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Angiographic Scoring System for Predicting Successful Percutaneous Coronary Intervention of In-Stent Chronic Total Occlusion

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Abstract

The purpose of this study was to develop a scoring model to predict the technical success of recanalizing via antegrade approach in-stent chronic total occlusion (IS-CTO) by percutaneous coronary intervention (PCI). We retrospectively collected data from 474 patients who underwent an uneasy IS-CTO PCI via antegrade approach from January 2015 to December 2018, consecutively. We selected clinical and angiographic factors and utilized a derivation and validation cohort (4:1 sampling ratio) analysis. Factors with strong correlations with technical failure, according to multivariable analysis, were assigned 1 point, and a scoring system with a 4-point maximum was established. The model was then validated with a validation cohort. The overall procedural success rate was 77.4%. On multivariable analysis, the factors that correlated with technical failure were proximal bending (beta coefficient [β] = 2.142), tortuosity (β = 2.622), stent under expansion (β = 3.052), and poor distal landing zone (β = 2.004). The IS-CTO score demonstrated good calibration and excellent predicting capacity in the derivation (receiver-operator characteristic [ROC] area = 0.973 and Hosmer-Lemeshow chi-squared = 5.252; p = 0.072) and validation (ROC area = 0.976 and Hosmer-Lemeshow chi-squared = 0.916; p = 0.632) cohorts. In the validation subset, the IS-CTO score demonstrated superior performance to the Japanese chronic total occlusion score (J-CTO) and PROGRESS CTO scores for predicting technical success (area under the a curve [AUC] 0.976 vs. 0.642 vs. 0.579, respectively; difference in AUC between the IS-CTO score and J-CTO score = 0.334, p < 0.01; difference in AUC between the IS-CTO score and PROGRESS score = 0.397, p < 0.01). Our results suggest that the IS-CTO score system is a helpful tool to predict the technical success of IS-CTO PCI via antegrade approach in china.

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Abbreviations

AUC:

area under the curve

ROC:

receiver-operator characteristic

CABG:

coronary artery bypass graft surgery

MI:

myocardial infarction

CTO:

chronic total occlusion

IS-CTO:

in-stent chronic total occlusion

PCI:

percutaneous coronary intervention

TIMI:

thrombolysis in myocardial infarction

LAD:

left anterior descending coronary artery

LCX:

left circumflex

RCA:

right coronary artery

J-CTO:

Japanese chronic total occlusion score

IVUS:

intravascular ultrasound

References

  1. Azzalini, L., Vo, M., Dens, J., & Agostoni, P. (2015). Myths to debunk to improve management, referral, and outcomes in patients with chronic total occlusion of an epicardial coronary artery. The American Journal of Cardiology, 116, 1774–1780.

    Article  Google Scholar 

  2. Abbas, A. E., Brewington, S. D., Dixon, S. R., Boura, J., Grines, C. L., & O’Neill, W. W. (2005). Success, safety, and mechanisms of failure of percutaneous coronary intervention for occlusive non-drug-eluting in-stent restenosis versus native artery total occlusion. The American Journal of Cardiology, 95, 1462–1466.

    Article  Google Scholar 

  3. William, M. W., Simon, J. J. W., Colm, G. H., Julian William, S., Jonathan, H., James, S., & James, C. S. (2014). A novel approach to the management of occlusive in-stent restenosis (ISR). EuroIntervention., 9, 1285–1293.

    Article  Google Scholar 

  4. Werner, G. S., Moehlis, H., & Tischer, K. (2009). Management of total restenotic occlusions. EuroIntervention, 5(Suppl D), D79–D83.

    PubMed  Google Scholar 

  5. Abdel-karim, A.-r R., Lombardi, W. B., Banerjee, S., & Brilakis, E. S. (2011). Contemporary outcomes of percutaneous intervention in chronic total coronary occlusions due to in-stent restenosis. Cardiovascular Revascularization Medicine, 12, 170–176.

