Brazilian Interventional Cardiology and Chronic Coronary Occlusions: Where Are We?

Coronary Occlusion/mortality; Coronary Occlusion/therapy; Drug-Eluting Stents; Ultrasonography,Interventional/methods; Coronary Angiography/methods; Diagnostic Imaging/methods

The coronary atherosclerotic disease has several facets of clinical presentation; chronic coronary occlusion (CCO) is one that produces total obstruction of the lumen of the vessel, known or presumed for three months or more. It is present in 16-18% of patients with significant coronary disease.¹

Percutaneous treatment of this type of lesion is almost as old as the first coronary angioplasty performed by Andreas Gruntzig in 1979. Martin Kaltenbach first performed it in Frankfurt in the late 1970s and by Geoffrey Hartzler in Kansas City in the following decades.²,³ Since then, the growing and spectacular incorporation of technology into medicine, especially in Interventional Cardiology, associated with the knowledge and expertise of new techniques dedicated to complex coronary interventions, which include CCO, have allowed great, safe, and effective advances in the approach to these lesions.

Records, documents, articles, and international consensuses are dedicated to this scenario.⁴-⁶ Knowing the national data is extremely important, as it positions us before the international community. It also enables the development of assertive and effective measures and programs dedicated to continuing medical education and the development of policies both in the public sphere and in supplementary health for this type of procedure, which requires not only technical knowledge but also dedicated high-cost devices, not always available.

In the article published here by Botelho da Silva AC et al.⁷ “Overview of percutaneous coronary interventions in chronic total occlusions in centers participating in the LATAM CTO REGISTRY in Brazil”, we have grateful happiness to observe that our country is very well positioned and represented in the face of the most important institutions in the world that are dedicated to the treatment of these obstructions, with similar technical success rates (84% of procedures), adverse events (2.3%) and mortality (0.75%). This first report from medical practice about the recanalization of CCO in 26 centers in Brazil also shows a key factor for our daily clinical practice, which is the exceptional adherence to the clinical indications for this type of procedure: about 95% of the patients had either angina or limiting or documented moderate/severe ischemia.

It is worth noting here, not only for this registry as well as for all others dedicated to this strategy, the low use of intravascular imaging, mainly intravascular ultrasound, used in 10% of the cases in this series, probably due to reimbursement problems both in the public sphere how private. Studies⁸ have shown a significant reduction in combined events (death and infarction) and target vessel revascularization when this tool is used to optimize intervention results and also to help identify and locate the proximal layer when it is ambiguous, as well as in dissection-reentry techniques, increasing the success rates of this procedure.

Brazilian Interventional Cardiology continues to be equated with the largest and best centers in the world, despite any and all limitations that may exist in our complex reimbursement system, whether public or private.

Happy reading to everyone.

Referências

• ¹
  Di Mario, C, Mashayekhi KA, Garbo R. Recanalisation of Coronary Chronic Total Occlusions. Eurointervention. 2022;18(7):535-1. Doi:10.4244/EIJ-D-21-01117
• ²
  Kober G, Hopf R, Reinemer H, Kaltenbach M. Langzeitergebnisse der transluminalen koronaren Angioplastie von chronischen Herzkranzgefässverschlüssen [Longterm results of transluminal coronary angioplasty of chronic coronary artery occlusions]. Z Kardiol. 1985;74(6):309-16.
• ³
  Sievert H, Köhler KP, Kober G, Kaltenbach M. Eröffnung chronischer Koronararterienverschlüsse mit einem Rekanalisationskatheter [Opening of chronic coronary artery occlusions with a recanalization catheter]. [Article in German]. Dtsch Med Wochenschr. 1988;113(44):1703-7. Doi:10.1055/s-2008-1067875
• ⁴
  Wu EB, Brilakis ES, Mashayekhi K, Mashayekhi K, Tsuchikane E, Alaswad K, et al. Global Chronic Total Occlusion Crossing Algorithm: JACC State of- the-Art Review. J Am Coll Cardiol. 2021;78(8):840-53. Doi:10.1016/jacc.2021.05.055
  » https://doi.org/10.1016/jacc.2021.05.055
• ⁵
  Brilakis ES, Mashayekhi K, Tsuchikane E, Muramatsu T, Kishi K, Muto M, et al. A Novel Algorithm for Treating Chronic Total Coronary Artery Occlusion. J Am Coll Cardiol. 2019;74(9):2392-404. Doi:10.1016/j.jacc.2019.08.1049
• ⁶
  Tajti P, Karmpaliotis D, Alaswad K. The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention: Update From the PROGRESS CTO Registry. JACC Cardiovasc Interv. 2018;11(14):1325-35.
• ⁷
  Silva ACB, Paula JET, Campos CM, Ribeiro MH, Martins Filho E, Oliveira MDP, et al. Overview of Percutaneous Coronary Interventions for Chronic Total Occlusions Treated at Brazilian Centers Participating in the LATAM CTO Registry. Arq Bras Cardiol. 2023; 120(4):e20210462.
• ⁸
  Kim BK, Shin DH, Hong MK, Park HS, Rha S-W, Mintz GS, et al. Clinical Impact of Intravascular Ultrasound-Guided Chronic Total Occlusion Intervention With Zotarolimus-Eluting Versus Biolimus-Eluting Stent Implantation: Randomized Study. CTO-IVUS investigator study. Circ Cardiovasc Interv.20158(7):e002592. Doi:10.1161/CIRINTERVENTIONS.115.002592
  » https://doi.org/10.1161/CIRINTERVENTIONS.115.002592

• Short Editorial related to the article: Overview of Percutaneous Coronary Interventions for Chronic Total Occlusions Treated at Brazilian Centers Participating in the LATAM CTO Registry

Publication Dates

• Publication in this collection
  01 May 2023
• Date of issue
  2023