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Objective: The research was carried out to determine and compare the efficiency of completely transradial access (cTRA) and transfemoral access (TFA) in retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: The cases of retrograde chronic total occlusion (CTO) percutaneous coronary intervention usually need the dual access. The transradial method is now used more frequently in CTO PCI, and improves the safety of CTO PCI. Methods: This retrospective, observational study was carried out in a single center. Participants were patients who underwent dual-access retrograde CTO PCI from January 2017 to October 2023, categorized into two groups: cTRA (biradial access) and TFA (bifemoral, or combined radial and femoral access). All patients in the cTRA group received conventional radial access. All punctures of the femoral artery were performed without fluoroscopic or ultrasound guidance. None of the patients in the TFA group accepted any arterial closure devices. Clinical, angiographic and procedural characteristics and the occurrence of in-hospital major adverse cardiovascular events (MACE) of the cTRA and TFA procedures were recorded. Results: This research involved 187 CTO PCI procedures with dual access, of which 88 were done using cTRA and the rest (99) were carried out through TFA. The J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) score was lower in the cTRA group than TFA group (2.1± 0.6 vs 3.0± 0.8; P <0.001). The technical success (84.1% vs 82.8%; P= 0.817), procedural success (80.7% vs 79.8%; P= 0.906) and in-hospital MACE rates (5.7% vs 4.0%; P= 0.510) were the same for both groups. For a J-CTO score of 3 or higher, technical success rate was significantly lower in the cTRA group than the TFA group (58.1% vs 74.2%; P < 0.001). Conclusion: In the retrograde CTO PCI, the percentages of success and in-hospital MACE were similar for both cTRA and TFA. Meanwhile, cTRA may be used for simpler lesions (J-CTO score < 3) as compared to TFA.

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INTRODUCTION: Oxidative response is a risk factor in the progression of arterial atherosclerosis. OBJECTIVE: This research study aimed to examine the effects of oxidative response on atherosclerotic susceptibility as well as the development of arteriosclerosis occlusions of the tibial artery through pro-inflammatory mediator genes in elderly patients with occlusion of coronary arteries. METHODS: We determined that oxidative stress biomarkers (Malondialdehyde-modified Low-density Lipoprotein (MDA-LDL), Oxidized Low-density Lipoprotein (Ox-LDL) as well as Heme Oxygenase- 1 (HO-1)] and the expressions of pro-inflammatory mediator genes [Toll-like Receptor 4 (TLR4), Nuclear Factor kappa-B (NF-κB), Myeloid Differentiating factor 88 (MyD88) and Growth Arrest-specific gene 6 (GAS6)] have an impact on the severity of arteriosclerosis occlusions of tibial artery in elderly patients suffering from occlusion of coronary arteries. RESULTS: Levels of MDA-LDL, Ox-LDL, HO-1, TLR4, NF-κB, MyD88, and GAS6 were increased in the occlusion of tibial arteries + two-vessel coronary occlusion group compared to the CON group and occlusion of tibial arteries + one-vessel coronary occlusion group, respectively (p < 0.001); they were also elevated in occlusion of tibial arteries + multiple-vessel coronary occlusion group compared to occlusion of tibial arteries + one-vessel coronary occlusion group and occlusion of tibial arteries + two-vessel coronary occlusion group, respectively (P < 0.001). This has indicated the key roles of oxidative stress and pro-inflammatory mediator genes in arteriosclerosis occlusions of tibial artery in elderly patients with occlusion of coronary arteries. CONCLUSION: Oxidative response may promote the expressions of inflammatory genes and enhance susceptibility to arteriosclerosis occlusions of the tibial artery in elderly patients with chronic total coronary occlusions.

