Procedural Success and Outcomes With Increasing Use of Enabling Strategies for Chronic Total Occlusion Intervention

Background: Enabling strategies (ESs) are increasingly used during percutaneous coronary intervention for chronic total occlusive disease (CTO-PCI), enhancing procedural success. Using the British Cardiovascular Society dataset, we examined changes in the use of ESs and procedural/clinical outcomes for CTO-PCI. Methods and Results: ESs were defined as intravascular ultrasound, rotational/laser atherectomy, dual arterial access, use of microcatheters, penetration catheters or CrossBoss, and procedures categorized by number of ESs used. Data were analysed on all elective CTO-PCI procedures performed in England and Wales between 2006 and 2014. Multivariable logistic regression was used to identify predictors of procedural success. During 28 050 CTO-PCIs, there were significant temporal increases in ES use. There was a stepwise increase in CTO success with increased ES use, with 83.8% of cases successful where ≥3 ESs were used. Overall, CTO-PCI success rate for the whole cohort increased from 55.4% in 2006 to 66.9% in 2014 (P <0.001), but the greatest increase in procedural success was associated with ≥3 ES use. In multivariable analysis, any ES use and the number of ESs used were predictive of procedural success. Coronary perforation increased from 1.2% with zero ES use to 4.0% with ≥3 (P <0.001). After adjustment, although arterial complication, in-hospital bleeding, in-hospital mortality, and major adverse cardiovascular or cerebrovascular events remained more likely with ES use, 30-day mortality was not significantly different between groups.Conclusions: ES use during CTO-PCI was associated with significant improvements in CTO-PCI success. ES use was associated with increased procedural complications and in-hospital major adverse cardiovascular events, but not with 30-day mortality.