PCI was shown to be nearly 10 percentage points more likely to succeed in recanalizing a CTO in patients who were first imaged via a coronary CTA, researchers report in JACC: Cardiovascular Imaging. This group also had a trend toward a lower incidence of coronary perforations.
"Treatment of simple lesions, not complex lesions, usually does not need this pre-procedural coronary CTA," Dr. Sung-Jin Hong and Dr. Yangsoo Jang told Reuters Health in a joint email. "Only use of angiography-guidance is sufficient to treat them. However, fixing chronic total occlusions (CTO) is difficult and has a lower success rate."
Dr. Hong and Dr. Jang, both at Yonsei University's Severance Cardiovascular Hospital in Seoul, South Korea, said physicians or operators typically identify the site of a CTO during roughly 15% to 25% of diagnostic coronary angiographies. While coronary CTAs fare better, they caution that the medical professional's familiarity parsing coronary CTA images is often critical.
For their study, the two researchers and their colleagues enrolled 400 patients with CTO at 12 centers in South Korea between 2014 and 2019. They included CTO patients with typical angina or a positive functional test for ischemia, excluding those displaying cardiogenic shock, a left ventricular ejection fraction under 25%, serum creatinine greater than 2 mg/dl, or an acute myocardial infarction within the previous 48 hours.
By random allocation, half the patients received pre-procedural coronary CTA (the CTA-guided group) and half did not (the angiography-guided group).
Later in each procedure, a second randomization was introduced in a 1:1 ratio by varying between two types of drug-eluting stents: the everolimus-eluting stent (XIENCE family, Abbott Vascular) and resolute zotarolimus-eluting stent (R-ZES, Medtronic).
The primary endpoint was successful recanalization, a final TIMI (Thrombolysis In Myocardial Infarction) grade of 2-or-higher and 30% or less residual stenosis on the final angiogram.
Occluded arteries were successfully recanalized in 187 of the coronary CTA-guided patients and 168 angiography-guided patients (93.5% vs. 84.0%; P=0.003).
There was significant interaction between the treatment arm and Multicenter CTO Registry of Japan (J-CTO) score, such that cases with a J-CTO score of at least 2 had significantly higher success rates with CTA guidance, while there was no significant difference in success rates for patients with a lower J-CTO score.
Coronary perforations occurred in two (1%) of the coronary CTA-patients and eight (4%) of the angiography-guided patients (P=0.055). There were no documented periprocedural heart attacks in the CTA-guided group, compared with four (2%) in the angiography-guided group (P=0.123).
At the one-year point, however, there were no significant differences between the groups in cardiac death, myocardial infarction linked to the CTO site, or target-vessel revascularization.
Dr. Pamela Douglas of Duke University School of Medicine, in Durham, North Carolina, who has studied the safety of coronary CTA, told Reuters Health by email that the one-year outcomes were inconclusive due to the study's small size.
"The randomized nature of the trial supports the claim for utility in initial procedural success," said Dr. Douglas, who was not involved the study. But she also noted that the confidence intervals on certain hazard ratios favoring coronary CTA were "very wide."
"One could claim a lack of precision," Dr. Douglas said. "More accurately, the outcomes are not different, a common finding with a trial that is underpowered for a secondary endpoint as this study was."
The study had no commercial funding, and the authors report no conflicts of interest.
SOURCE: https://bit.ly/3n0o4U4 JACC: Cardiovascular Imaging, October 2021.
By Matthew Phelan
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