    Article  Google Scholar 

  6. Christopoulos, G., Karmpaliotis, D., Alaswad, K., Lombardi, W. L., Grantham, J. A., Rangan, B. V., Kotsia, A. P., Lembo, N., Kandzari, D. E., Lee, J., Kalynych, A., Carlson, H., Garcia, S., Banerjee, S., Thompson, C. A., & Brilakis, E. S. (2014). The efficacy of “hybrid” percutaneous coronary intervention in chronic total occlusions caused by in-stent restenosis: insights from a US multicenter registry. Catheterization and Cardiovascular Interventions: Official Journal of the Society for Cardiac Angiography & Interventions, 84, 646–651.

    Article  Google Scholar 

  7. Nombela-Franco, L., Urena, M., Jerez-Valero, M., Nguyen, C. M., Ribeiro, H. B., Bataille, Y., Rodes-Cabau, J., & Rinfret, S. (2013). Validation of the J-chronic total occlusion score for chronic total occlusion percutaneous coronary intervention in an independent contemporary cohort. Circulation. Cardiovascular Interventions, 6, 635–643.

    Article  Google Scholar 

  8. Christopoulos, G., Kandzari, D. E., Yeh, R. W., Jaffer, F. A., Karmpaliotis, D., Wyman, M. R., Alaswad, K., Lombardi, W., Grantham, J. A., Moses, J., Christakopoulos, G., Tarar, M. N. J., Rangan, B. V., Lembo, N., Garcia, S., Cipher, D., Thompson, C. A., Banerjee, S., & Brilakis, E. S. (2016). Development and validation of a novel scoring system for predicting technical success of chronic total occlusion percutaneous coronary interventions: the PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Score. JACC. Cardiovascular Interventions, 9, 1–9.

    Article  Google Scholar 

  9. Azzalini, L., Dautov, R., Ojeda, S., Benincasa, S., Bellini, B., Giannini, F., Chavarria, J., Pan, M., Carlino, M., Colombo, A., & Rinfret, S. (2017). Procedural and long-term outcomes of percutaneous coronary intervention for in-stent chronic total occlusion. JACC. Cardiovascular Interventions, 10, 892–902.

    Article  Google Scholar 

  10. Levine, G. N., Bates, E. R., Blankenship, J. C., Bailey, S. R., Bittl, J. A., Cercek, B., Chambers, C. E., Ellis, S. G., Guyton, R. A., Hollenberg, S. M., Khot, U. N., Lange, R. A., Mauri, L., Mehran, R., Moussa, I. D., Mukherjee, D., Nallamothu, B. K., & Ting, H. H. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation., 124, e574–e651.

    PubMed  Google Scholar 

  11. Task Force on Myocardial Revascularization of the European Society of C, the European Association for Cardio-Thoracic S, European Association for Percutaneous Cardiovascular I, Wijns, W., Kolh, P., Danchin, N., Di Mario, C., Falk, V., Folliguet, T., Garg, S., Huber, K., James, S., Knuuti, J., Lopez-Sendon, J., Marco, J., Menicanti, L., Ostojic, M., Piepoli, M. F., Pirlet, C., Pomar, J. L., Reifart, N., Ribichini, F. L., Schalij, M. J., Sergeant, P., Serruys, P. W., Silber, S., Sousa Uva, M., & Taggart, D. (2010). Guidelines on myocardial revascularization. European Heart Journal, 31, 2501–2555.

    Article  Google Scholar 

  12. Dangas, G. D., Claessen, B. E., Caixeta, A., Sanidas, E. A., Mintz, G. S., & Mehran, R. (2010). In-stent restenosis in the drug-eluting stent era. Journal of the American College of Cardiology, 56, 1897–1907.

    Article  Google Scholar 

  13. Karmpaliotis, D., & Hatem, R. (2017). In-Stent CTO, Not as easy as it looks. JACC. Cardiovascular Interventions, 10, 903–905.

