title: Procedural failure of chronic total occlusion percutaneous coronary intervention: Insights from a multicenter US registry.
abstract: BACKGROUND
  The hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly increased procedural success rates, yet some cases still fail. We sought to evaluate the causes of failure in a contemporary CTO PCI registry.
  
  
  METHODS
  We examined 380 consecutive patients who underwent CTO-PCI at 4 high volume CTO PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, complication, and efficiency outcomes were compared between successful and failed cases. Failed cases were individually reviewed by an independent reviewer to determine the cause of failure.
  
  
  RESULTS
  Procedural success was 91.3%. Compared with patients in whom CTO PCI was successful, those in whom CTO PCI failed had similar baseline clinical characteristics, but were more likely to have longer occlusion length, more tortuosity, more proximal cap ambiguity and blunt stump, and higher mean J-CTO scores (2.8 ± 1.1 vs. 3.5 ± 1.0, P < 0.001), and less likely to have collaterals suitable for the retrograde approach (66% vs. 45%, P = 0.021). Failure was due to a complication in 10 cases (30%). In the remaining 23 cases (70%) failure was due to inability to wire the lesion (n = 21, 4 of which were CTOs due to in-stent restenosis), or poor antegrade flow after PCI (n = 5).
  
  
  CONCLUSIONS
  Compared with successful cases, failed CTO-PCI cases are more likely to have higher J-CTO scores, longer occlusion length, ambiguous proximal cap and no appropriate collaterals for retrograde crossing. Development of novel CTO crossing techniques is needed to further increase CTO PCI success rates.
authors.affiliation: Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: James
authors.initials: J
authors.lastname: Sapontis
authors.affiliation: VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Georgios
authors.initials: G
authors.lastname: Christopoulos
authors.affiliation: Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri.
authors.forename: J Aaron
authors.initials: JA
authors.lastname: Grantham
authors.affiliation: Torrance Memorial Center, Loas Angeles, California.
authors.forename: R Michael
authors.initials: RM
authors.lastname: Wyman
authors.affiliation: Appleton Medical Center and Theda Clark Medical Center, Appleton, Wisconsin.
authors.forename: Khaldoon
authors.initials: K
authors.lastname: Alaswad
authors.affiliation: Columbia University, New York, New York.
authors.forename: Dimitri
authors.initials: D
authors.lastname: Karmpaliotis
authors.affiliation: University of Washington, Seattle, Washington.
authors.forename: William L
authors.initials: WL
authors.lastname: Lombardi
authors.affiliation: University of Washington, Seattle, Washington.
authors.forename: James M
authors.initials: JM
authors.lastname: McCabe
authors.affiliation: VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Steven P
authors.initials: SP
authors.lastname: Marso
authors.affiliation: VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Anna P
authors.initials: AP
authors.lastname: Kotsia
authors.affiliation: VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Bavana V
authors.initials: BV
authors.lastname: Rangan
authors.affiliation: VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Georgios E
authors.initials: GE
authors.lastname: Christakopoulos
authors.affiliation: Minneapolis VA Healthcare System and University of Minnesota, Minneapolis, Minnesota.
authors.forename: Santiago
authors.initials: S
authors.lastname: Garcia
authors.affiliation: Boston Scientific, Natick, Massachusetts.
authors.forename: Craig A
authors.initials: CA
authors.lastname: Thompson
authors.affiliation: VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Subhash
authors.initials: S
authors.lastname: Banerjee
authors.affiliation: VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Emmanouil S
authors.initials: ES
authors.lastname: Brilakis
mesh_terms: D000368:Aged; D002908:Chronic Disease; D003097:Collateral Circulation; D017023:Coronary Angiography; D003326:Coronary Circulation; D054059:Coronary Occlusion / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D023903:Coronary Restenosis / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D005260:Female; D061847:Hospitals, High-Volume; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000379:methods; D012042:Registries; D012307:Risk Factors; D017211:Treatment Failure; D014481:United States
keywords: complex PCI; complications; percutaneous coronary intervention