Skip to main content
SpringerLink
Log in

Angiography-derived physiological assessment after percutaneous coronary intervention of chronic total occlusions

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Scant data exploring potential suboptimal physiological results after angiographic successful percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) are available. Sixty cases of successful CTO-PCI were selected for this retrospective analysis. Post-CTO-PCI angiography-based fractional flow reserve was computed using the Murray-based fractional flow reserve (μFR) software. Vessel-specific μFR, residual trans-stent gradient (TSG) and corrected TSGstent were calculated. In physiological suboptimal results (μFR < 0.90), the virtual pullback pressure gradient (PPG) curves were analyzed to localize the main pressure drop-down and characterize the patterns of residual disease. The virtual pullback pressure gradient index (vPPGi) was then calculated to objectively characterize the predominant pattern of residual disease (diffuse vs focal). The physiological result was suboptimal in 28 cases (46.7%). The main pressure drop was localised proximal to the stent in 2 (7.1%), distal in 17 (60.7%) and intra-stent in 9 cases (32.2%). Intra-stent residual disease was diffuse in 7 cases and mixed in 2. Distal residual disease was characterised by a pure focal pattern in 12 cases, diffuse in 2 and mixed in 3. In the predominant diffuse phenotype (vPPGi < 0.65), we found a higher rate of TSG ≥ 0.04 (61.5% vs 20.0%, p = 0.025) and TSGstent ≥ 0.009 (46.2% vs 20.0%, p = 0.017) while in the dominant focal phenotype poor-quality distal vessel was constantly present. In our cohort, post-CTO-PCI suboptimal physiological result was frequent (46.7%). Predominant focal phenotype was constantly associated with poor-quality distal vessel, while in the predominant diffuse phenotype, the rate of TSG ≥ 0.04 and TSGstent ≥ 0.009 were significantly higher.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

CTO:

Chronic total occlusion

μFR:

Murray-based fractional flow reserve

PCI:

Percutaneous coronary intervention

TSG,:

Trans-stent gradient

TSGstent :

Trans-stent gradient adjusted for total stent length

vPPGi:

Virtual pullback pressure gradient

References

  1. Azzalini L, Carlino M, Bellini B et al (2020) Long-term outcomes of chronic total occlusion recanalization versus percutaneous coronary intervention for complex non-occlusive coronary artery disease. Am J Cardiol 125(2):182–188. https://doi.org/10.1016/j.amjcard.2019.10.034

    Article  PubMed  Google Scholar 

  2. Kotsia A, Navara R, Michael TT et al (2015) The AngiographiC Evaluation of the everolimus-eluting stent in Chronic Total Occlusion (ACE-CTO) study. J Invasive Cardiol 27(9):393–400

    PubMed  Google Scholar 

  3. Di Mario C, Mashayekhi KA, Garbo R, Pyxaras SA, Ciardetti N, Werner GS (2022) Recanalisation of coronary chronic total occlusions. EuroIntervention 18(7):535–561. https://doi.org/10.4244/EIJ-D-21-01117

    Article  PubMed  Google Scholar 

  4. Butala NM, Tamez H, Secemsky EA et al (2022) Predicting residual angina after chronic total occlusion percutaneous coronary intervention: insights from the OPEN-CTO registry. J Am Heart Assoc 11(10):e024056. https://doi.org/10.1161/JAHA.121.024056

    Article  PubMed  PubMed Central  Google Scholar 

  5. Biscaglia S, Uretsky B, Barbato E et al (2021) Invasive coronary physiology after stent implantation: another step toward precision medicine. JACC Cardiovasc Interv 14(3):237–246. https://doi.org/10.1016/j.jcin.2020.10.055

    Article  PubMed  Google Scholar 

  6. Biscaglia S, Uretsky BF, Tebaldi M et al (2022) Angio-based fractional flow reserve, functional pattern of coronary artery disease, and prediction of percutaneous coronary intervention result: a proof-of-concept study. Cardiovasc Drugs Ther 36(4):645–653. https://doi.org/10.1007/s10557-021-07162-6

