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Introduction:Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with increased risk of periprocedural complications. Estimating the risk of complications facilitates risk-benefit assessment and procedural planning.Methods:We analyzed the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO, NCT02061436) and created a risk score for in-hospital all-cause mortality. Logistic regression prediction modeling was used to identify independently associated variables and the model was internally validated with bootstrapping.Results:Of the 10,480 CTO PCI cases performed between 2012-2022 at 40 US and non-US centers, in-hospital mortality occurred in 47 (0.45%). The final prediction model identified 4 independent predictors of mortality: Age ≥65 years, Odds Ratio [OR]: 2.83 (95% confidence interval [CI], 1.30-6.16), 1-point; Left ventricular ejection fraction ≤45%, OR: 2.13 (95% CI, 1.14-3.98), 1-point; Moderate-severe calcification, OR: 2.45 (95% CI, 1.18-5.08), 1-point; and Antegrade dissection re-entry, OR: 2.81 (95% CI, 1.06-7.43), 1-point; or Retrograde strategy, OR: 3.51 (95% CI, 1.67-7.37), 1-point; with a bootstrap corrected c-statistics of 0.71 (95% confidence interval: 0.63-0.81). The calculated risk percentages for mortality based on the PROGRESS-CTO mortality score ranged from 0.05-2.42% for mortality, and 63% of patients in the PROGRESS-CTO cohort had PROGRESS-CTO mortality score of 1 or 2, corresponding to a mortality risk of 0.1-0.5% (Figure 1).Conclusions:The PROGRESS-CTO in-hospital mortality risk score can facilitate risk-benefit assessment and procedural planning in patients undergoing CTO PCI.

Introduction:Use of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been increasing.Methods:We examined the clinical characteristics and procedural outcomes of patients who underwent CTO PCI with radial versus femoral access in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436).Results:Of 10,954 patients who underwent CTO PCI at 55 centers in 7 countries between 2012 and 2022, 2,578 (24%) had a radial-only approach. Patients who underwent radial-only access were younger (63 ± 10 vs. 65 ± 10, years, p<0.001), more likely to be men (84% vs. 81%, p=0.001), and had a significantly lower prevalence of comorbidities compared with the femoral group, including diabetes mellitus (39% vs. 45%, p<0.001) and coronary artery bypass graft surgery (57% vs. 64%, p<0.001). In addition, radial-only cases had lower angiographic complexity with lower J-CTO (2.0 ± 1.3 vs. 2.5 ± 1.2, p<0.001) and PROGRESS-CTO (1.2 ± 1.0 vs. 1.3 ± 1.0, p<0.001) scores. After adjusting for potential confounders, radial-only access was associated with a lower risk of access site complications (odds ratio [OR]: 0.45, 95% confidence interval [CI], 0.22-0.91), similar technical success (OR: 0.87, 95% CI, 0.74-1.04) and major adverse cardiovascular events (MACE) (OR: 0.65, 95% CI, 0.40-1.07), compared with the femoral access group (Figure 1).Conclusions:Radial-only access was used in 24% of CTO PCIs and was associated with lower access site complications, and similar technical success and MACE compared with the femoral access group.

Background:Predicting technical failure in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can assist with decision making and planning of the procedure.Methods:We analyzed 6,946 CTO PCIs performed between 2016 and June 2022 at 36 international centers in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) and created a score for risk of technical failure. Logistic regression prediction modeling was used to identify independently associated variables with technical failure and model were internally validated with bootstrapping.Results:Mean patient age was 64.0±10 years, 82% were men and technical success was 86%. The following variables were independently associated with technical failure and were included in the final model: age (odds ratio [OR]: 1.08, 95% Confidence Intervals [CI]: [1.00-1.15], p=0.039; age≥ 65 years; 1 point), CTO length (OR: 1.13, 95% CI [1.10, 1.17]; length≥ 20 mm; 1 point), moderate/severe calcification (OR: 1.35, 95% CI [1.17, 1.56]; 1 point), proximal cap ambiguity (OR: 2.25, 95% CI [1.95, 2.59]; 2 points), lack of interventional collaterals (OR: 1.60, 95% CI [1.39, 1.84]; 1 point), and lack of good distal landing zone (OR: 1.51, 95% CI [1.31, 1.75]; 1 point). The resulting score showed acceptable performance on receiver-operating characteristic (ROC) curve, AUC: 0.68 (95% CI [0.67-0.71]). Internal validation with bootstrapping of 1000 samples demonstrated a good agreement with the model, observed AUC: 0.68, (95% bias corrected CI [0.67, 0.70]). PROGRESS-CTO technical failure score and corresponding risk percentage and the percentage of patients in the respective risk group within the PROGRESS-CTO registry are represented in Figure 1.Conclusion:The updated PROGRESS CTO score may be useful for assessing the likelihood of technical failure success in CTO PCI.

