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Chronic Total Occlusion PCI Is Getting Safer –

ATLANTA — Percutaneous coronary intervention for chronic total occlusion (CTO PCI) has improved in success rates, but the pandemic might have impacted complication rates, a registry study showed.

Technical and procedural success rates steadily improved over time from 2016 to 2021, rising from 81.6% to 88.1% and 80.0% to 87.0%, respectively (both P<0.0001). And the number of cases recorded in the PROGRESS-CTO registry from 63 participating centers in countries had been steadily rising too, until the pandemic, reported Spyridon Kostantinis, MD, of the Minneapolis Heart Institute Center for Coronary Artery Disease.

Case numbers peaked in 2019 then fell back to 2018 levels, he said at the Society for Cardiovascular Angiography and Interventions (SCAI) meeting.

“And that was the year you had your lowest complication rate,” pointed out SCAI past president Kirk Garratt, MD, MSc, of the Christiana Care Health System Center for Heart and Vascular Health in Newark, Delaware. “Thereafter, the rate jumped a fair bit actually.”

Patient risk scores remained fairly high over time, perhaps reflecting the kind of patients referred to the experienced centers participating in the registry.

However, in-hospital major cardiovascular adverse event (AE) trends reversed. They had been falling, from 3.1% in 2016 to 1.6% in 2019 but then rose to 2.7% in 2020 and 1.7% in 2021.

“I suspect there is a pandemic impact embedded here,” Garratt told MedPage Today at a SCAI press conference.

Kostantinis agreed: “That might be true that characteristics of patients may have changed, or operators in those 2 years did fewer cases. That is probably why the complication rates are still high, but I think the trend of decreasing complication rates will follow in next couple of years.”

Further improvement will be important, Garratt said. “We’re all excited about the improvement in CTO success rates. We’re also all very aware and sensitive to the risk profile. Although the risk profile has improved slowly over time, it is my impression that it is not yet where it needs to be.”

“Without any question, one method for minimizing the risk is to concentrate these cases in the hands of those who do many of them. So as I see the numbers go down, I worry that it is inevitable that complication rates will go up again,” he noted.

A parallel situation has happened across PCI and elsewhere in medicine, with case numbers dipping in the pandemic and now catching up, Garratt pointed out.

The registry included 10,019 patients treated at participating centers in the U.S., Canada, Greece, Turkey, Bahrain, Lebanon, Egypt, India, and Russia from 2012 through 2022.

Other findings in the registry included an increase in antegrade wire escalation as the final successful crossing strategy (46% in 2016 to 61% in 2021). At the same time, decreases occurred in antegrade dissection and re-entry (ADR, 15% to 9%) and retrograde wiring (21% to 18%).

With technological improvements, steady decreases were also seen in contrast volume used, air kerma radiation dose, fluoroscopy time, and procedure time.

SCAI session co-moderator Cindy L. Grines, MD, of Northside Hospital Cardiovascular Institute in Atlanta, called it encouraging to see that so many of successes were antegrade and that this was also the safest in terms of AEs across the board from mortality and major cardiovascular AEs to vascular access site complications.

“Traditionally the U.S. has been much faster to go to ADR, retrograde than other countries,” responded study co-investigator Emmanouil S Brilakis, MD, PhD, director of the Center for Complex Coronary Interventions at the Minneapolis Heart Institute, speaking from the audience. “We don’t do parallel wiring. In the past, actually there was stigma to parallel wiring.”

But now with “much better wires, the chance of succeeding antegrade is much, much higher,” he said. There’s room to improve on CTO success, Brilakis added. “Retrograde is great but has pretty bad complications.”

More than 80% of the patients treated in the registry were male, which Kostantinis suggested reflected undertreatment of women, as has been seen in other registries.

One limitation of the dataset was that while the cases are supposed to be consecutive, there is no adjudication or core lab.

Disclosures

Kostantinis disclosed no relationships with industry.

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