Percutaneous coronary intervention (PCI) of aorto-ostial coronary chronic total occlusion (CTO) can be a particularly challenging lesion subset due to the lack of antegrade support, proximal cap ambiguity, and unclear vessel course, among other factors. The aim of this study was to analyse the procedural aspects and outcomes of aorto-ostial CTO PCI.
Methods and Results
All patients undergoing aorto-ostial CTO PCI between February 2013 and December 2018 at two high-volume centres with specialised CTO PCI programmes were included in this study. During this time, 1,053 CTO were percutaneously approached and 80 (7.6%) were aorto-ostial CTO. Aorto-ostial CTO location was considered if the proximal cap was within 5 mm of the aortocoronary ostium. Technical success was defined as residual stenosis <30% with thrombolysis in myocardial infarction 3 flow in the CTO vessel and procedural success as technical success plus the absence of in-hospital adverse events (all-cause death, Q-wave myocardial infarction, stroke, recurrent angina requiring target-vessel revascularisation with PCI or coronary artery bypass graft, and tamponade requiring pericardiocentesis or surgery). Major adverse cardiac events (MACE) on follow-up were defined as a composite of cardiac death, myocardial infarction, and clinical-driven target lesion revascularisation. A total of 80 patients were included. The mean age was 63±11 years, and 92.5% of the patients were male. The most frequent target CTO vessel was the right coronary artery (n=77, 96.2%). Three patients (3.7%) presented an occluded left main and one patient (1.2%) had a CTO of a circumflex artery with an independent ostium. The mean J-CTO score was 2.9±1.0 and 26 (32.5%) were flush ostial CTO (i.e., total absence of a stump). The access site was bifemoral or radial-femoral in 66 of the patients (82.5%). A retrograde approach was attempted in 59 of the patients (73.7%). Technical and procedural success were achieved in 61 (76.2%) patients. The most frequent successful crossing techniques were retrograde techniques: true-to-true in 12 patients (19.7%) and reverse controlled antegrade and retrograde tracking in 25 patients (41.1%) patients. In flush ostial CTO, retrograde techniques were the crossing technique in an even higher proportion of cases (n=15, 78.9% versus n=22, 52.4%, in flush versus no flush ostial CTO; p<0.01), without differences in the failure rate between both types of aorto-ostial CTO (26.9% versus 22.2%; p=nonsignificant). Reasons for failed recanalisation were the absence of interventional collaterals in 9 of 19 patients (47.4%), the presence of an impenetrable cap in 7 patients (36.8%), and the impossibility to advance the microcatheter through the collaterals after successful wiring in the remaining 3 (15.8%). On multivariable analysis, the only predictor of recanalisation failure was the absence of interventional collaterals (odds ratio [OR]: 15.49, 95% confidence interval [CI]: 3.01–79.85; p=0.001). Regarding in-hospital complications, five (6.2%) patients had a periprocedural non-Q wave myocardial infarction, two of whom had this in the context of a coronary perforation requiring intervention. Three (3.7%) coronary perforations were identified and resolved by covered stent implantation without cardiac tamponade. The rate of contrast-induced nephropathy was 5.0% and it was usually associated with other complications. After a median follow-up of 30 months, MACE rate was 11.2%. Two (2.5%) patients died from cardiovascular cause and seven (8.7%) needed repeat target vessel revascularisation.
Aorto-ostial CTO is a complex and challenging anatomic subset. In the authors’ series, success rates were lower than those reported in contemporary registries in all-comers with CTO. Since a retrograde approach is usually required to cross the occluded segment, the presence of interventional collaterals seems to be key in the procedure success.