technique in 78 (9.9%) sion, diabetes mellitus, hyperlipidemia, family history,
cases of the successful procedures. The IVUS guided wire smoking, previous MI, previous CABG, unstable angina,
crossing was performed at different stages of the procedure body surface area, previous PCI, in-stent restenosis, and
in 78 (10%) of the successful procedures. significant side branch at CTO site in the successful and
Several different guidewires were used ranging from soft failure groups. Only severe tortuosity and moderate-to-
wires to intermediate wires and CTO dedicated wires along severe calcification were associated with technical failure in
with various back up supporting catheters. The final guide- this series.
wires used were stiff wires (60% of cases), polymer-coated
hydrophilic wires (19%), and soft wires in (21%) of the
Table 5. Logistic Regression Result for Unsuccessful CTO Procedures
cases.
The majority of the patients were treated with stents 95% Confidence
Variables Odds Ratio Interval p Value
(74.3%) after successful recanalization and balloon angio-
plasty was the main device used in 18% of the cases. Several Female 0.93 0.571.52 0.787
other adjunctive mechanical devices were used such as Age 0.98 0.971.0 0.164
directional coronary atherectomy, cutting balloon angio- Diabetes mellitus 1.08 0.781.51 0.628
plasty, and rotablation. However, cutting balloon angio- Hypertension 0.88 0.631.24 0.499
plasty, rotablation, and directional coronary atherectomy Hyperlipidemia 0.93 0.671.30 0.695
were the primary treatment devices in 31 (4%), 22 (3%), and Family history 0.89 0.571.40 0.637

6 (1%) cases, respectively. Smoking 0.87 0.601.25 0.463

In-hospital complications. The in-hospital complications for Previous MI 0.81 0.501.34 0.427

both success and failure groups are shown in Table 4. Total Previous CABG 0.74 0.431.05 0.195

in-hospital MACE was low (1.9%) and was slightly higher Unstable angina 0.61 0.361.06 0.084

in the CTO failure group (1.5% vs. 4.4%, p 0.02). The BSA 0.50 0.201.24 0.137
Previous PCI 1.17 0.751.83 0.472
in-hospital mortality was 0.25% and 2.6% in CTO success
In-stent restenosis 1.27 0.652.49 0.478
and failure groups, respectively. The Q-wave MI/non
Absence of side branch 1.96 1.183.26 0.009
Q-wave MI rate was 0.5%/2.5% and 0.8%/1.76% in CTO
Severe tortuosity 2.30 1.264.18 0.006
success and CTO failure groups, respectively. One patient
Moderate calcication 1.95 1.193.21 0.008
in each group needed urgent CABG, and urgent repeat PCI
Severe calcication 1.60 0.972.65 0.064
due to acute vessel closure was seen in 5 (0.6%) cases. Nonaorto-ostial 0.70 0.441.11 0.132
Delayed cardiac tamponade needing pericardiocentesis was Multivessel disease 1.20 0.851.69 0.283
seen in 6 (0.6%) cases. Aortic dissection was seen in 2
BSA body surface area; other abbreviations as in Table 1.
patients, 1 in each group, needing conservative treatment.
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 2, NO. 6, 2009 Rathore et al. 495
JUNE 2009:489 97 Impact of Novel Guidewire Techniques