    Article  CAS  PubMed  Google Scholar 

  7. Tu S, Ding D, Chang Y, Li C, Wijns W, Xu B (2021) Diagnostic accuracy of quantitative flow ratio for assessment of coronary stenosis significance from a single angiographic view: a novel method based on bifurcation fractal law. Catheter Cardiovasc Interv 97(Suppl 2):1040–1047. https://doi.org/10.1002/ccd.29592

    Article  PubMed  Google Scholar 

  8. Uretsky BF, Agarwal SK, Vallurupalli S et al (2022) Trans-stent FFR gradient as a modifiable integrant in predicting long-term target vessel failure. JACC Cardiovasc Interv 15(21):2192–2202. https://doi.org/10.1016/j.jcin.2022.08.036

    Article  PubMed  Google Scholar 

  9. Yang H, Lim H, Yoon M et al (2020) Usefulness of the trans-stent fractional flow reserve gradient for predicting clinical outcomes. Cathet Cardio Intervent 95(5):E123–E129. https://doi.org/10.1002/ccd.28363

    Article  Google Scholar 

  10. Collet C, Sonck J, Vandeloo B et al (2019) Measurement of hyperemic pullback pressure gradients to characterize patterns of coronary atherosclerosis. J Am Coll Cardiol 74(14):1772–1784. https://doi.org/10.1016/j.jacc.2019.07.072

    Article  PubMed  Google Scholar 

  11. Dai N, Zhang R, Yuan S et al (2022) Prognostic implications of quantitative flow ratio-derived physiological 2-dimensional residual disease patterns after stenting. JACC Cardiovasc Interv 15(16):1624–1634. https://doi.org/10.1016/j.jcin.2022.06.021

    Article  PubMed  Google Scholar 

  12. Scarsini R, Fezzi S, Pesarini G et al (2022) Impact of physiologically diffuse versus focal pattern of coronary disease on quantitative flow reserve diagnostic accuracy. Catheter Cardiovasc Interv 99(3):736–745. https://doi.org/10.1002/ccd.30007

    Article  PubMed  Google Scholar 

  13. Tebaldi M, Biscaglia S, Fineschi M et al (2018) Evolving routine standards in invasive hemodynamic assessment of coronary stenosis. JACC Cardiovasc Interv 11(15):1482–1491. https://doi.org/10.1016/j.jcin.2018.04.037

    Article  PubMed  Google Scholar 

  14. Azzalini L, Poletti E, Demir OM et al (2019) Impact of post-percutaneous coronary intervention fractional flow reserve measurement on procedural management and clinical outcomes: the REPEAT-FFR study. J Invasive Cardiol 31(8):229–234

    PubMed  Google Scholar 

  15. Collison D, Didagelos M, Aetesam-ur-Rahman M et al (2021) Post-stenting fractional flow reserve vs coronary angiography for optimization of percutaneous coronary intervention (TARGET-FFR). Eur Heart J 42(45):4656–4668. https://doi.org/10.1093/eurheartj/ehab449

    Article  PubMed  PubMed Central  Google Scholar 

  16. Neleman T, Scoccia A, Masdjedi K et al (2022) The prognostic value of angiography-based vessel fractional flow reserve after percutaneous coronary intervention: the FAST outcome study. Int J Cardiol 359:14–19. https://doi.org/10.1016/j.ijcard.2022.04.021

    Article  PubMed  Google Scholar 

  17. Biscaglia S, Tebaldi M, Brugaletta S et al (2019) Prognostic value of QFR measured immediately after successful stent implantation: the international multicenter prospective HAWKEYE study. JACC Cardiovasc Interv 12(20):2079–2088. https://doi.org/10.1016/j.jcin.2019.06.003

