Establishing chronic total occlusion programme in a tertiary australian centre -description of early experience.

Abstract

Introduction: Chronic total occlusions (CTO) represent a unique set of lesions for percutaneous coronary intervention (PCI) because of the complexity of techniques required to treat them, prompting recommendations for institutions to adopt dedicated CTO revascularisation programs. Objective(s): The aim of our study was to investigate the baseline, Procedural characteristics and in-hospital outcomes during the initiation phase of establishment of a dedicated CTO programme. Method(s): We retrospectively reviewed the CTO-PCI experience between January 2010 and December 2012 in a multi-operator single centre, which is one of the largest volume PCI centres in Australia. Data were collected for patient, lesional and procedural characteristics, including procedural success and in-hospital outcomes. Result(s): 82 CTO-PCI procedures were performed. Mean age of the overall cohort was 62.6+/-11.3 years with 85% males. Multivessel disease was present in 78%. The most common site of CTO was RCA (44%), followed by LCX (30%) and LAD (26%). By lesional QCA analysis, the frequencies of complex CTO angiographic features were: 13% for moderate-to-severe calcification, 26% for blunt or ambiguous proximal cap, 16% for angulation of the distal vessel greater than 45+/- and 34% for the presence bridging collaterals. Mean lesional length was 10.1+7.7 mm. Retrograde Rentrop grade III collaterals were observed in 30%. Adopting the Japanese CTO scoring system, 34% of lesions were classified as easy, 37% intermediate, 23% difficult and 6% very difficult. Procedures were undertaken by ten different operators with varying levels of experience, with all cases performed by antegrade guide-wire approach. Selected procedural characteristics included: re-attempt procedure,10%; mutiple access sites, 21%; more than one guide wire, 77%; additional support modality, 60%; DES, 97%; stent number, 1.6+/-0.9; total stent length, 40.1+/-24.5mm; fluroscopy time, 31.7+/-17.5 min; contrast volume, 257.2+/-110.9 mL. Overall CTO success rate was 60%. In-hospital adverse outcomes, included: 3% mortality, 28% peri-procedural myocardial infarction, 17% emergency bypass surgery, 3% tamponade and 7% contrast-induced nephropathy. Conclusion(s): Modest success rates were achieved in a relatively conservative CTO cohort, in this single centre experience, prior to the initiation of a dedicated CTO revascularisation program. These results emphasise the need for Australian centres to adopt a systematic and specialised approach to CTO-PCI.