    Article  Google Scholar 

  14. Brilakis, E. S., Banerjee, S., Karmpaliotis, D., Lombardi, W. L., Tsai, T. T., Shunk, K. A., Kennedy, K. F., Spertus, J. A., Holmes, D. R., & Grantham, J. A. (2015). Procedural outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National Cardiovascular Data Registry). JACC. Cardiovascular Interventions, 8, 245–253.

    Article  Google Scholar 

  15. Thompson, C. A., Jayne, J. E., Robb, J. F., Friedman, B. J., Kaplan, A. V., Hettleman, B. D., Niles, N. W., & Lombardi, W. L. (2009). Retrograde techniques and the impact of operator volume on percutaneous intervention for coronary chronic total occlusions an early U.S. experience. JACC. Cardiovascular Interventions, 2, 834–842.

    Article  Google Scholar 

  16. Jang, W. J., Yang, J. H., Choi, S.-H., Song, Y. B., Hahn, J.-Y., Choi, J.-H., Kim, W. S., Lee, Y. T., & Gwon, H.-C. (2015). Long-term survival benefit of revascularization compared with medical therapy in patients with coronary chronic total occlusion and well-developed collateral circulation. JACC. Cardiovascular Interventions, 8, 271–279.

    Article  Google Scholar 

  17. Hsu, J. T., Kyo, E., Chu, C. M., Tsuji, T., & Watanabe, S. (2011). Impact of calcification length ratio on the intervention for chronic total occlusions. International Journal of Cardiology, 150, 135–141.

    Article  Google Scholar 

  18. Ahn, J., Rha, S. W., Choi, B., Choi, S. Y., Byun, J. K., Mashaly, A., Abdelshafi, K., Park, Y., Jang, W. Y., Kim, W., Choi, J. Y., Park, E., Na, J. O., Choi, C. U., Kim, E., Park, C. G., Seo, H. S., Oh, D. J., Byeon, J., Park, S., & Yu, H. (2018). Impact of chronic total occlusion lesion length on six-month angiographic and 2-year clinical outcomes. PLoS One, 13, e0198571.

    Article  Google Scholar 

  19. Brilakis, E. S., Grantham, J. A., Rinfret, S., Wyman, R. M., Burke, M. N., Karmpaliotis, D., Lembo, N., Pershad, A., Kandzari, D. E., Buller, C. E., DeMartini, T., Lombardi, W. L., & Thompson, C. A. (2012). A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC. Cardiovascular Interventions, 5, 367–379.

    Article  Google Scholar 

  20. Hasegawa, T., Godino, C., Basavarajaiah, S., Takagi, K., Rezq, A., Latib, A., Alaide, C., Montorfano, M., Carlino, M., & Colombo, A. (2014). Differences in the clinical and angiographic characteristics of chronic total occlusion lesions in the three major coronary arteries. Journal of Interventional Cardiology, 27, 44–49.

    Article  Google Scholar 

  21. Christopoulos, G., Karmpaliotis, D., Wyman, M. R., Alaswad, K., McCabe, J., Lombardi, W. L., Grantham, J. A., Marso, S. P., Kotsia, A. P., Rangan, B. V., Garcia, S. A., Lembo, N., Kandzari, D., Lee, J., Kalynych, A., Carlson, H., Thompson, C. A., Banerjee, S., & Brilakis, E. S. (2014). Percutaneous intervention of circumflex chronic total occlusions is associated with worse procedural outcomes: Insights from a multicentre US registry. Canadian Journal of Cardiology, 30, 1588–1594.

    Article  Google Scholar 

  22. Alessandrino, G., Chevalier, B., Lefevre, T., Sanguineti, F., Garot, P., Unterseeh, T., Hovasse, T., Morice, M. C., & Louvard, Y. (2015). A clinical and angiographic scoring system to predict the probability of successful first-attempt percutaneous coronary intervention in patients with total chronic coronary occlusion. JACC. Cardiovascular Interventions, 8, 1540–1548.

    Article  Google Scholar 

  23. Michael, T. T., Karmpaliotis, D., Brilakis, E. S., Abdullah, S. M., Kirkland, B. L., Mishoe, K. L., Lembo, N., Kalynych, A., Carlson, H., Banerjee, S., Lombardi, W., & Kandzari, D. E. (2013). Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularisation: Insights from a multicentre US registry. Heart., 99, 1515–1518.

