Large Shift in How Centers Perform CTO PCI

The radial approach is becoming more popular in chronic total occlusion (CTO) percutaneous coronary intervention (PCI), leaving patients with less major bleeding, registry data showed.

Of 3,790 CTO PCIs recorded in 2012-2018, 42% involved transradial access (growing from 11% in 2012 to 67% in 2018, P<0.001), according to the study in JACC: Cardiovascular Interventions.

Access site made no difference in technical success or procedural success, both generally staying above 80% whether the radial or femoral access was used, or a combination of both approaches. Similarly, in-hospital major complications (counting death, myocardial infarction, urgent repeat target vessel revascularization, tamponade, and stroke) occurred at the same rates no matter the access strategy (2.47% for radial vs 3.40% for radial-femoral vs 2.18% for femoral, P=0.830).

Yet major bleeding was reduced with radial-only access (0.55% vs 1.94% vs 0.88%, P=0.013), Emmanouil Brilakis, MD, PhD, of Minneapolis Heart Institute, and colleagues observed. Their study was based on the PROGRESS CTO registry, with 23 participating centers in the U.S., Europe, and Russia.

“The high success achieved with transradial access in our study is likely related to increasing operator expertise in both CTO PCI and the use of radial access and increasing use of large guide catheters (7-F). It could also be related to better patient selection, with less complex cases being performed via transradial access,” the team wrote.

Newer and smaller devices such as guide catheter extensions, sheathless guides, slender sheaths, and microcatheters and guidewires with improved handling characteristics also likely played a role, they said.

The rise of radial access in CTO PCI parallels its growing popularity in PCI in general.

In the registry, patients getting access through the wrist were younger, had fewer risk factors, and were less likely to have had a prior coronary artery bypass graft surgery or PCI, compared with those who had femoral-only or radial-femoral access. Radial access lesions also had lower J-CTO and PROGRESS CTO scores.

Operators used smaller sheaths in radial access and did not use as much antegrade dissection re-entry, instead opting for more antegrade wire escalation.

“One particular strategic approach is not necessarily better than another, and each strategy is associated with its own particular advantages and disadvantages,” said Salman Arain, MD, and H. Vernon Anderson, MD, both of McGovern Medical School at the University of Texas Health Science Center in Houston, in an accompanying editorial.

“Because it is well established that access site bleeding is higher with femoral sheaths, many operators strike a balance by employing a combination of radial and femoral access during CTO-PCI,” they wrote. “Other common variations include biradial access or one radial along with one or two femoral arteries. The latter option allows use of mechanical support devices.”

Brilakis and colleagues found that the bilateral approach was associated with greater technical and procedural success but numerically more in-hospital major adverse cardiovascular events.

The mean age of the registry participants was 65, and 85% were men.

Besides its observational nature, the study was limited by short follow-up and inclusion of only high-volume CTO centers with experienced operators, and the centers also did not check for post-procedural radial artery occlusion, Brilakis and co-authors noted.

“Although there are many observational single-center and registry studies of various sizes, only three randomized trials of CTO-PCI have been reported,” Arain and Anderson said (pointing to EXPLORE, DECISION-CTO, and EuroCTO), but they noted interpretation of these studies is “seriously” hampered by their limitations.

“For example, all were stopped early due to slow enrollment, thereby reducing statistical power. Thus, the evidence base for decision making in patients with coronary chronic occlusion is still lacking, even as the techniques and equipment for CTO-PCI continue to be refined,” the editorialists wrote. “To fix or not to fix the CTO — that is still the real question.”