Angioplasty Validation of the J-Chronic Total Occlusion Score for Chronic Total Occlusion Percutaneous Coronary Intervention in an Independent Contemporary Cohort Luis Nombela-Franco, MD; Marina Urena, MD; Miguel Jerez-Valero, MD; Can Manh Nguyen, MD; Henrique Barbosa Ribeiro, MD; Yoann Bataille, MD; Josep Rodés-Cabau, MD; Stéphane Rinfret, MD, SM Background—Chronic total occlusion (CTO) recanalization is a complex and technically challenging procedure. The J-CTO score has been proposed to stratify case complexity and procedural success rates. However, the score has never been tested outside the setting of the original study. Moreover, its predictive value when using a hybrid antegrade or retrograde approach is unknown. We investigated the performance of the J-CTO score for predicting procedure complexity and success in an independent contemporary cohort. Methods and Results—A total of 209 consecutive patients who underwent CTO recanalization by a high-volume operator were included. Clinical and angiographic data were prospectively collected. The J-CTO score was applied for each patient, and discrimination and calibration were evaluated in the whole cohort, and according to the approach (antegrade 47% and retrograde 53%). Clinical and angiographic differences were noted between the original and studied cohort. The mean J-CTO score was 2.18±1.26, and successful guidewire crossing within 30 minutes and final angiographic success were 44.5% and 90.4%, respectively. The J-CTO score demonstrated good discrimination (c statistic, >0.70) and calibration (Hosmer–Lemeshow P>0.1) in the whole cohort and for antegrade and retrograde approaches. However, the final success rate was not associated with the J-CTO score. Conclusions—In this independent cohort, the J-CTO score showed good discriminatory and calibration capacity for guidewire CTO crossing within 30 minutes but it does not for final success rate. The J-CTO score helps to predict complexity of CTO recanalization, and the simplicity of the score supports the widespread use as a clinical tool. (Circ Cardiovasc Interv. 2013;6:635-643.) Key Words: chronic disease ◼ coronary occlusion ◼ percutaneous coronary intervention
C
hronic total occlusion (CTO) is a common finding in patients with coronary artery disease1 and is associated with poorer outcomes compared with patients with ischemia with non-CTO disease.2–5 Although better clinical outcomes have been associated with successful recanalization in observational studies,6–8 CTO percutaneous coronary intervention (PCI) remains a major challenge for many interventional cardiologists, and developing new strategies to approach CTO is important for the field. Angiographic CTO lesion characteristics are predictive of success rate and procedure time.9–11 The multicenter Japanese CTO Registry12 investigators developed the J-CTO score as a scoring system to grade the difficulty in crossing a CTO within 30 minutes and overall success rate.13 Thus, it might be a valuable tool for some operators dealing with the challenge of
patient selection for CTO PCI and for schedule management. However, the J-CTO score has never been tested outside the setting of the original study, and its validity has not been established in a non-Japanese population. Moreover, the retrograde approach is an established procedure, which improves the success rate,14 but the proportion of patients with retrograde approach in the original Japanese registry was relatively low. Hence, the predictive value of the J-CTO score when using modern hybrid antegrade and retrograde approaches is unknown. The purpose of the study was therefore to (1) evaluate the performance of the J-CTO score for predicting procedure complexity defined as guidewire CTO crossing within 30 minutes and final success rate in an independent CTO cohort and (2) to assess its performance for antegrade and retrograde approaches.
Received April 20, 2013; accepted October 10, 2013. From the Multidisciplinary Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Laval University, Quebec City, Quebec, Canada. Correspondence to Stéphane Rinfret, MD, SM, Interventional Cardiology and Clinical Research, Multidisciplinary Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Ste-Foy, Quebec City, G1V 4G5 Quebec, Canada. E-mail [email protected] © 2013 American Heart Association, Inc. Circ Cardiovasc Interv is available at http://circinterventions.ahajournals.org
DOI: 10.1161/CIRCINTERVENTIONS.113.000447
Downloaded from http://circinterventions.ahajournals.org/ by guest on April 15, 2015 635
636 Circ Cardiovasc Interv December 2013
What Is Known
• Chronic
total occlusion (CTO) percutaneous coronary intervention remains a difficult procedure associated with higher failure rates than angioplasty for subtotal lesions. • The J-CTO score, derived from a large registry, stratifies case complexity and the likelihood of success.
What the Study Adds
• However, the score had not been validated in an independent cohort.
• This study indicates that the J-chronic total occlusion score is valid and useful to predict the time required to cross the chronic total occlusion, the total procedure time, and radiation dose and contrast use. • However, it was not helpful to predict success rate, using hybrid antegrade, retrograde, and reentry techniques.