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BACKGROUND: Cardiac tamponade or pericardial tamponade (PT) can be a complication following invasive cardiac procedures. METHODS: Patients who underwent various procedures in the cardiac catheterization lab (viz. coronary interventions) were identified using the International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification (International classification of diseases [ICD]-9-Clinical modification [CM] and ICD-10-CM, respectively) from the Nationwide Inpatient Sample (NIS) database. Patient demographics, presence of comorbidities, PT-related events, and in-hospital death were also abstracted from the NIS database. RESULTS: The frequency of PT-related events in the patients undergoing CI from 2010 to 2017 ranged from 3.3% to 8.4%. Combined in-hospital mortality/morbidity of PT-related events were higher with increasing age (odds ratio [OR] [95% CI]: chronic total occlusion (CTO) = 1.19 [1.10-1.29]; acute coronary syndrome (ACS) = 1.21 [1.11-1.33], both p < 0.0001) and female sex (OR [95%CI]: CTO = 1.70 [1.45-2.00]; ACS = 1.72 [1.44-2.06], both p < 0.0001). In-hospital mortality related to PT-related events was found to be 8.5% for coronary procedures. In-hospital mortality was highest amongst the patients undergoing percutaneous transluminal coronary angioplasty (PTCA) for ACS (ACS vs. non-CTO PTCA vs. CTO PTCA: 15.7% vs. 10.4% and 14.4%, p < 0.0001 and ACS vs. non-CTO PTCA vs. CTO PTCA: 12.1% vs. 8.1% and 5.6%, p = 0.0001, respectively). CONCLUSIONS: In the real-world setting, PT-related events in CI were found to be 3.3%-8.4%, with in-hospital mortality of 8.5%. The patients undergoing PTCA for ACS were found to have highest mortality. Older patients undergoing CTO PTCA independently predicted higher mortality.

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Chronic total occlusions (CTOs) present significant challenges in interventional cardiology. This meta-analysis aims to compare the efficacy and safety of retrograde versus antegrade techniques in CTO percutaneous coronary intervention (PCI). A systematic review and meta-analysis were conducted following PRISMA guidelines. Electronic databases were searched through June 20, 2024. Studies comparing outcomes between antegrade and retrograde methods for CTO-PCI were included. Primary outcomes were procedural and technical success. Secondary outcomes included major adverse cardiac events (MACE), all-cause mortality, and myocardial infarction. The final analysis included seventeen studies. The antegrade approach showed a 5% higher likelihood of technical success (OR: 1.05, 95% CI: 1.02-1.09) and 14% higher odds of procedural success (OR: 1.14, 95% CI: 1.10-1.19) compared to the retrograde approach. The antegrade group also demonstrated lower risks of MACE, all-cause mortality, and myocardial infarction (RR: 0.40, 95% CI: 0.26-0.63). This meta-analysis suggests that the antegrade approach in CTO-PCI is associated with higher success rates and lower risks of adverse outcomes compared to the retrograde approach. However, the retrograde technique remains crucial for complex lesions and patients with multiple comorbidities.

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Objectives: Patients undergoing a prior failed attempt of chronic total occlusion-percutaneous coronary intervention (CTO-PCI) represent a challenging subgroup across all patients undergoing CTO-PCI. There are limited data on the effects of a prior failed attempt on the outcomes of subsequent CTO-PCI. We aimed to compare the procedural results and 24-month outcomes of prior-failed-attempt CTO-PCI with those of initial-attempt CTO-PCI. Methods: Patients who underwent attempted CTO-PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 24-month major adverse cardiac events (MACE) between patients who underwent prior-failed-attempt and initial-attempt CTO-PCI. MACE was defined as a composite of cardiac death, target vessel-related myocardial infarction, and ischemia-driven target vessel revascularization (TVR) during follow-up. Results: In total, 484 patients who underwent CTO-PCI (prior-failed-attempt, n = 49; initial-attempt, n = 435) were enrolled during the study period. After propensity score matching (1:3), 147 patients were included in the initial-attempt group. The proportion of the Japanese-CTO (J-CTO) score ≥2 was higher in the patients who underwent prior failed attempt than in those who underwent initial attempt (77.5% vs. 38.8%, p < 0.001). The retrograde approach was more often adopted in the prior-failed-attempt group than in the initial-attempt group (32.7% vs. 3.4%, [P< 0.001). Successful CTO revascularization rates were significantly lower in the prior-failed attempt-group than in the initial attempt group (53.1% vs. 83.3%, P < 0.001). The multivariate analysis revealed that J-CTO score ≥2 [odds ratio (OR), 0.359; 95% confidence interval (CI), 0.159-0.812; P = 0.014], intravascular ultrasound procedure (OR, 4.640; 95% CI, 1.380-15.603; P = 0.013), and prior failed attempt (OR, 0.285; 95% CI, 0.125-0.648; P = 0.003) were the independent predictors for successful CTO revascularization. There were no significant differences in major procedural complications (2.0% vs. 0.7%, p = 0.438) and MACE rates (4.1% vs. 8.8%, p = 0.438) between the groups, mainly due to the TVR rate (4.1% vs. 8.2%, P = 0.522). Conclusions: Compared with initial-attempt CTO-PCI, prior-failed-attempt CTO-PCI deserves more attention, since it is associated with a lower successful CTO revascularization rate. Prior failed attempt, J-CTO score ≥2, and IVUS procedure are the determining factors for predicting successful CTO revascularization. There are no significantly different unfavorable outcomes between patients who undergo prior-failed-attempt and initial-attempt CTO-PCI.

