Conference Coverage

Hybrid PCI strategy rules for complex CTO



– The so-called hybrid strategy is now the preferred approach to percutaneous coronary intervention (PCI) for chronic total occlusions (CTO), 12-month outcomes of the multicenter observational CONSISTENT CTO trial suggest, according to Simon J. Walsh, MD, an interventional cardiologist at Belfast Health and Social Care Trust.

Dr. Simon J. Walsh, an interventional cardiologist at Belfast Health and Social Care Trust Bruce Jancin/MDedge News

Dr. Simon J. Walsh

With use of the hybrid strategy, a CTO’s anatomic complexity is no longer a barrier to performing PCI with a success rate that by former standards would be considered astronomical, he said in presenting the CONSISTENT CTO results at the annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

Indeed, the key take-home messages from CONSISTENT CTO were that technical success rates were dramatic at 98.6%, the target vessel failure rate at 12 months was impressively low at 5.24%, and quality of life scores showed clinically meaningful gains maintained through 1 year.

“Opening a CTO makes people better, reduces their symptom burden, and is something worth doing,” Dr. Walsh concluded.

That hasn’t always been the prevailing view. Historically, most interventional cardiologists had a pessimistic attitude regarding PCI for CTOs. The procedures had a low technical success rate, frequent complications, and lousy durability. Moreover, these subpar results came at a considerable price in terms of extensive radiation exposure and catheterization laboratory time. These various shortcomings became particularly prominent when traditional wire-based PCI strategies were applied to long, complex occlusions.

All that has changed as a result of improved stent technologies and procedural techniques, along with the development of the hybrid PCI algorithm by U.S. cardiologists. Using these tools, an interventionalist skilled in the hybrid strategy now selects cases on the basis of clinical indications, such as disabling angina, rather than on anatomic considerations. This point was emphatically brought home in CONSISTENT CTO (Conventional antegrade vs. sub-intimal synergy stenting in chronic total occlusions).

“This is the most complex set of treated CTO lesions ever investigated in this rigorous way,” according to Dr. Walsh.

This assertion was bolstered by the fact that the average Japan CTO (JCTO) score in the 210 study participants was 2.4, climbing to 2.9 in the 101 patients with dissection present. Further adding to the lesion complexity was the fact that roughly one in five subjects had a degenerated coronary artery graft in their target vessel. The average lesion length as measured at the study core lab was 29.1 mm. The impetus for the CONSISTENT CTO Study was a recognition that, even though a growing number of skilled operators are embracing the hybrid PCI strategy with heretofore unprecedented favorable results, there remains an evidence gap, with little in the way of long-term studies featuring rigorous follow-up. Participants in CONSISTENT CTO therefore underwent baseline formal quality of life assessment, repeated at 12 months of follow-up together with angiography and/or optical coherence tomography. Further follow-up is planned at 2, 3, and 5 years.

Of the 231 patients who consented to participate in the study, 210, or 90%, were able to have their CTO opened with a Synergy everolimus-eluting stent. Those 210 constituted the study population.


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