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ORLANDO -- Failing to open a coronary chronic total occlusion (CTO) is associated with worse in-hospital outcomes than successfully passing the guide wire through, a meta-analysis showed.

In pooled results from 18 studies, failed percutaneous coronary intervention (PCI) was associated with higher rates of in-hospital mortality (1.15% versus 0.47%), major adverse cardiovascular events (9.28% versus 4.12%), and urgent CABG (4.92% versus 0.68%), according to Muhammad Fahad Khan, of the Southern Arizona VA Health Care System in Tucson.

The rate of periprocedural myocardial infarction did not differ significantly based on whether the intervention was successful (2.63%) or unsuccessful (3.4%), he reported at the Society for Cardiovascular Angiography and Interventions meeting.

In terms of an explanation for the worse outcomes associated with a failed intervention, he and his colleagues found that cardiac tamponade and coronary perforation were much more frequent when the intervention was not successful.

"What we propose is the careful evaluation of a CTO lesion before you proceed to intervene," Khan said in an interview.

He suggested using the J-CTO score, which was recently developed from a Japanese registry to help predict the likelihood of being able to pass the guide wire through a CTO within 30 minutes. The score consists of five factors, each worth 1 point:

• Calcification
• Bending more than 45 degrees in the CTO segment
• Blunt proximal cap
• Occlusion length more than 20 mm
• Previous failed attempt

The presence of four or five of those characteristics makes it unlikely that an intervention will be successful, he said.

"If you think it's a complex lesion and you are not comfortable with it, you probably need to send it to a high-volume operator or expert center where they regularly perform these types of procedures," Khan said, adding that CABG is another option, as well.

It is known that compared with PCI in non-CTO lesions, interventions for CTOs carry a higher risk, and there is a low chance of success, Khan said. What's unknown, however, is whether a failed CTO intervention is associated with worse patient outcomes around the time of the procedure compared with successful recanalization.

To explore the issue, he and his colleagues identified 18 observational studies that included a total of 10,566 patients with a symptomatic CTO. Of those patients, 73% had a successful intervention.

Successful recanalization was associated with lower risks of in-hospital death (RR 0.35, 95% CI 0.22 to 0.57), inpatient major adverse cardiovascular events (RR 0.46, 95% CI 0.32 to 0.65), and urgent CABG (RR 0.14, 95% CI 0.10 to 0.22, P<0.001 for all).

The analysis of the pooled data also showed higher rates of coronary perforations (6.1% versus 0.90%) and cardiac tamponade (1.5% versus 0%) in patients with unsuccessful CTO PCI.

"We know that a failed CTO intervention is not a benign procedure," Khan said. "It has its consequences."

Researchers need to "continue the development of techniques, approaches, and guide wires to improve the procedure success rate and decrease the vascular complications," he said.

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