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In seeking to improve upon CTO percutaneous coronary intervention (PCI) success rates and minimize risk, CTO modification procedures (investment procedures) have been developed and utilized with increasing frequency. Two key techniques have emerged: subintimal tracking and re-entry (STAR) and subintimal plaque modification (SPM). Both require a staged approach with an index procedure for plaque modification and a second procedure weeks later for stenting. Both approaches require entry and wiring with a polymer jacketed wire in the extra plaque space (EPS), yet unlike SPM which exclusively requires angioplasty of the EPS throughout the CTO segment, STAR also involves re-entry into the true lumen distal to the CTO before angioplasty. STAR and SPM in many ways represent a paradigm shift in our approach to CTO PCI from a 1-step to 2-step approach in complex cases. In this review, we discuss the technical aspects of the procedures, as well as controversies and ongoing trials pointing to the future of these techniques. We also highlight non-device-based and intravascular ultrasound-based approaches to antegrade dissection and re-entry, which add to the CTO operator's toolkit for challenging cases.

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Complications in percutaneous coronary intervention (PCI), particularly in chronic total occlusion (CTO) cases, pose notable challenges, with a mortality rate of approximately 0.4% during hospitalization, mainly due to issues like perforation and tamponade. While risk assessment tools can aid in evaluating periprocedural complication risk, prevention and preparedness take precedence. Guided by the "3 Ps" framework-prevention, preparedness, and planning-we navigate the complexities of managing complications in CTO PCI procedures. This emphasizes the importance of comprehensive patient discussions, adherence to appropriateness use criteria, and ensuring a well-trained team equipped with standardized equipment. Furthermore, it is crucial to extract valuable insights from encountered complications, turning potential setbacks into invaluable learning opportunities. This positive approach not only fosters individual growth but also contributes to the advancement of CTO PCI practices. Various complications specific to CTO PCI are addressed, including donor vessel injury, equipment loss/entrapment, radiation injury and coronary perforation.

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Because there is a lack of comparative studies assessing drug-coated balloon (DCB) and drug-eluting stent (DES) outcomes with respect to intraluminal (IL) and subintimal (SI) approaches in femoropopliteal (FP) total occlusive lesions, we compared the outcomes between DCB (including bailout stenting) and DES treatments for this lesion. A total of 487 limbs (434 patients) were divided into the IL (n = 344, DCB: n = 268, DES: n = 76) and SI (n = 143, DCB: n = 83, DES: n = 60) approach groups. The primary outcome was a major adverse limb event (MALE), defined as above-ankle amputation or repeat revascularization of the index limb. Secondary outcomes included clinically driven target lesion revascularization (TLR), loss of clinical patency, and all-cause death. After adjustment, in each IL and SI approach, the 2-year rates of MALE (p = 0.180 and p = 0.236, respectively), TLR, loss of clinical patency, and all-cause death were similar between the DCB and DES groups. In the DCB and DES groups, both primary and secondary outcomes were similar between the IL and SI approaches. DCB and DES strategies for patients presenting with FP total occlusive lesions demonstrated similar outcomes regardless of the IL or SI approach.Clinical Trial Registration: NCT02748226.

