Application of the "Hybrid Approach" to Chronic Total Occlusions in a Contemporary Multicenter US Registry

BACKGROUND: The "hybrid" approach to coronary chronic total occlusion (CTO) crossing was developed to optimize procedural efficacy, efficiency, and safety. Current strategies of crossing CTOs include antegrade wire escalation, antegrade dissection re-entry, and the retrograde approach. The "hybrid" approach is an algorithm that, based on angiographic characteristics of the lesion, streamlines the selection of the optimal technique for crossing the CTO. The goal of this study was to analyze the impact of the "hybrid" approach to CTO percutaneous coronary intervention on procedural workflow and outcomes at five high-volume US centers. METHODS: We examined the procedural techniques and outcomes of 489 consecutive CTO cases performed using the "hybrid" approach between 2012 and 2013 at 5 US centers from cities including Appleton WI, Atlanta GA, Bellingham WA, Kansas City MO, and Dallas TX. RESULTS: Mean age was 63.8 ± 9.8 years and 86.9% of the patients were men, with high prevalence of diabetes mellitus (41.7%) and prior coronary artery bypass graft surgery (35.7%). Most target CTOs were located in the right coronary artery (61.5%), followed by the left anterior descending artery (20.9%) and left circumflex (16.8%). Dual injection was used in 73.3%. Overall, antegrade wire escalation was used in 62.8%, antegrade dissection re-entry in 38.9% and retrograde in 44.2%. Among successful cases, the final successful crossing technique was antegrade wire escalation in 40.6%, antegrade dissection and re-entry in 27.5%, and retrograde in 31.9%. The initial crossing strategy was successful in 62.0% of the patients, whereas 35.8% required an additional 1 to 4 crossing strategies. Technical success was achieved in 91.6% and major procedural complications occurred in 1.6%. Mean contrast volume, fluoroscopy time, and air kerma radiation exposure were 297.6 ± 154.7 ml, 48.9 ± 31.4 min, 4.4 ± 3.8 Gray, respectively. CONCLUSION: Application of the "hybrid" approach to CTO crossing resulted in high success and low complication rates among a varied operator group and hospital structure, further supporting the value of the "hybrid" approach in crossing these challenging coronary lesions.