Intravascular Ultrasound Analysis of Intraplaque Versus Subintimal Tracking in Percutaneous Intervention for Coronary Chronic Total Occlusions and Association With Procedural Outcomes.

OBJECTIVES

Using intravascular ultrasound (IVUS), the authors compared outcomes by observed wire position (intraplaque vs. subintimal) achieved during successful chronic total occlusion (CTO) lesion treatment.

BACKGROUND

Recent successes in CTO percutaneous coronary intervention (PCI) have used both intraluminal and subintimal wire tracking to improve procedural success. IVUS may be used to determine the course of wire tracking after crossing a CTO.

METHODS

From March 2014 to March 2016, data were collected into a single-center database from 219 patients undergoing CTO PCI with concomitant IVUS imaging. IVUS-visualized wire tracking patterns were then retrospectively examined. Clinical outcomes with a composite in-hospital cardiovascular endpoint of all-cause death, periprocedural myocardial infarction, and in-hospital target lesion revascularization were analyzed along with IVUS-detected vascular injury.

RESULTS

Of the 524 lesions assessed, 219 patients with successfully recanalized CTO lesions had adequate IVUS imaging and were included. Subintimal tracking was detected in 52.1% of overall cases (86.7% dissection re-entry, 27.9% wire escalation). Minimal stent area of the CTO segment and prevalence of significant edge dissection were similar in the 2 groups. In the subintimal tracking group, there was a higher rate of the composite endpoint, mostly driven by periprocedural myocardial infarction. Subintimal tracking was associated with significantly greater IVUS-detected vascular injury, angiographic dye staining/extravasation, and branch occlusion.

CONCLUSIONS

IVUS-detected subintimal tracking is observed in approximately one-half of all successful CTO PCI cases and is associated with an expected higher, yet acceptable, event rate with no difference in minimal stent area or edge dissection among patients undergoing contemporary hybrid CTO PCI.