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In patients with coronary artery disease (CAD), collateral circulation aids in sustaining myocardial perfusion and cardiac function. The circle of Vieussens is a rare collateral pathway between the right coronary artery and the left anterior descending artery (LAD) that plays a significant role specifically in patients with chronic total occlusions (CTOs). This article presents a unique case of the circle of Vieussens in a 26-year-old Asian female with a history of Kawasaki disease and CTO of the proximal LAD. Despite the CTO, the patient remains asymptomatic and maintains normal left ventricular function, attributed to an effective collateral network including a right-to-left arterial ring providing TIMI 3 flow. The case illustrates the crucial role of collateral circulation in managing complex coronary anomalies and underscores the need for comprehensive cardiac evaluations in patients with Kawasaki disease. This finding also highlights the potential of the circle of Vieussens as a lifesaving alternate conduit in severe CAD scenarios.

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Background: Coronary chronic total occlusion (CTO) increases the risk of developing major adverse cardiovascular events (MACE) and cardiogenic shock. Coronary computed tomography angiography (CCTA) is a safe, noninvasive method to diagnose CTO lesions. With the development of artificial intelligence (AI), AI has been broadly applied in cardiovascular images, but AI-based detection of CTO lesions from CCTA images is difficult. We aim to evaluate the performance of AI in detecting the CTO lesions of coronary arteries based on CCTA images. Methods: We retrospectively and consecutively enrolled patients with 50% stenosis, 50-99% stenosis, and CTO lesions who received CCTA scans between June 2021 and June 2022 in Beijing Anzhen Hospital. Four-fifths of them were randomly assigned to the training dataset, while the rest (1/5) were randomly assigned to the testing dataset. Performance of the AI-assisted CCTA (CCTA-AI) in detecting the CTO lesions was evaluated through sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and receiver operating characteristic analysis. With invasive coronary angiography as the reference, the diagnostic performance of AI method and manual method was compared. Results: A total of 537 patients with 1,569 stenotic lesions (including 672 lesions with <50% stenosis, 493 lesions with 50-99% stenosis, and 404 CTO lesions) were enrolled in our study. CCTA-AI saved 75% of the time in post-processing and interpreting the CCTA images when compared to the manual method (116±15 vs. 472±45 seconds). In the testing dataset, the accuracy of CCTA-AI in detecting CTO lesions was 86.2% (79.0%, 90.3%), with the area under the curve of 0.874. No significant difference was found in detecting CTO lesions between AI and manual methods (P=0.53). Conclusions: AI can automatically detect CTO lesions based on CCTA images, with high diagnostic accuracy and efficiency.

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A bidirectional approach is necessary for treating critical limb ischemia with complex, multiple lesions. We report an ultrasound-guided bidirectional puncture through an occluded vessel to treat an obstruction extending from the anterior tibial artery to the dorsal foot artery in a patient with toe gangrene and rest pain. This technique effectively restored arterial patency and is a promising approach for managing challenging critical limb ischemia occlusions.

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The optimal extent of revascularization in patients with chronic total occlusion (CTO) undergoing percutaneous coronary intervention (PCI) remains debated. This meta-analysis aimed to compare the clinical outcomes of complete versus incomplete revascularization in CTO patients. A systematic search of EMBASE, PubMed, and Web of Science was conducted up to July 6, 2024. Studies reporting outcomes in CTO patients undergoing PCI with complete or incomplete revascularization were included. The primary outcomes were major adverse cardiovascular events (MACE), all-cause mortality, and cardiovascular mortality. Eight studies with a total of 7,067 patients (4,854 complete and 2,213 incomplete revascularization) were included. Complete revascularization was associated with a significantly lower risk of MACE (RR: 0.57, 95% CI: 0.43-0.77), all-cause mortality (RR: 0.54, 95% CI: 0.37-0.78), and cardiovascular mortality (RR: 0.46, 95% CI: 0.29-0.75) compared to incomplete revascularization. There was no significant difference in the risk of recurrent myocardial infarction between the two groups (RR: 0.60, 95% CI: 0.20-1.80). In patients with CTO undergoing PCI, complete revascularization is associated with significantly better clinical outcomes, including lower risks of MACE, all-cause mortality, and cardiovascular mortality, compared to incomplete revascularization. These findings suggest that achieving complete revascularization should be prioritized when feasible in CTO patients.

