title: Hybrid approach improves success of chronic total occlusion angioplasty.
abstract: Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques.
  
  
  
  Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan (J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30% residual stenosis, subclassified as at first attempt or overall. Inhospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded.
  
  
  
  1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79% (first attempt) and 90% (overall) with 30-day MACE of 1.6%. AWE was highly effective in less complex lesions (J-CTO ≤1 94% success vs 79% in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions (J-CTO≤1 15% vs J-CTO ≥2 56%). Need for multiple approaches during each attempt increased with lesion complexity (17% J-CTO ≤1 vs 48% J-CTO ≥2). Lesion modification ('investment procedures') at the end of unsuccessful first attempts increased the chance of subsequent success (96% vs 71%).
  
  
  
  Hybrid-trained operators can achieve overall success rates of 90% in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.
authors.affiliation: Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: W M
authors.initials: WM
authors.lastname: Wilson
authors.affiliation: Belfast Health and Social Care Trust, Belfast, UK.
authors.forename: S J
authors.initials: SJ
authors.lastname: Walsh
authors.affiliation: St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: A T
authors.initials: AT
authors.lastname: Yan
authors.affiliation: Belfast Health and Social Care Trust, Belfast, UK.
authors.forename: C G
authors.initials: CG
authors.lastname: Hanratty
authors.affiliation: Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: A J
authors.initials: AJ
authors.lastname: Bagnall
authors.affiliation: Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: M
authors.initials: M
authors.lastname: Egred
authors.affiliation: The London Chest Hospital (Barts Health Centre, Barts Health NHS Trust), London, UK.
authors.forename: E
authors.initials: E
authors.lastname: Smith
authors.affiliation: Golden Jubilee National Hospital, Glasgow, UK.
authors.forename: K G
authors.initials: KG
authors.lastname: Oldroyd
authors.affiliation: Golden Jubilee National Hospital, Glasgow, UK.
authors.forename: M
authors.initials: M
authors.lastname: McEntegart
authors.affiliation: Ninewells Hospital, Dundee, UK.
authors.forename: J
authors.initials: J
authors.lastname: Irving
authors.affiliation: Bristol Heart Institute, Bristol, UK.
authors.forename: J
authors.initials: J
authors.lastname: Strange
authors.affiliation: Belfast Health and Social Care Trust, Belfast, UK.
authors.forename: H
authors.initials: H
authors.lastname: Douglas
authors.affiliation: Golden Jubilee National Hospital, Glasgow, UK Edinburgh Heart Centre, Edinburgh, UK Forth Valley Acute Hospitals, Larbert, UK.
authors.forename: J C
authors.initials: JC
authors.lastname: Spratt
mesh_terms: D000368:Aged; D002908:Chronic Disease; D003097:Collateral Circulation; D017023:Coronary Angiography; D003326:Coronary Circulation; D054059:Coronary Occlusion / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom; D014654:Vascular Patency