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Assessment of the ERCTO Score for Predicting Success in Retrograde Chronic Total Occlusion Percutaneous Coronary Interventions in the PROGRESS-CTO Registry
Abstract
BACKGROUND: The retrograde strategy is a common approach used in complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The ERCTO Retrograde score is a tool that aims to predict the likelihood of technical success for retrograde CTO PCI procedures by evaluating five parameters: calcification, distal opacification, proximal tortuosity, collateral connection classification, and operator volume.
METHODS: We evaluated the performance of the ERCTO Retrograde score using data from 2,341 patients enrolled in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) at 35 centers between 2013 and 2023.
RESULTS: Retrograde CTO PCI was the primary crossing strategy in 871 cases (37.2%) and a secondary crossing strategy in 1,467 cases (62.8%). Technical success was achieved in 1,810 cases (77.3%). The technical success rate was higher for primary retrograde cases compared with secondary retrograde cases (79.8% vs 75.9%; P=.031). The ERCTO Retrograde score was positively associated with the likelihood of procedural success. The c-statistic of the ERCTO retrograde score was 0.636 (95% confidence intervals [CI]: 0.610 – 0.662) for all cases and 0.651 (95% CI: 0.607 – 0.695) for primary retrograde cases.
CONCLUSIONS: The ERCTO Retrograde score has modest predictive capacity for technical success in retrograde CTO PCI.
J INVASIVE CARDIOL 2023;35(6):E294-E296. doi: 10.25270/jic/23.00036. Epub April 14
Key words: chronic total occlusions, intravascular imaging, intravascular ultrasound, percutaneous coronary intervention
The retrograde strategy is often used in chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially in complex cases, but is associated with increased risk of complications.1 Hence, optimal selection of patients who may benefit from the retrograde approach is critical.2 Myat et al developed the European Registry of Chronic Total Occlusion (ERCTO) Retrograde score that assesses the likelihood of technical success for retrograde CTO-PCI using 5 variables: calcification, distal opacification, proximal tortuosity, collateral connection classification, and operator volume.3
We evaluated the ERCTO Retrograde score in 2341 patients from the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) study who underwent retrograde CTO-PCI at 35 centers in the United States and internationally between 2013 and 2023. Retrograde CTO-PCI was defined as either primary retrograde CTO-PCI or primary antegrade CTO-PCI that was converted to the retrograde approach. The ERCTO Retrograde score was calculated for all patients, and patient characteristics and outcomes were summarized. Patients were divided into five quantiles based on their scores, and the technical success rate was evaluated for each quantile. Univariable logistic regression was utilized to investigate the association between technical success and the ERCTO Retrograde score of patients. The discriminative capacity of the score was assessed using the area under the curve (AUC) of the receiver-operating characteristic (ROC) curve. All statistical analyses were performed using R Statistical Software, version 4.2.2 (R Foundation for Statistical Computing).
The mean age of patients was 64 ± 10 years and 83.4% of them were men. The most common target vessel was the right coronary artery (68.1%), followed by the left anterior descending coronary artery (16.5%), and the left circumflex coronary artery (13.6%). Retrograde CTO-PCI was the primary crossing strategy in 871 cases (37.2%) and the secondary crossing strategy in 1467 cases (62.8%). Technical success was achieved in 1810 cases (77.3%). The technical success rate was higher for primary retrograde compared with secondary retrograde cases (79.8% vs 75.9%; P=.031).
The ERCTO Retrograde score was positively associated with the likelihood of technical success (odds ratio: 1.11 per 10 score unit increase; 95% confidence intervals [CI]: 1.09-1.14; P<.001). Patients whose scores where in the higher quintiles had significantly higher rates of technical success compared with patients in the lower quintiles (Figure 1A). The AUC of the ERCTO retrograde score was .636 (95% CI: .610-.662) for all cases (Figure 1B) and .651 (95% CI: .607-.695) for primary retrograde cases.
Although we found a positive association between technical success and the ERCTO Retrograde score, its predictive ability was modest with an AUC of .636, hence its practical utility may be limited.
Study limitations. The limitations of this study include its retrospective design, the absence of core laboratory assessment of angiograms, and a lack of clinical event evaluation. The CTO-PCIs in the PROGRESS-CTO registry were carried out at specialized, high-volume CTO centers with experienced operators, which may limit the applicability of the results to centers with less experience in CTO-PCI.
Acknowledgements. The authors are grateful for the philanthropic support of our generous anonymous donors, and the philanthropic support of Drs Mary Ann and Donald A Sens; Mrs Diane and Dr Cline Hickok; Mrs Wilma and Mr Dale Johnson; Mrs Charlotte and Mr Jerry Golinvaux Family Fund; the Roehl Family Foundation; and the Joseph Durda Foundation. The generous gifts of these donors to the Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease (CCAD) helped support this research project.
Affiliations and Disclosures
From the 1Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota; 2Cardiovascular Division, Henry Ford Hospital Cardiology Heart Care, Detroit, Michigan; and 3Interventional Cardiology Unit, Division of Cardiology, Promed Hospital, Chennai, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Alaswad has been a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. Dr. Brilakis reports consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, Teleflex, and Terumo; research support from Boston Scientific, GE Healthcare; is owner of Hippocrates LLC; is a shareholder in MHI Ventures, Cleerly Health, Stallion Medical. The remaining authors report no disclosures.
Manuscript accepted February 15, 2023.
Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, Minnesota, 55407. Email: esbrilakis@gmail.com
References
- Konstantinidis NV, Werner GS, Deftereos S, et al. Temporal trends in chronic total occlusion interventions in Europe. Circ Cardiovasc Interv. 2018;11(10):e006229. doi:10.1161/CIRCINTERVENTIONS.117.006229
- Megaly M, Xenogiannis I, Abi Rafeh N, et al. Retrograde approach to chronic total occlusion percutaneous coronary intervention. Circ Cardiovasc Interv. 2020;13(5):e008900. doi:10.1161/CIRCINTERVENTIONS.119.008900
- Myat A, Galassi AR, Werner GS, et al. Retrograde chronic total occlusion percutaneous coronary interventions: Predictors of procedural success from the ERCTO Registry. JACC Cardiovasc Interv. 2022;15(8):834-842. doi:10.1016/j.jcin.2022.02.013
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