16:53 CTO PCI Outcome associated with poor quality of the distal target vessel Emmanouil Brilakis (Minneapolis - USA) _____________________________________________ PARALLEL SESSION Interventional CTO & Chip Research Best CTO Publications 2022-23 (selected by the Editors of the Cardiology Interventional journals) Auditorium Zubin Mehta - Friday 16:30 - 17:16 Chairpersons: Davide Capodanno (Catania), Carlo Di Mario (Florence), Giuseppe Tarantini (Padua) Panelist: Roberto Diletti (Rotterdam - NL), Giovanni Esposito (Naples), Paul Knaapen (Amsterdam - NL), Maksymilian Opolski (Warsaw - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

1. Emmanouil Brilakis, MD, PhD
Distal Target Vessel Quality and
Outcomes of Chronic Total Occlusion
Percutaneous Coronary Intervention
Friday, September 8, 2023
16.53-17.00

2. Disclosure Statement of Financial Interest
• Consulting/speaker honoraria: Abbott Vascular,
American Heart Association (associate editor
Circulation), Amgen, Asahi Intecc, Biotronik, Boston
Scientific, Cardiovascular Innovations Foundation (Board
of Directors), ControlRad, CSI, Elsevier, GE Healthcare,
IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens,
and Teleflex
• Research support: Boston Scientific, GE Healthcare
• Owner: Hippocrates LLC
• Shareholder: MHI Ventures, Cleerly Health

3. Introduction
• Distal vessel quality is a key parameter in the global chronic total
occlusion (CTO) crossing algorithm.
• The aim of the study was to evaluate the association of distal vessel
quality with the outcomes of CTO percutaneous coronary
intervention (PCI).

4. Methods
• 10,028 CTO PCIs performed at 39 US and non-US centers between
2012 and 2022 from PROGRESS-CTO registry.
• Poor quality distal vessel was defined as <2 mm diameter or with
significant diffuse atherosclerotic disease.
• In-hospital major adverse cardiac events (MACE) included death,
myocardial infarction (MI), urgent repeat target-vessel
revascularization, tamponade requiring pericardiocentesis or surgery,
and stroke.

5. Table: Clinical and angiographic characteristics of the study lesions classified according to the quality of the distal target vessel
Variables Overall (n=9836) Good Quality Distal Vessel (n=6562) Poor Quality Distal Vessel (n=3274) p-value
Age (years) 64.3+/-10.3 64.4+/-10.4 64.0+/-10.1 0.05
Men (%) 81.3% 81.3% 81.6% 0.60
Body Mass Index (kg/m2) 30.7+/-18.3 30.8+/-21.8 30.5+/-7.2 0.20
Diabetes Mellitus 43% 40% 49.2% <0.001
Hypertension 89.2% 88.6% 90.3% 0.01
Dyslipidemia 85.3% 83.7% 88.7% <0.001
Smoking (current) 23.4% 23.3% 23.7% 0.62
Left ventricular EF 50.3+/-13.0 50.9+/-12.5 49.3+/-13.5 <0.001
Family History of CAD 32.4% 31.8% 33.6% 0.11
Congestive Heart Failure 28.8% 26.7% 33.0% <0.001
Prior Myocardial Infarction 45.2% 42.6% 50.3% <0.001
Prior PCI 60.9% 57.5% 67.9% <0.001
Prior CABG 28.5% 23.9% 37.8% <0.001
Cerebrovascular Disease 10.1% 9.4% 11.7% 0.07
Peripheral Arterial Disease 13.9% 12.8% 16.3% <0.001
CTO Target Vessel <0.001
Right coronary artery 52.8% 52.9% 52.5%
Left anterior descending 26.0% 27.2% 23.6%
Left circumflex 19.1% 17.9% 21.5%
Left main 0.6% 0.5% 0.6%
Other 1.6% 1.5% 1.7%
J-CTO score 2.4+/-1.3 2.2+/-1.3 2.7+/-1.2 <0.001
Progress CTO score 1.3+/-1.0 1.2+/-1.0 1.5+/-1.0 <0.001
Calcification (moderate/severe) 44.4% 40.9% 51.4% <0.001
Proximal vessel tortuosity
(moderate/severe)
28.9% 25.2% 36.1% <0.001
Proximal cap ambiguity 34.7% 31.7% 40.7% <0.001
In-stent restenosis 16.1% 14.4% 19.6% <0.001
Side branch at the proximal cap 54.9% 54.1% 56.5% 0.03
Blunt/no stump, % 52.1% 48.5% 59.3% <0.001
Proximal Vessel diameter (mm) 2.9+/-2.4 3.0+/-2.9 2.8+/-0.6 <0.001
Occlusion length (mm) 30.3+/-20.7 27.4+/-18.5 36.1+/-23.4 <0.001
Number of stents used 2.3+/-1.1 2.2+/-1.0 2.5+/-1.2 <0.001

