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Objectives: Our purpose was to determine if "Japanese style" technical strategies can be successfully applied in the U.S. practice environment and to better understand the learning curve for chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Background: Procedural technical success remains the major limiting factor for CTO PCI, and has been unchanged over time., Methods: Demographic, procedural, and outcome data were collected on 636 consecutive patients between January 2005 and March 2008 having CTO PCI (514 antegrade, 122 retrograde attempts) at 2 U.S. medical centers. Operators were divided into 2 groups: higher CTO volume, retrograde operators (ROs) (>75 total CTO PCI cases and >20 retrograde attempts during the study period) and lower CTO volume, nonretrograde operators (NROs) to evaluate the impact of CTO-specific operator case volume and retrograde techniques on procedural outcomes., Results: Two operators met the criteria for RO category and 10 were NRO. ROs performed 395 CTO PCI cases (mean total CTO case experience = 197.5, 60 retrograde) and NROs performed 241 CTO PCI cases (mean total CTO case experience = 24.1, <1 retrograde) during the observed timeframe. The overall technical success was 58.9% for NROs and 75.2% for ROs (p < 0.0001). The technical success rate of NROs did not change, but the technical success for the ROs increased to 90% over time (p < 0.0001 for trend, 94.4% for retrograde and 85.7% for antegrade approaches). Observed major adverse events were similar between ROs and NROs., Conclusions: Complex antegrade and retrograde "Japanese style" PCI approaches can be applied in the U.S. practice environment with high technical success and low adverse event rates. Higher CTO-specific operator case volume is associated with improved technical success rates.

Introduction: Limited data are available on contemporary percutaneous coronary intervention (PCI) practice patterns and outcomes in elderly patients. The objective of this study was to evaluate "real-world" PCI in elderly and nonelderly patients during the first year of availability of drug-eluting stents (DES) in the United States market (May 1, 2003-April 30, 2004)., Methods: One thousand one hundred sixty-six consecutive patients (272 elderly [age > or =75 years] and 894 nonelderly [age <75 years]) having PCI for de novo coronary artery disease (CAD) at Dartmouth-Hitchcock Medical Center were included in this study. Primary outcome measures of this study were in-hospital major adverse cardiac events (MACE-death, new MI, urgent revascularization). Secondary end points included acute renal failure, respiratory failure, and vascular complications., Results: Elderly patients had higher MACE (8.5% vs 1.5%, P < or = 0.001), unadjusted in-hospital mortality (7.4% vs 0.8%, P < or = 0.001), in-hospital cardiac arrest (1.5% vs 0.3%, P = 0.03), requirements for assisted blood pressure support (13.2% vs 7.0%, P = 0.0001), respiratory failure (2.2% vs 0.9%, P = 0.08), acute renal failure (2.9% vs 0.8%, P = 0.005), and vascular complications (10.3% vs 5.5%, P = 0.005) than their nonelderly counterparts. Higher MACE rates persisted in the elderly despite correction for baseline differences using multivariate regression modeling., Conclusions: Advanced age remains a predictor of adverse outcomes attending PCI even in the contemporary era in which DES are available. This study highlights the need for further progress and investigation to optimize outcomes of PCI in the elderly.