title: Prevalence, indications and management of balloon uncrossable chronic total occlusions: Insights from a contemporary multicenter US registry.
abstract: BACKGROUND
  Balloon uncrossable lesions can be challenging to treat, requiring specialized techniques and equipment.
  
  
  METHODS
  We examined the prevalence, clinical and angiographic characteristics, management and procedural outcomes of balloon uncrossable lesions in a multicenter chronic total occlusion (CTO) percutaneous coronary intervention (PCI) registry.
  
  
  RESULTS
  Between 2012 and 2016, 718 CTO PCIs (in which the occlusion was successfully crossed with a guidewire) were performed in 701 patients at 11 US centers. Mean age was 65.6 ± 10 years and 84% of the patients were men. Balloon uncrossable lesions represented 9% of all CTOs. Balloon uncrossable CTOs had more moderate/severe calcification (82% vs. 52%, P < 0.0001), moderate/severe tortuosity (61% vs. 35% P < 0.0001) and higher J-CTO score (2.95 ± 1.32 vs. 2.43 ± 1.23, P = 0.005) as compared with the remaining lesions. Technical and procedural success was significantly lower for balloon uncrossable lesions (90.5% vs. 98.3%, P < 0.0001 and 88.9% vs. 96.6% P = 0.004), respectively, but the incidence of major adverse events was similar (1.6% vs. 2.2%, P = 0.751). Balloon uncrossable lesions required longer procedure (208 [interquartile range: 135, 258] vs. 135 [94, 194] min, P < 0.0001) and fluoroscopy (77 [52, 100] vs. 45 min [27, 75], P < 0.0001) time. Techniques used to treat balloon uncrossable lesions included balloon-assisted microdissection (23%), excimer laser atherectomy (18%), and rotational atherectomy (16%). Excimer laser atherectomy and balloon-assisted microdissection were associated with the highest technical and procedural success rates.
  
  
  CONCLUSIONS
  Balloon uncrossable CTOs are common, are associated with high rates of technical failure, and require specialized techniques for successful treatment. © 2016 Wiley Periodicals, Inc.
authors.affiliation: VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.|Division of Invasive Cardiology, Second Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary.
authors.forename: Judit
authors.initials: J
authors.lastname: Karacsonyi
authors.affiliation: Columbia University, New York, New York.
authors.forename: Dimitri
authors.initials: D
authors.lastname: Karmpaliotis
authors.affiliation: Henry Ford Hospital, Cardiology Department, Detroit, Michigan.
authors.forename: Khaldoon
authors.initials: K
authors.lastname: Alaswad
authors.affiliation: Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Farouc A
authors.initials: FA
authors.lastname: Jaffer
authors.affiliation: Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Yeh
authors.affiliation: VA San Diego Healthcare System and University of California San Diego, San Diego, California.
authors.forename: Mitul
authors.initials: M
authors.lastname: Patel
authors.affiliation: VA San Diego Healthcare System and University of California San Diego, San Diego, California.
authors.forename: John
authors.initials: J
authors.lastname: Bahadorani
authors.affiliation: Medical Center of the Rockies, Loveland, Colorado.
authors.forename: Anthony
authors.initials: A
authors.lastname: Doing
authors.affiliation: Columbia University, New York, New York.
authors.forename: Ziad A
authors.initials: ZA
authors.lastname: Ali
authors.affiliation: VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.
authors.forename: Aris
authors.initials: A
authors.lastname: Karatasakis
authors.affiliation: VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Danek
authors.affiliation: VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.
authors.forename: Bavana V
authors.initials: BV
authors.lastname: Rangan
authors.affiliation: VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.
authors.forename: Aya J
authors.initials: AJ
authors.lastname: Alame
authors.affiliation: VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.
authors.forename: Subhash
authors.initials: S
authors.lastname: Banerjee
authors.affiliation: VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.|Minnepolis Heart Institute, Minneapolis, Minnesota.
authors.forename: Emmanouil S
authors.initials: ES
authors.lastname: Brilakis
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D017225:Atherectomy, Coronary / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D002908:Chronic Disease; D017023:Coronary Angiography; D054059:Coronary Occlusion / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D006801:Humans; D054018:Lasers, Excimer / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012042:Registries; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: balloon angioplasty; balloon uncrossable lesion; chronic total occlusion; percutaneous coronary intervention