6. Antegrade
Wiring
ADR
Retrograde
None
60%
11.7%
14.9%
13.6%
Good quality distal target
48.3%
15.9%
25.3%
10.6%
Poor quality distal target vessel
Successful Crossing Strategies

7. Table: Procedural strategies used in the study lesions classified according to the quality of the distal target vessel
Variables Overall (n=10028)
Good Quality Distal
Vessel (n=6690)
Poor Quality Distal
Vessel (n=3338)
p-value
Successful Crossing Strategy
<0.001
Antegrade wiring 5609 (56.1%) 3999 (59.90%) 1610 (48.3%)
Retrograde 1833 (18.3%) 991 (14.9%) 842 (25.2%)
Antegrade dissection and re-entry
1256 (12.5%) 904 (13.5%) 352 (10.6%)
None 1309 (13.1%) 779 (11.7%) 530 (15.9%)
First Crossing Strategy
<0.001
Antegrade wiring 8410 (84.0%) 5808 (87.0%) 2602 (78.0%)
Retrograde 1228 (12.3%) 608 (9.1%) 620 (18.6%)
Antegrade dissection and re-entry
375 (3.7%) 262 (3.9%) 113 (3.4%)
Average stent diameter (mm) 2.8 ± 0.5 2.9 ± 0.5 2.7 ± 0.6 <0.001
Number of stents used 2 (1,3) 2 (1,3) 2 (2,3) <0.001
Rotational atherectomy 378 (3.8%) 233 (3.5%) 145 (4.3%) 0.03
Orbital atherectomy 84 (0.84%) 46 (0.69%) 38 (1.14%) 0.02
Intravascular lithotripsy 93 (0.98%) 65 (0.97%) 28 (0.84%) 0.51
Drug eluting balloon 34 (0.75%) 16 (0.53%) 18 (1.22%) 0.02
Intracoronary Imaging 4192 (41.8%) 2686 (40.2%) 1506 (45.1%) <0.001
Flow restored in all branches 7130 (83.3%) 4972 (85.8%) 2158 (78.1%) <0.001
Additional steps to restore flow in all
branches
1156 (17.4%) 664 (14.2%) 493 (23.8%) <0.001
Procedure time (minutes) 112 (73,165) 105 (69,156) 130 (86,182) <0.001
Fluoroscopy time (minutes) 42 (25,67) 38 (24,60) 50 (30,76) <0.001
Air kerma radiation dose (Gy) 2.2 (1.2,3.7) 2.0 (1.1,3.5) 2.4 (1.3,4.0) 0.002
Contrast volume 205 (150,300) 202 (150,300) 210 (150,300) 0.80
Data presented as percentage, median (Interquartile range) or mean +/- standard deviation.

8. 86,9 86,8
1,7
79,9 79
2,5
0
10
20
30
40
50
60
70
80
90
100
Technical Success Procedural Success In hospital MACE
Good Quality Distal Vessel Poor Quality Distal vessel
p<0.001 p<0.01
p=0.01
%

9. MACE Death Acute MI Repeat PCI Stroke
Emergency
CABG
Tamponade Perforation
Donor vessel
Injury
Good Quality Distal Vessel 1,7 0,28 0,49 0,18 0,12 0,06 0,78 3,7 0,5
Poor Quality Distal Vessel 2,5 0,54 0,66 0,18 0,21 0,03 1,1 6,4 1,1
0
1
2
3
4
5
6
7
%
Titolo asse
Good Quality Distal Vessel Poor Quality Distal Vessel
p=0.01
p=0.53
p=0.05 p=0.29 p=0.99 p=0.27
p=0.07
p<0.001
p=0.001

13. Poor quality distal vessel in CTO lesions is associated with higher lesion
complexity, higher need for retrograde crossing, lower technical and
procedural success, higher incidence of MACE and coronary perforation,
and higher radiation dose.
Conclusions