    Article  PubMed  Google Scholar 

  18. Keulards DCJ, Vlaar PJ, Wijnbergen I, Pijls NHJ, Teeuwen K (2021) Coronary physiology before and after chronic total occlusion treatment: what does it tell us? Neth Heart J 29(1):22–29. https://doi.org/10.1007/s12471-020-01470-6

    Article  CAS  PubMed  Google Scholar 

  19. Castaldi G, Benedetti A, Zivelonghi C et al (2023) A glimpse into the future of the percutaneous treatment of coronary chronic total occlusions. Minerva Cardiol Angiol. https://doi.org/10.23736/S2724-5683.23.06293-2

    Article  PubMed  Google Scholar 

  20. Tu S, Ding D, Chang Y, Li C, Wijns W, Xu B (2021) Diagnostic accuracy of quantitative flow ratio for assessment of coronary stenosis significance from a single angiographic view: a novel method based on bifurcation fractal law. Catheter Cardiovasc Interv 97(S2):1040–1047. https://doi.org/10.1002/ccd.29592

    Article  PubMed  Google Scholar 

  21. van der Hoeven NW, Janssens GN, de Waard GA et al (2019) Temporal changes in coronary hyperemic and resting hemodynamic indices in nonculprit vessels of patients with ST-segment elevation myocardial infarction. JAMA Cardiol 4(8):736–744. https://doi.org/10.1001/jamacardio.2019.2138

    Article  PubMed  PubMed Central  Google Scholar 

  22. Lauri F, Macaya F, Mejía-Rentería H et al (2020) Angiography-derived functional assessment of non-culprit coronary stenoses in primary percutaneous coronary intervention. EuroIntervention 15(18):e1594–e1601. https://doi.org/10.4244/EIJ-D-18-01165

    Article  PubMed  Google Scholar 

  23. Faria D, Hennessey B, Shabbir A et al (2023) Functional coronary angiography for the assessment of the epicardial vessels and the microcirculation. EuroIntervention 19(3):203–221. https://doi.org/10.4244/EIJ-D-22-00969

    Article  PubMed  Google Scholar 

  24. Scoccia A, Scarparo P, Neleman T et al (2022) Diagnostic accuracy of angiography-based vessel fractional flow reserve after chronic coronary total occlusion recanalization. Catheter Cardiovasc Interv 100(6):964–970. https://doi.org/10.1002/ccd.30439

    Article  PubMed  PubMed Central  Google Scholar 

  25. Erriquez A, Uretsky BF, Brugaletta S et al (2022) Impact of trans-stent gradient on outcome after PCI: results from a HAWKEYE substudy. Int J Cardiovasc Imaging 38(12):2819–2827. https://doi.org/10.1007/s10554-022-02708-7

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium

    Gianluca Castaldi & Johan Bennett

  2. Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium

    Gianluca Castaldi, Alice Benedetti, Enrico Poletti, Alice Moroni, Benjamin Scott, Paul Vermeersch, Carlo Zivelonghi & Pierfrancesco Agostoni

Authors
  1. Gianluca Castaldi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alice Benedetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Enrico Poletti
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alice Moroni
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Benjamin Scott
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Paul Vermeersch
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Carlo Zivelonghi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Johan Bennett
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Pierfrancesco Agostoni
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

GC: study design, collection of data, statistical analyses, drafting of the manuscript. AB, EP, AM, BS, PV, CZ: collection of data, revision of the manuscript. PA, JB: critical revision for important intellectual content, and final approval of the submitted manuscript. Each author agreed to be responsible for the article and agreed on the final manuscript.

Corresponding author

Correspondence to Gianluca Castaldi.

Ethics declarations

Conflict of interest

The authors do not have conflict of interest or funding to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Fig. 1 Flow diagram of the study (TIFF 293 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Castaldi, G., Benedetti, A., Poletti, E. et al. Angiography-derived physiological assessment after percutaneous coronary intervention of chronic total occlusions. Int J Cardiovasc Imaging (2024). https://doi.org/10.1007/s10554-024-03065-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10554-024-03065-3

Keywords

Search

Navigation