Methods Study Population and CTO Procedures Between January 2010 and December 2012, a total of 245 consecutive CTO PCI were performed by a single operator (S.R.). Of these, 36 (14.7%) patients were performed outside our institution and were not
Table 1. Patient and Lesion Baseline Characteristics of the Study Population and Differences With the Derivation J-CTO Score Population Study Population (Canadian; n=209)
Variables
122 (37.1) 68 (20.7)
LM
2 (1.0)
1 (0.3)
…
RCA
171 (81.8)
Previous CABG EF, %
124 (59.3)
138 (42.0)
Previously failed attempt
64 (30.6)
38 (11.6)
263 (79.9)
Ostial location
36 (17.2)
35 (10.6)
…
Side branches
114 (54.5)
271 (82.4)
Blunt stump at entry site
110 (52.6)
133 (40.4)
Calcifications
90 (43.1)
180 (54.7)
137 (65.6)
141 (42.9)
59 (28.2)
28 (8.5)
55.3±11.1
Target lesion 39 (18.7)
87 (26.4)
29.3±5.3
J-CTO Population (Japanese; n=329)
43 (20.6)
48 (23.0)
BMI, kg/m
Study Population (Canadian; n=209)
LCx
67 (60–74)
Previous PCI
Variables LAD
Age≥75 y 2
Table 2. Angiographic and Procedural Characteristics
J-CTO Population (Japanese; n=329)
Age, y (median) Men
available for angiographic analysis. Hence, the final study population consisted of 209 patients, all patients referred for CTO PCI, without angiographic exclusion criteria. Baseline, procedural and hospitalization data were prospectively collected and entered in a dedicated database. Our institutional review committee approved prospective data collection as part of the Recherche Évaluative en Cardiologie InTervenionnelle (RÉCIT) registry, and subjects provided signed informed consent. A CTO was defined as an obstruction of a coronary artery with anterograde thrombolysis in myocardial infarction flow grade 0 that was confirmed or presumed to be ≥3 months old.11 The duration of the CTO was estimated by clinical information or the results of previous angiography. Successful angiographic recanalization was defined as a restoration of thrombolysis in myocardial infarction flow grade 3 and residual stenosis 25% of the baseline value.15 Neither occluded arterial graft nor vein graft lesions were considered for this study. When possible, arterial access was established via bilateral radial approach (right radial for the left main catheter and left radial for the right coronary artery catheter to optimize support), and 6F catheters were used primarily.16 The preferred guiding catheter curves were Amplatz left (AL) 0.75 for the right coronary and extra back-up (XB) 3.5 for the left. FinecrossMG (Terumo, Tokyo, Japan) and Corsair (Asahi Intecc, Nagoya, Japan) microcatheters were generally used for antegrade and retrograde approaches, respectively. Dual injection was used routinely when contralateral collaterals were present. The approach to the CTO was based on the anatomy following
…
Bridging collaterals
81 (38.8)
77 (23.4)
EF≤40
19 (9.1)
46 (14.0)
Bending >45°
92 (44.0)
143 (43.5)
Heart failure
19 (9.1)
41 (12.5)
Occlusion length, mm
26.2±23.4
13.0±12.3
Previous MI
117 (56.0)
151 (45.9)
≥20
99 (47.4)
72 (21.9)
Multivessel disease
110 (52.6)
214 (65.1)
Retrograde collateral (grade=3)
148 (70.8)
277 (84.2)
eGFR, mL/min
76.7 (63.5–93.6)
…
Successful guidewire crossing in
C
hronic total occlusion (CTO) is a common finding in patients with coronary artery disease1 and is associated with poorer outcomes compared with patients with ischemia with non-CTO disease.2–5 Although better clinical outcomes have been associated with successful recanalization in observational studies,6–8 CTO percutaneous coronary intervention (PCI) remains a major challenge for many interventional cardiologists, and developing new strategies to approach CTO is important for the field. Angiographic CTO lesion characteristics are predictive of success rate and procedure time.9–11 The multicenter Japanese CTO Registry12 investigators developed the J-CTO score as a scoring system to grade the difficulty in crossing a CTO within 30 minutes and overall success rate.13 Thus, it might be a valuable tool for some operators dealing with the challenge of
patient selection for CTO PCI and for schedule management. However, the J-CTO score has never been tested outside the setting of the original study, and its validity has not been established in a non-Japanese population. Moreover, the retrograde approach is an established procedure, which improves the success rate,14 but the proportion of patients with retrograde approach in the original Japanese registry was relatively low. Hence, the predictive value of the J-CTO score when using modern hybrid antegrade and retrograde approaches is unknown. The purpose of the study was therefore to (1) evaluate the performance of the J-CTO score for predicting procedure complexity defined as guidewire CTO crossing within 30 minutes and final success rate in an independent CTO cohort and (2) to assess its performance for antegrade and retrograde approaches.