Discussion seen in 22 (2.4%) of the patients. Cardiac tamponade,

possibly due to the wire perforation, occurred in only 6
Our study. The major findings of this study are that in an (0.66%) patients. These in-hospital complications are sim-
unselected population of patients undergoing PCI for CTO ilar to those reported in the literature. Olivari et al. (13)
procedure of more than 3 months duration: 1) the technical reported MACE rates of 5.1% and MI rates of 4.25% in a
success rate in the current era is high around 87%; 2) the multicenter registry. Hoye at al. (3) reported MACE rates
in-hospital MACE and other complications are low and of 3.5%, with high incidence in the failed group very similar
comparable to other nonCTO-PCI data (19,20); and 3) to our study. Prasad et al. (12) reported reducing MACE
the incidence of Type 1 coronary perforation was higher rates and the need for urgent CABG over time with recent
with the use of novel wiring techniques and high usage of rates of around 3.5% and 0.7%, respectively. Our data are
stiff guidewires. comparable to recently published literature for urgent
The procedural success rate for CTO-PCI has improved CABG, MI, and MACE following contemporary coronary
over the years with the uptake of new techniques (IVUS interventions.
guided, retrograde, and CART) and available equipment. In There was a higher incidence of Type 1 coronary perfo-
our series, the success rates have increased from 80% to ration in our series with higher usage of stiff guidewires and
around 90% from the year 2004 onward, and this is complex wiring techniques. However, they did not result in
associated with the introduction of retrograde wiring tech- significant adverse events and were mostly managed conser-
nique, CART procedure, and IVUS guided wiring tech- vatively by prolonged balloon inflation and reversing anti-
niques. This is the largest series describing the lesion coagulation.
morphology and guidewire crossing strategies and their The procedure time, fluoroscopy time, and fluoroscopy
influence on successful recanalization of the CTO lesions. dosage increased with increasing complexity of the cases and
Several studies have looked at the in-hospital outcomes the wiring techniques. As expected, in some cases, a
and complications following CTO-PCI. The majority of stepwise approach of different techniques results in accumu-
these studies have included patients with occlusion duration lating time and radiation dosing.
of 4 weeks or more as the definition for CTO lesion. The high success rate in our study is due to the combi-
Compared with these studies, our series included complex nation of factors such as increased operators experience,
cases of CTO and showed the continuing high success rate availability of dedicated CTO wires and microcatheters, and
with low complications. use of advanced guidewiring techniques. Interestingly, the
Procedural success rates. Suero et al. (10) have reported an high success rate was not associated with increased adverse
overall success rate of 69.9% in their cohort during the events, despite the use of more aggressive devices and
period of 1980 to 1999 with only 7% usage of stents. In the techniques.
same era, Stone et al. (4) reported a success rate of 72%. Our results of in-hospital complications are similar to
More recently, Hoye et al. (3) and Olivari et al. (13) those shown in large databases with nonCTO-PCI
reported procedural success rates of 65.1% and 73.3%, (19,20).
respectively. Both these studies used 4 weeks duration to Predictors of success. In the multivariate analysis, severe
define the CTO lesion and the stent use was high (around tortuosity and moderate-to-severe calcification are the only
80%). More recently, Prasad et al. (12) published the predictors shown to be significantly associated with proce-
25-year experience of their institution and showed a proce- dural failure in our study. The other important observation
dural success rate of around 70%, with not much improve- from our study is that 22 patients (20%) in the failed group
ment in success rate with widespread use of stent and with had CTO attempted to the branch artery. There were
time. The predominant reason for the low success rate in the significant low success rate with branch CTO lesion (6.6%
treatment of CTO is the failure to cross the lesion with the vs. 19.6%). This is merely a fact that it is technically difficult
guidewire (4 11). to recanalize the branch; also, more aggressive strategies
Our data suggest that advances in guidewire techniques, could not be applied to the branch lesions. Multivessel
such as parallel wire technique, retrograde technique, disease and side branch at CTO site were not found to be
CART technique, and IVUS guided wiring, have improved related to procedural failure in our study.
the success rate in CTO-PCI in this group of patients with Presence of multivessel disease, CTO length more than
complex lesion morphology. 15 mm, and moderate-to-severe calcifications were shown
In-hospital outcomes. The higher success rate in our series to be independent predictors of unsuccessful procedures in a
of patients is not associated with an increase in acute study by Olivari et al. (13). Multivessel disease, previous
complications rates, despite high use of stiff wires and MI, and previous CABG were also noted to occur with high
aggressive guidewire strategies. Major adverse cardiac events frequency in the study by Prasad et al. (12). Side branch at
occurred in only 17 patients (1.8%) with the prevalence of the occlusion site has also been shown to be a negative
Q-wave MI in 5 (0.5%) patients and nonQ-wave MI was predictor of success along with bridging collaterals and
496 Rathore et al. JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 2, NO. 6, 2009

Impact of Novel Guidewire Techniques JUNE 2009:489 97

abrupt stump in some older studies (8,21). The majority of recommend that PCI should be considered as the preferred
these predictors of unfavorable outcomes were observed strategy for patients who are symptomatic with CTO of the
with antegrade approach to recanalization of the CTO coronary arteries.
lesion, although, this was not observed in our study. Also,
these differences can be explained by increasing use of Reprint requests and correspondence: Dr. Sudhir Rathore,
retrograde and IVUS guided wiring techniques. Department of Cardiology, Toyohashi Heart Center, 21-1, Gobu-
Our study has shown a high incidence of previous MI and dori, Oyama-cho, Toyohashi 441-8530, Japan. E-mail:
previous CABG as reported in literature, but they are not [email protected].
significantly different in patients in the successful and failed
PCI groups.
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