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Coronary perforation (CP) poses a significant risk of morbidity and mortality, particularly, in patients with a history of cardiac surgery. The occurrence of loculated pericardial effusion presents distinctive challenges in these postcardiac surgical patients. This study delves into the complexities arising from the formation of loculated pericardial effusions subsequent to CP, with a specific focus on the loculated effusion in the posterior wall leading to left atrial compression syndrome. This analysis is dedicated to elucidating pathophysiology diagnostic and treatment strategies tailored for addressing left atrium compression syndrome, providing invaluable insights into the intricacies of diagnosing, treating, and managing this entity in the postcardiac surgical patient.

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With increased complexity in both medical comorbidities and coronary anatomy, the proportion of surgically turndown patients and high-risk PCI will continue to rise. Impella-assisted complex PCI can be performed with high technical success and can improve quality of life, angina score, and potentially left ventricular ejection fraction.

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Introduction: There is current controversy surrounding the benefits of percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTO). We aimed to evaluate the impact of complete percutaneous revascularization on major adverse cardiovascular events (MACE) in patients with CTO. Methods: A retrospective observational study was conducted of consecutive patients referred for invasive coronary angiography at a single center between January 2018 and December 2019 and at least a CTO. The patients were divided into two groups according to the result of the procedure: complete revascularization of CTO (CR-CTO) versus incomplete revascularization (ICR-CTO) (patients with at least one non-recanalized CTO). Short- and mid-term clinical outcomes were evaluated. The primary endpoint was a composite of MACE that included all-cause death, non-fatal myocardial infarction, non-fatal stroke, or unplanned revascularization. Results: In total, 359 patients with CTO were included. The median age was 68 years [interquartile range (IQR) 60-77 years], 66 (18%) were women and 169 (47.3%) had diabetes mellitus. In all, 167 (46.5%) patients received complete revascularization. After a median follow-up of 42 months (IQR 46-50 months), the primary endpoint occurred in 39 (23.4%) patients in the CR-CTO group and in 75 (39.1%) in the ICR-CTO group (HR 0.50, 95% CI 0.34-0.74; p < 0.001). This association remained significant in an inverse probability weighted model considering prognostic factors (adjusted HR 0.61, 95% CI 0.41-0.92; p = 0.018) and was driven by lower rates of all-cause death (adjusted OR 0.50, 95% CI 0.23-0.84; p = 0.01). Conclusions: Complete revascularization of CTO was associated with a lower risk of MACE in the midterm follow up.

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Background: The atherogenic index of plasma (AIP) and hyperuricemia (HUA) have been shown to be closely associated with morbidity and mortality of coronary artery disease. However, studies targeting predictive value of AIP and HUA for chronic total occlusion (CTO) lesions are still lacking. Methods: In total, 5,238 patients meeting the eligibility criteria were recruited in this analysis. CTO was defined as the condition of lesions without forward blood flow and with over three months of occlusion time. AIP was calculated as log10 [triglycerides (mmol/L)/high-density lipoprotein cholesterol (mmol/L)]. HUA was defined based on sex-specific criteria: serum uric acid 420 and 360 µmol/L for males and females, respectively. Results: CTO lesions were presented in 907 (17.3%) patients. Compared with patients showing lower AIP levels and non-HUA, the CTO lesion risks increased by 5.225 and 2.765 times in patients with higher AIP levels and HUA. Patients with AIP >0.15 and HUA exhibited the greatest CTO incidence (odds ratio 11.491; 95% confidence interval 9.019-14.641, P < 0.001). In addition, AIP combined with HUA had significantly increased effects (a 38.5% increase in CTO risk) relative to the sum of respective effects. Conclusion: Patients having higher AIP levels and HUA exhibited the highest CTO incidence, in comparison with patients who have the increased single index. AIP combined with HUA displayed significant synergistic effect on the prediction of CTO lesion.

