The success rate of CTO PCI was increased significantly with the development of device and advancement of technique recently. The attempt rate of CTO recanalization was decreased before 20046, it has been investigated that the success rate in antegrade and retrograde approach was 77%, and 79.8% respectively7. The new research demonstrated that the success rate was nearly 90%1,8. Experienced experts are willing to challenge the CTO lesions with prior failure9. However, the success rate of CTO PCI for previous failure was just acceptable. In our study, the technical success rate was 66.0%, similar with previous study10. the acceptable result was related to the lesion characteristics, expert experience and the device.
Morino et al5 believe that previous failure is an independent predictor of CTO recanalization. Lesion characteristics of CTO with previous failure is different from that with initial attempt. Calcification, bending and long lesion was more common10, incidence of in-stent restenosis (ISR) was higher, and the operator is more willing to attempt via retrograde approach11, so we need a scoring system to evaluate the difficulty of this kind of situation.
There are several scoring systems for predicting the difficulty of CTO lesion12,13. lesion characteristics including stump morphology, occlusion length, ostial, target vessel, tortuous, calcification, distal vessel and collaterals play important roles in most of scoring systems. Other parameters such as age and past history is also involved in some systems. J-CTO score is the earliest and widely used scoring system, predicting the probability of guidewire crossing through the CTO in 30 minutes. It consists of 5 identified factors, it is also the only scoring system that uses previous failure as a predictor. Recently, three large studies are published for predicting CTO failure rate13–16. All of them studied more than 500 attempted PCI for CTO intervention to find the predictors of CTO-PCI failure. However, none of studies above developed a specific scoring system for CTO with prior failure.
This study is one of the largest retrospective reports to investigate the CTO PCI with previous failure, first proposed a scoring system to assess the difficulty of such procedures. In our study, we examined all factors studied previously for CTO-PCI from lesion characteristics to novel equipment and techniques for CTO recanalization. From multivariate logistic regression, the predictors of technical success consisted of procedural strategy and lesion characteristics. Our result found technical success was not related to proximal morphology and tortuosity, which may associate with advancement of device and technique. These complex problems should be resolved by scratch and go technique, IVUS, or coronary CTA, so that factors are also involved in QRA and CL score12.
Our result was the first scoring system involving procedural strategy. It has been investigated that complex cases, as quantified by the J-CTO score, had a higher incidence of in-hospital MACE and should preferably be performed following proper planning and preparation17. All of cases in this study was not the initial attempt, the median of J-CTO score was 3, 60.3% of cases was very difficult. With sufficient preparation, 55 cases (28.4%) of the lesions directly initiated the retrograde approach in this study. most cases (89.1%) had technical success. We found retrograde approach as initial strategy was an independent predictor in planed PCI. In general, as long as there are collaterals available for intervention, retrograde approach can be initiated 18. Initiation in retrograde seems to be complicated and prolonged the operation time, but actually it can avoid the antegrade dissection induced by excessive manipulation of guidewire, shorten the operation time and improve the success rate. However, the premise of starting the retrograde is interventional collaterals. Although the premise of starting the retrograde is interventional collaterals, the absence of interventional collaterals is not the contra-indication of retrograde approach. In this situation, one of useful skills is septal surfing. In this study, retrograde approach was not selected as initial strategy in all of patients without interventional collaterals, and only 2 patients received successful retrograde PCI after antegrade failure. In addition, the operators judge the difficulty of antegrade based on the condition of the proximal cap, the quality of the landing zone, the length of the occlusion, and the previous failure reason.
Regarding factors, our patients with a score of 0 showed 100% failure, so further attempt should be avoided for this kind of patients due to poor vessel condition. Ischemia evaluation and risk balancing should be needed in patients with a score of 1~2. Higher success rate was seen in patients with score of 3 or more, the elective redo CTO PCI should be performed by experienced expert after fully preparation.
With regard to in-hospital MACE, the overall results were acceptable and similar with other CTO PCI reports for previous failure10,11, but were worse than in previous “all comer” reports 19–21. One reason of the worse result may be previous failure of the enrolled patients. On the other hand, the more aggressive operations should be attempted in retry PCI to receive successful result.
There are several limitations in this study. Firstly, this was a retrospective study with inherent disadvantage. Secondly, this was single center study with small sample of population, and the reasons of previous failure were not mentioned. Therefore, larger clinical trial is expected.
In conclusion the technical success rate for CTO PCI with previous failure was acceptable. Our score system can be used to predict the success rate of re-attempt CTO PCI. In patients with a score of 0, the re-attempt should be avoided, redo-CTO PCI should be attempted with caution in patients with a score of 1~2, and the success rate should be higher with a score of 3 or more.