Prevalence, Presentation and Treatment of 'Balloon Undilatable' Chronic Total Occlusions: Insights from a Multicenter US Registry

Abstract

Background: The prevalence, treatment and outcomes of balloon undilatable chronic total occlusions (CTOs) have received limited study.

Methods: We examined the prevalence, clinical and angiographic characteristics, and procedural outcomes of percutaneous coronary interventions (PCIs) for balloon undilatable CTOs in a contemporary multicenter US registry.

Results: Between 2012 and 2017 data on balloon undilatable lesions were available for 425 consecutive CTO PCIs in 415 patients in whom guidewire crossing was successful: 52 of 425 CTOs were balloon undilatable (12%). Mean patient age was 65 ± 10 years and most patients were men (84%). Patients with balloon undilatable CTOs were more likely to be diabetic (67 vs. 41%, P < 0.001) and have heart failure (44 vs. 28%, P = 0.027). Balloon undilatable CTOs were longer (40 mm [interquartile range, IQR 20-50] vs. 30 [IQR 15-40], P = 0.016), more likely to have moderate/severe calcification (87 vs. 54%, P < 0.001), and had higher J-CTO score (3.2 ± 1.1 vs. 2.5 ± 1.3, P < 0.001) and PROGRESS-CTO complications score (3.9 ± 1.7 vs. 3.1 ± 2.0, P < 0.005). They were associated with lower technical and procedural success (92 vs. 98%, P = 0.024; and 88 vs. 96%, P = 0.034, respectively) and higher risk for in-hospital major adverse events (8 vs. 2%, P = 0.008) due to higher perforation rates. The most frequent treatments for balloon undilatable CTOs were high pressure balloon inflations (64%), rotational atherectomy (31%), laser (21%), and cutting balloons (15%).

Conclusions: Balloon undilatable CTOs are common and are associated with lower success and higher complication rates.

Trial registration: ClinicalTrials.gov NCT02061436.

Keywords: chronic total occlusion; complex coronary intervention; percutaneous coronary intervention.

Figure 1

Challenging PCI for balloon undilatable ostial right coronary artery (RCA) chronic total occlusion (CTO). Panel A-B. Short (10 mm) ostial right coronary artery CTO that was crossed with a Fielder FC guidwire advanced through a Caravel microcatheter (Asahi Intecc, Nagoya, Japan). Panel C-D. Orbital atherectomy for plaque modification (18 passes), that was complicated by crown fracture and entrapment. The fractured crown was retrieved after removal of the Viper guidewire. Panel E. The lesion failed to dilate despited multiple balloon inflations (2.0×20 and 2.5×20 mm balloon inflated at 20-24 Atm [red arrowhead]). Panel F. An AngioSculpt balloon (Spectranetics, Fremont, CA, USA) delivered and inflated using a GuideLiner V3 (Vascular Solutions, Minneapolis, MN, USA) guide catheter extension. Panel G. Rotational atherectomy (yellow arrowhead) was performed (8 passes, upsizing the burr diameter from 1.2 mm to 1.25 mm) over a RotaWire Floppy guidewire (Boston Scientific, Natick, MA, USA) Panel H. Optical coherence tomography demonstrating heavy circumferential calcification in the proximal right coronary artery. Panel I. Final angiographic result after stenting.

Figure 2

Treatment algorithm for balloon undilatable lesions. Modified with permission from(19)