    Article  Google Scholar 

  24. Teramoto, T., Tsuchikane, E., Matsuo, H., Suzuki, Y., Ito, T., Ito, T., Habara, M., Nasu, K., Kimura, M., Kinoshita, Y., Terashima, M., Asakura, Y., Matsubara, T., & Suzuki, T. (2014). Initial success rate of percutaneous coronary intervention for chronic total occlusion in a native coronary artery is decreased in patients who underwent previous coronary artery bypass graft surgery. JACC. Cardiovascular Interventions, 7, 39–46.

    Article  Google Scholar 

  25. Michael, T. T., Karmpaliotis, D., Brilakis, E. S., Alomar, M., Abdullah, S. M., Kirkland, B. L., Mishoe, K. L., Lembo, N., Kalynych, A., Carlson, H., Banerjee, S., Luna, M., Lombardi, W., & Kandzari, D. E. (2015). Temporal trends of fluoroscopy time and contrast utilization in coronary chronic total occlusion revascularization: insights from a multicenter United States registry. Catheterization and Cardiovascular Interventions, 85, 393–399.

    Article  Google Scholar 

  26. Christopoulos, G., Menon, R. V., Karmpaliotis, D., Alaswad, K., Lombardi, W., Grantham, J. A., Michael, T. T., Patel, V. G., Rangan, B. V., Kotsia, A. P., Lembo, N., Kandzari, D. E., Lee, J., Kalynych, A., Carlson, H., Garcia, S., Banerjee, S., Thompson, C. A., & Brilakis, E. S. (2014). Application of the “hybrid approach” to chronic total occlusions in patients with previous coronary artery bypass graft surgery (from a contemporary multicenter US registry). The American Journal of Cardiology, 113, 1990–1994.

    Article  Google Scholar 

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Acknowledgments

The authors thank the voluntary contribution of the patients in this study.

Author information

Authors and Affiliations

  1. Department of Cardiology, Dalian The Fifth People’s Hospital, No. 890 Huanghe Road, Shahekou District, Dalian, 116021, Liaoning, China

    Minglian Gong, Jing Zhang, Mingrui Lv & Xin Li

  2. Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, No. 2 Chaoyang Road, Chaoyang District, Beijing, 100029, China

    Minglian Gong, Hongyu Peng, Zheng Wu, Wenzheng Li, Yun Lv, Yuan Lv, Ze Zheng & Jinghua Liu

  3. Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Center for Cardiovascular Disease, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China

    Tao An & Yi Mao

  4. Department of Cardiology, Dalian The Sixth People’s Hospital, No.269 Luganghuibo Road, Ganjingzi District, Dalian, 116033, Liaoning, China

    Hangyu Gong

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  1. Minglian Gong
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  11. Xin Li
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  14. Jinghua Liu
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Contributions

Study conception and design: YM and J-HL. Acquisition of data: M-LG, W-ZL, YL, YUL, M-RL, XL, JZ, Y-HG, TA, and XL. Analysis and interpretation of data (e.g., statistical and computational analysis): M-LG, TA, H-YP, ZW, YM, J-HL, and ZZ. Writing, review, and/or revision of the manuscript: M-LG, YM, and J-HL. Study supervision: YM and J-HL.

Corresponding authors

Correspondence to Yi Mao or Jinghua Liu.

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Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This investigation was approved by the institutional review boards of the two centers and was conducted in line with the principles of the Helsinki declaration. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all participants included in the study.

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Associate Editor Angela Taylor oversaw the review of this article.

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Gong, M., Peng, H., Wu, Z. et al. Angiographic Scoring System for Predicting Successful Percutaneous Coronary Intervention of In-Stent Chronic Total Occlusion. J. of Cardiovasc. Trans. Res. 14, 598–609 (2021). https://doi.org/10.1007/s12265-020-10090-9

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