Periprocedural myocardial injury (PMI) is known to be a predictor of in-hospital cardiac events and long-term adverse outcomes following a percutaneous coronary intervention (PCI). We aimed to evaluate the correlation between preprocedural serum lipid levels and PMI in patients undergoing elective PCI.

The objective of this study is to determine the effect of intravenous (i.v.) or oral N-acetylcysteine (NAC) in preventing contrast-induced nephropathy (CIN) in patients with moderate-to-severe renal insufficiency undergoing intra-arterial interventions.

Background Carotid artery stenting (CAS) with a carotid protection device (CPD) has become the standard practice in patients with severe carotid stenosis and high surgical risk. However, the clinical efficacy and safety of CPDs are still controversial issues. We aimed to compare the clinical outcomes of the CAS without CPD with CAS combined with CPD.Methods This is a multicenter randomized prospective study registered with http://clinicaltrials.gov(NCT02781181). After the exclusion, 279 patients were enrolled (139 patients in the CAS with CPD group and 140 patients in the CAS without CPD group). The primary outcome was a combination of peri-procedural in-hospital transient ischemic attack (TIA), ipsilateral stroke, or death. The secondary outcome was new ischemic brain lesions on post-procedural diffusion-weighted magnetic resonance imaging (DW-MRI).Results Two patients died in CAS without CPD group, one patient died in CAS with CPD group. TIA was only seen in patients who underwent CAS under protection (n = 5). The combined primary outcome of TIA, ipsilateral stroke, and death rate was not different between groups (5.7% vs. 2.8%; p = 0.254). New defects were noted on the post-procedural DW-MRI in 28% of patients in the CPD group and 27% of patients in the no CPD group (p = 0.881).Conclusions This study suggests that CAS without CPD is not associated with higher rates of peri-procedural TIA, stroke, and death or new ischemic brain lesions on post-procedural DW-MRI compared to CAS with CPD in selected symptomatic and asymptomatic patients with significant carotid artery stenosis provided that there is no visible thrombus.

Objective— We sought to determine the in-hospital incidence and predictors of ischaemic stroke in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).Methods— We reviewed 2638 consecutive patients undergoing 2722 pimary PCI procedures for STEMI during in-hospital stay. Stroke was defined as any new focal neurological deficit lasting > 24 h, occurring anytime during or after PCI until discharge. Patients with haemorrhagic stroke were excluded. Clinical characteristics and in-hospital outcome were analysed regarding ischaemic stroke in patients undergoing primary PCI.Results— Ischaemic stroke was observed in 20 of the 2722 procedures, an incidence of 0.73%. Patients with ischaemic stroke were older than patients without stroke (mean age 67 ± 9.6 vs. 56.6 ± 11.8, P > 0.001). Compared to patients without stroke, female gender, diabetes and hypertension were more prevalent in patients with stroke. Ischaemic stroke was found to be a powerful independent predictor of in-hospital cardiovascular mortality (odds ratio [OR] 6.32, 1.15-34.7; P < 0.001). Left ventricular ejection fraction (LVEF) < 35% (OR 3.13, P = 0.04), contrast-induced nephropathy (OR 2.91, P = 0.04) and tirofiban use (OR 0.23, P = 0.02) were the independent predictors for in-hospital ischaemic stroke.Conclusions— The present study shows that the incidence of ischaemic stroke in patients undergoing PCI for STEMI is higher and ischaemic stroke increases in-hospital mortality in these patients. Moreover, LVEF < 35% and contrast-induced nephropathy were independent predictors of ischaemic stroke, whereas tirofiban use demonstrated a protective effect to this potentially catastrophic complication.

