Procedural Results and Long-Term Outcomes of Percutaneous Coronary Intervention for in-Stent Restenosis Chronic Total Occlusion Compared with de novo Chronic Total Occlusion

Figures & data

Table 1 Baseline Clinical Characteristics

	ISR CTO Group	de novo CTO Group	P value
	(n=69)	(n=357)
Age (years)	64.8±9.8	63.1±11.6	0.263
Male gender	57 (82.6)	299 (83.8)	0.814
Current smoker	27 (39.1)	160 (44.8)	0.383
Hypertension	48 (69.6)	251 (70.3)	0.902
Diabetes mellitus	35 (50.7)	166 (46.5)	0.520
Dyslipidemia	49 (71.0)	219 (61.3)	0.128
Previous MI	40 (58.0)	64 (17.9)	<0.001
Indication of CTO PCI			0.002
Silent ischemia without symptoms	0 (0)	34 (9.5)
Stable angina	20 (29.0)	104 (29.1)
ACS	39 (56.5)	201 (56.3)
other	10 (14.5)	18 (5.0)
LDL-C (mmol/l)	2.05 (1.66, 2.56)	2.14 (1.70, 2.75)	0.210
eGFR (mL·min^−1·1.73^−1)	93.3±27.2	94.9±27.4	0.654
LVEF (%)	51.1±11.1	57.4±12.7	0.540
HFrEF	9 (13.0)	65 (18.2)	0.300
Medication
Aspirin	68 (98.6)	355 (99.4)	0.412
Clopidogrel	50 (72.5)	292 (81.8)	0.075
Ticagrelor	17 (24.6)	54 (15.1)	0.052
Statins	69 (100)	349 (97.8)	0.441
ß-B	51 (73.9)	254 (71.1)	0.641
ACEI/ARB	42 (60.9)	193 (54.1)	0.298

Notes: Values are mean ± SD, n (%), n/N (%), or median (interquartile range).

Abbreviations: ISR, in-stent restenosis; MI, myocardial infarction; CTO, chronic total occlusion; PCI, percutaneous coronary intervention; ACS, acute coronary syndrome; LDL-c, low density lipoprotein cholesterol; eGFR, estimated glomerular filtration rate; LVEF, Left ventricular ejection fraction; HFrEF, heart failure with reduced ejection fraction (EF<40%); ß-B, ß-receptor blocker; ACEI/ARB, angiotensin converting enzyme inhibitors/angiotensin receptor inhibitors.

Table 2 Angiographic Characteristics

	ISR CTO PCI	de novo CTO PCI	P value
	(n=84)	(n=400)
LM disease	1/69 (1.4)	21/357 (5.9)	0.220
Three-vessel coronary disease	48/69 (69.6)	229/357 (64.1)	0.387
LM plus three-vessel coronary disease	1/69 (1.4)	17/357 (4.8)	0.355
CTO location
LAD	27/69 (39.1)	160/357 (44.8)	0.383
LCX	18/69 (26.1)	95/357 (26.6)	0.928
RCA	35/69 (50.7)	167/357 (46.8)	0.548
Multivessel CTO
LAD plus LCX	1/69 (1.4)	10/357 (2.8)	0.815
LAD plus RCA	4/69 (5.8)	20/357 (5.6)	1.000
LCX plus RCA	6/69 (8.7)	27/357 (7.6)	0.747
LAD, LCX plus RCA	0/69 (0)	4/357 (1.1)	1.000
Syntax score	21.5 (14.5, 27.0)	23.0 (17.5, 30.5)	0.039
Target CTO vessel
LAD	33 (39.3)	165 (41.3)	0.739
LCX	12 (14.3)	74 (18.5)	0.358
RCA	39 (46.4)	161 (40.3)	0.296
Branch vessel CTO	3 (3.6)	35 (8.8)	0.109
J-CTO score	2.0 (1.0, 2.0)	1.0 (1.0, 2.0)	<0.001
J-CTO score ≥3	15 (17.9)	37 (9.3)	0.021
Rentrop grade 3	27 (32.1)	194 (48.5)	0.006
Prior attempt	9 (10.7)	40 (10.0)	0.844

Notes: Values are mean ± SD, n (%), n/N (%), or median (interquartile range).