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Objective: To explore the association between the quantity of hibernating myocardium (HM) and collateral circulation in patients with coronary chronic total occlusion (CTO). Materials and methods: 88 CTO patients were retrospectively analyzed who underwent evaluation for HM using both 99mTc-sestamibi Single photon emission computed tomography (99mTc-MIBI SPECT) myocardial perfusion imaging (MPI) combined with 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) myocardial metabolism imaging (MMI). They were divided into two groups according Rentrop grading: the poorly/well-developed collateral circulation group (PD/WD group, Rentrop grades 0-1/2-3). After adjusting for the potential confounding factors and conducting a stratified analysis, we explored the association between the HM index within CTO region and the grading of collateral circulation. Results: In the WD group, the HM index was notably higher than PD group (46.2 ± 15.7% vs. 20.9 ± 16.7%, P < 0.001). When dividing the HM index into tertiles and after adjusting for potential confounders, we observed that the proportion of patients with WD rose as the HM index increased (OR: 1.322, 95% CI: 0.893-1.750, P < 0.001), the proportion of patients with WD was 17.4%, 63.3%, and 88.6% for Tertile 1 to Tertile 3.This increasing trend was statistically significant (OR: 1.369, 95% CI: 0.873-1.864, P < 0.001), especially between Tertile 3 vs. Tertile 1 (OR: 4.330, 95% CI: 1.459-12.850, P = 0.008). Curve fitting displaying an almost linear positive correlation between the two. Conclusion: The HM index within CTO region is an independent correlation factor for the grading of coronary collateral circulation. A greater HM index corresponded to an increased likelihood of WD.

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Concomitant aortic stenosis and coronary artery disease in the elderly population is frequent and the proper therapeutic approach is a matter of debate. We present 2 challenging cases of patients affected by severe aortic stenosis and chronic total occlusion of the left main, demonstrating the safety and feasibility of transcatheter aortic valve replacement, performed both with balloon-expandable and self-expanding valves.

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BACKGROUND: As the burden and distribution of calcification within chronic total occlusion (CTO) lesions can be diverse, its effect on CTO recanalization using multiple devices and techniques is debatable. This study investigated the role of calcification in wiring-based intraplaque tracking techniques for CTO recanalization. METHODS: A modified J-CTO score without counting calcification was used to analyze the procedures of 458 consecutive patients who underwent CTO interventions. Failed guidewire crossing and intraplaque tracking were considered procedural failures. Recanalization time details were analyzed for successful procedures. RESULTS: In patients with calcified CTO, the rate of procedural success only significantly declined to be lower than that of noncalcified CTO when the modified J-CTO score was ≥3 (77% vs. 94%, p = 0.008). In 422 patients with successful procedures, the presence of calcification was irrelevant to guidewire crossing time, but was accompanied with longer time from guidewire cross to final angiogram when the modified J-CTO score was 1-2 (53 ± 35 vs. 35 ± 17 [noncalcified] min, p < 0.001). Multivariate analyses showed that calcification was independently associated with procedural failure (odds ratio [OR] = 5.1, 95% confidence interval [CI] = 1.4-18.3) in lesions with modified J-CTO ≥3, and prolonged angioplasty/stenting procedures >60 min (OR = 4.8, 95% CI = 2.2-10.2) in successfully recanalized lesions with modified J-CTO score 1-2. CONCLUSIONS: Using intraplaque guidewire tracking, calcification was unfavorable for very difficult CTO lesions, and caused prolongation of angioplasty time for lesions with moderate complexity. This suggested that the role of calcification in the J-CTO score could be altered when different recanalization techniques were applied for CTO interventions.

Since several commonly used scoring systems for grading the difficulty of CTO-PCI are derived from multiple recanalization techniques and devices, their application should be fundamental. However, most CTO interventionists usually have their own favored recanalization techniques in the real-world. As one of the parameters of J-CTO score, the findings of the study suggest that the interpretation of calcification during CTO-PCI could be altered and should be cautious if different recanalization technique was used.

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