Received April 20, 2013; accepted October 10, 2013. From the Multidisciplinary Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Laval University, Quebec City, Quebec, Canada. Correspondence to Stéphane Rinfret, MD, SM, Interventional Cardiology and Clinical Research, Multidisciplinary Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Ste-Foy, Quebec City, G1V 4G5 Quebec, Canada. E-mail [email protected] © 2013 American Heart Association, Inc. Circ Cardiovasc Interv is available at http://circinterventions.ahajournals.org
DOI: 10.1161/CIRCINTERVENTIONS.113.000447
Downloaded from http://circinterventions.ahajournals.org/ by guest on April 15, 2015 635
636 Circ Cardiovasc Interv December 2013
What Is Known
• Chronic
total occlusion (CTO) percutaneous coronary intervention remains a difficult procedure associated with higher failure rates than angioplasty for subtotal lesions. • The J-CTO score, derived from a large registry, stratifies case complexity and the likelihood of success.
What the Study Adds
• However, the score had not been validated in an independent cohort.
• This study indicates that the J-chronic total occlusion score is valid and useful to predict the time required to cross the chronic total occlusion, the total procedure time, and radiation dose and contrast use. • However, it was not helpful to predict success rate, using hybrid antegrade, retrograde, and reentry techniques.
Methods Study Population and CTO Procedures Between January 2010 and December 2012, a total of 245 consecutive CTO PCI were performed by a single operator (S.R.). Of these, 36 (14.7%) patients were performed outside our institution and were not
Table 1. Patient and Lesion Baseline Characteristics of the Study Population and Differences With the Derivation J-CTO Score Population Study Population (Canadian; n=209)
Variables
122 (37.1) 68 (20.7)
LM
2 (1.0)
1 (0.3)
…
RCA
171 (81.8)
Previous CABG EF, %
124 (59.3)
138 (42.0)
Previously failed attempt
64 (30.6)
38 (11.6)
263 (79.9)
Ostial location
36 (17.2)
35 (10.6)
…
Side branches
114 (54.5)
271 (82.4)
Blunt stump at entry site
110 (52.6)
133 (40.4)
Calcifications
90 (43.1)
180 (54.7)
137 (65.6)
141 (42.9)
59 (28.2)
28 (8.5)
55.3±11.1
Target lesion 39 (18.7)
87 (26.4)
29.3±5.3
J-CTO Population (Japanese; n=329)
43 (20.6)
48 (23.0)
BMI, kg/m
Study Population (Canadian; n=209)
LCx
67 (60–74)
Previous PCI
Variables LAD
Age≥75 y 2
Table 2. Angiographic and Procedural Characteristics
J-CTO Population (Japanese; n=329)
Age, y (median) Men
available for angiographic analysis. Hence, the final study population consisted of 209 patients, all patients referred for CTO PCI, without angiographic exclusion criteria. Baseline, procedural and hospitalization data were prospectively collected and entered in a dedicated database. Our institutional review committee approved prospective data collection as part of the Recherche Évaluative en Cardiologie InTervenionnelle (RÉCIT) registry, and subjects provided signed informed consent. A CTO was defined as an obstruction of a coronary artery with anterograde thrombolysis in myocardial infarction flow grade 0 that was confirmed or presumed to be ≥3 months old.11 The duration of the CTO was estimated by clinical information or the results of previous angiography. Successful angiographic recanalization was defined as a restoration of thrombolysis in myocardial infarction flow grade 3 and residual stenosis 25% of the baseline value.15 Neither occluded arterial graft nor vein graft lesions were considered for this study. When possible, arterial access was established via bilateral radial approach (right radial for the left main catheter and left radial for the right coronary artery catheter to optimize support), and 6F catheters were used primarily.16 The preferred guiding catheter curves were Amplatz left (AL) 0.75 for the right coronary and extra back-up (XB) 3.5 for the left. FinecrossMG (Terumo, Tokyo, Japan) and Corsair (Asahi Intecc, Nagoya, Japan) microcatheters were generally used for antegrade and retrograde approaches, respectively. Dual injection was used routinely when contralateral collaterals were present. The approach to the CTO was based on the anatomy following
…
Bridging collaterals
81 (38.8)
77 (23.4)
EF≤40
19 (9.1)
46 (14.0)
Bending >45°
92 (44.0)
143 (43.5)
Heart failure
19 (9.1)
41 (12.5)
Occlusion length, mm
26.2±23.4
13.0±12.3
Previous MI
117 (56.0)
151 (45.9)
≥20
99 (47.4)
72 (21.9)
Multivessel disease
110 (52.6)
214 (65.1)
Retrograde collateral (grade=3)
148 (70.8)
277 (84.2)
eGFR, mL/min
76.7 (63.5–93.6)
…
Successful guidewire crossing in