Abbreviations: ISR, in-stent restenosis; CTO, chronic total occlusion; PCI, percutaneous coronary intervention; LM, left main; J-CTO, Japanese-CTO; LAD, left anterior descending artery; LCX, left circumflex; RCA, right coronary artery.

Table 3 Procedural Characteristics

	ISR CTO PCI	de novo CTO PCI	P value
	(n=84)	(n=400)
Radial access	65 (77.4)	326 (81.5)	0.384
Dual injection	14 (16.7)	130 (32.5)	0.004
7 Fr Guiding catheter	8 (9.5)	18 (4.5)	0.112
Crossing strategy			0.548
Antegrade approach	80 (95.2)	374 (93.5)
Retrograde approach	4 (4.8)	26 (6.5)
IVUS use	15 (17.9)	60 (15.0)	0.511
Technical success	62 (73.8)	316 (79.0)	0.296
Procedural success	61 (72.6)	310 (77.5)	0.336
Type of intervention			<0.001
Drug-eluting stent	30/62 (48.4)	251/316 (79.4)
Drug coating balloon	32/62 (51.6)	65/316 (20.6)
Contrast volume (mL)	239 (180, 280)	250 (200, 300)	0.058
Fluoroscopy time (min)	34.0 (23.0, 54.5)	33.5 (23.0, 54.0)	0.939
Non-CTO lesion PCI	18/69 (26.1)	145/357 (40.6)	0.023
CR	40/69 (58.0)	176/357 (49.3)	0.187
Major procedural complications	1 (1.2)	9 (2.3)	0.842
Acute stent thrombosis	0 (0)	3 (0.8)	1.000
In-hospital death	0/69 (0)	2/357 (0.6)	1.000

Notes: Values are mean ± SD, n (%), n/N (%), or median (interquartile range).

Abbreviations: ISR, in-stent restenosis; CTO, chronic total occlusion; PCI, percutaneous coronary intervention; IVUS, intravascular ultrasound; CR, complete revascularization.

Table 4 Clinical Outcomes on 24-Month Follow-Up

	ISR CTO Group (n=66)	de novo CTO Group (n=350)	P value
Angiographic follow-up	31 (47.0)	112 (32.0)	0.019
Re-occlusion	6/31 (22.6)	10/112 (8.9)	0.078
TV MI	2 (3.0)	7 (2.0)	0.947
TVR	20/81 (24.7)	30/393 (7.6)	<0.001
Cardiac death	1 (1.5)	3 (0.9)	0.500
MACE	22 (33.3)	36 (10.3)	<0.001

Note: Values are n (%).

Abbreviations: ISR, in-stent restenosis; CTO, chronic total occlusion; TV, target vessel; MI, myocardial infarction; TVR, target vessel revascularization; MACE, major adverse cardiac event.

Figure 1 Two-year MACE rates in patients who underwent CTO PCI. Patients who underwent ISR CTO PCI versus those who underwent de novo CTO PCI, Log-rank P<0.0001.

Abbreviations: MACE, major adverse cardiac events; CTO, chronic total occlusion; PCI, percutaneous coronary intervention; ISR, in-stent restenosis.

Figure 2 Two-year TVR rates in patients who underwent CTO PCI. Patients who underwent ISR CTO PCI versus those who underwent de novo CTO PCI, Log-rank P<0.0001.

Abbreviations: TVR, target vessel revascularization; CTO, chronic total occlusion; PCI, percutaneous coronary intervention; ISR, in-stent restenosis.

Table 5 Independent Predictors of MACEs in Patients Who Underwent CTO PCI

	HR	95% CI	P value
Previous MI	1.071	0.500–2.292	0.861
eGFR	0.992	0.981–1.003	0.139
Syntax score	1.026	0.993–1.060	0.126
J-CTO score	1.340	0.940—1.912	0.106
ISR CTO	4.124	1.951–8.717	<0.001
Retrograde approach	2.129	0.699–6.488	0.184
CR	0.636	0.309–1.310	0.220
Major procedural complications	4.403	0.980–19.787	0.053

Abbreviations: MACE, major adverse cardiac event; CTO, chronic total occlusion; PCI, percutaneous coronary intervention; HR, hazard ratio; CI, confidence interval; MI, myocardial infarction; eGFR, estimated glomerular filtration rate; J-CTO, Japanese-CTO; ISR, in-stent restenosis; CR, complete revascularization.