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Optimising patient selection for CTO PCI – The PICA approach

  • Heerajnarain Bulluck
    Correspondence
    Corresponding author at: Consultant Cardiologist and Honorary Senior Clinical Lecturer, Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, UK.
    Affiliations
    Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK

    Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
    Search for articles by this author
  • Abdul M. Mozid
    Affiliations
    Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK

    Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
    Search for articles by this author
Published:November 19, 2022DOI:https://doi.org/10.1016/j.ijcard.2022.11.020
      Chronic total occlusion (CTO) is defined as 100% occlusion of an epicardial coronary artery with Thrombolysis in Myocardial Infarction (TIMI) 0 flow for at least 3 months. Contemporary registries have shown that a CTO lesion is present in up to 1 in 5 patients [
      • Fefer P.
      • Knudtson M.L.
      • Cheema A.N.
      • Galbraith P.D.
      • Osherov A.B.
      • Yalonetsky S.
      • et al.
      Current perspectives on coronary chronic total occlusions: the Canadian multicenter chronic total occlusions registry.
      ,
      • Azzalini L.
      • Jolicoeur E.M.
      • Pighi M.
      • Millan X.
      • Picard F.
      • Tadros V.X.
      • et al.
      Epidemiology, management strategies, and outcomes of patients with chronic Total coronary occlusion.
      ]. Randomised controlled trials for CTO revascularisation have failed to show an improvement in left ventricular ejection fraction or hard clinical outcomes [
      • Mashayekhi K.
      • Nuhrenberg T.G.
      • Toma A.
      • Gick M.
      • Ferenc M.
      • Hochholzer W.
      • et al.
      A randomized trial to assess regional left ventricular function after stent implantation in chronic total occlusion: the REVASC trial.
      ,
      • Henriques J.P.
      • Hoebers L.P.
      • Ramunddal T.
      • Laanmets P.
      • Eriksen E.
      • Bax M.
      • et al.
      Percutaneous intervention for concurrent chronic Total occlusions in patients with STEMI: the EXPLORE trial.
      ]. The recent global expert consensus document recommends revascularisation of CTO lesions to improve anginal or angina-equivalent symptoms [
      • Brilakis E.S.
      • Mashayekhi K.
      • Tsuchikane E.
      • Abi Rafeh N.
      • Alaswad K.
      • Araya M.
      • et al.
      Guiding principles for chronic Total occlusion percutaneous coronary intervention.
      ]. However, the risk-benefit ratio to attempt CTO percutaneous coronary intervention (PCI) should be considered on a per-patient basis as this procedure involves greater contrast volume, longer fluoroscopy time, and higher MACE rates in comparison with non-CTO patients [
      • Brilakis E.S.
      • Banerjee S.
      • Karmpaliotis D.
      • Lombardi W.L.
      • Tsai T.T.
      • Shunk K.A.
      • et al.
      Procedural outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National Cardiovascular Data Registry).
      ]. Success rate of CTO-PCI can be as high as 90% in experience centres [
      • Wilson W.M.
      • Walsh S.J.
      • Yan A.T.
      • Hanratty C.G.
      • Bagnall A.J.
      • Egred M.
      • et al.
      Hybrid approach improves success of chronic total occlusion angioplasty.
      ] and successful CTO-PCI has been shown to be associated with lower long term mortality than unsuccessful CTO-PCI [
      • Ramunddal T.
      • Hoebers L.P.
      • Henriques J.P.
      • Dworeck C.
      • Angeras O.
      • Odenstedt J.
      • et al.
      Chronic total occlusions in Sweden--a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).
      ].

      Keywords

      Abbreviations:

      CTO (chronic total occlusion), TIMI (Thrombolysis in Myocardial Infarction), PCI (percutaneous coronary intervention), CMR (cardiac magnetic resonance), PET (positron emission tomography), LGE (late gadolinium enhancement), LDD (Low-dose dobutamine), TTE (transthoracic echocardiography)
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