Introduction:Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is an evolving field.Methods:We examined the clinical and angiographic characteristics and procedural outcomes of 8,666 CTO PCIs performed at 36 centers between 2012 and 2021.Results:Mean age was 64±10 years and 82% of the patients were men. The prevalence of prior PCI (62%) and diabetes mellitus (43%) was high. Median ejection fraction was 54% (42%, 60%). Radial access was used in 50%. The most common target vessel was the right coronary artery (52%), followed by the left anterior descending artery (26%). The target CTOs were highly complex with mean J-CTO score of 2.4 ±1.3 and PROGRESS score of (1.3 ±1). Technical and procedural success rates were high (86% and 85% respectively) with a relatively low percentage of in-hospital major adverse cardiac events (Figure 1). The final successful crossing strategy was antegrade wire escalation in 62%, retrograde in 22%, and antegrade dissection re-entry in 16%. Median contrast volume, air kerma radiation dose and procedure time were 220 (155, 300) ml, 2.2 (1.2, 3.8) Gray and 116 (75, 172) minutes, respectively.Conclusions:High success and acceptable complication rates can currently be achieved in CTO PCI among high-volume, experienced centers.

Objective— The primary aim of this study was to assess the effect of glucometabolic disorders on coronary collateral vessels in patients with occlusive coronary artery disease.Methods and results— Hundred and ninety-five consecutive patients with at least single-vessel occlusion were enrolled in this study prospectively. The standard oral glucose tolerance test was performed according to the criteria of the World Health Organization. Collateral circulation was graded according to the Rentrop classification. The mean Rentrop scores in normal glucose tolerance (NGT), impaired glucose tolerance (IGT), and diabetes were 1.40 ± 1.02, 1.05 ± 0.84, 1.00 ± 0.98, respectively (P= 0.043).The percentage of patients without collateral circulation (Rentrop-0) was greatest in the diabetic group (44.4%), while the percentage was 21.8% in the IGT group and 22.0% in the NGT group. Ninety-five patients with at least one totally occluded coronary artery were analysed as a subgroup. In the totally occluded artery subgroup postprandial glycaemia was the only parameter that was associated with the Rentrop score in the univariate analysis (r = –0.34, P= 0.002)Conclusions— In conclusion, our study results, which are in agreement with previous results, indicate that not only diabetic glucose tolerance but also impaired glucose tolerance has an adverse impact on the development of coronary collaterals.

Aim— Recently, the close relationship between aortic stiffness and cardiovascular mortality has aroused the interest of investigators in carrying out studies related to aortic stiffness.This study aims to investigate the aortic stiffness parameters in patients with cardiac syndrome X, a disorder that is believed to be a generalized disturbance of the vasodilator function of small arteries.Material and methods— 18 patients with typical chest pain and angiographically normal coronary arteries associated with a positive exercise test were included in the study. The control group consisted of 27 patients with angiographically normal coronary arteries and no ischaemia on exercise testing. Antianginal medication was withheld 4 weeks before the study and transthoracic echocardiography was performed using a Hewlett-Packard Sonos 1500 instrument with a 2.5 MHz phased array transducer. Ascending aorta diameters were measured on the M-mode tracing at a level 3 cm above the aortic valve. Diameter change, pulse pressure, aortic strain and distensibility were measured as aortic stiffness parameters.Results—The aortic diameter change was less in the syndrome X group than in the control group (0.15±0.04 cm/m2vs. 0.28±0.12 cm/m2, p<0.001). Likewise, aortic strain (9±3% vs. 18±8%, p<0.001) and distensibility (4.01±1.71 cm2.dyn-1.10-3vs. 9.95±5.08 cm2.dyn-1.10-3, p<0.001) was significantly lower in the syndrome X group than in the control group.Conclusion—The deterioration in aortic elasticity properties in patients with cardiac syndrome X suggests that this disease may be a more generalized disturbance of the vasculature.