Scoring systems for chronic total occlusion percutaneous coronary intervention: if you fail to prepare you are preparing to fail

1. Coronary artery chronic total
occlusion scores

2. Chronic total
occlusion
• Chronic coronary total
occlusion (CTO) occurs when
either the left main or right
coronary artery — one of the
arteries that delivers oxygen-
rich blood to your heart —
has become completely
blocked or occluded for
three months or longer.
Approximately 15 to 20
percent of people with
coronary artery disease have
a CTO
• Ivanhoe RJ, Weintraub WS,
Douglas JS, Lembo NJ,
Furman M, Gershony G,
Cohen CL, King SB.
Percutaneous transluminal
coronary angioplasty of
chronic total occlusions.
Primary success,
restenosis, and long-term
clinical follow-up.
Circulation. 1992
Jan;85(1):106-15

3. PCI • The success of chronic total
occlusion (CTO)
percutaneous coronary
intervention (PCI)
significantly increased from
77% between 2000 and 2011
1 to 85% to 90% currently at
experienced centers and
depends on center and
operator experience and
lesion characteristics
• Patel VG, Brayton KM,
Tamayo A, Mogabgab O,
Michael TT, Lo N, Alomar
M, Shorrock D, Cipher D,
Abdullah S, et al.
Angiographic success and
procedural complications
in patients undergoing
percutaneous coronary
chronic total occlusion
interventions: a weighted
meta-analysis of 18,061
patients from 65 studies.
JACC Cardiovasc Interv.
2013;6:128-136

4. Japan chronic total occlusion (J-CTO) score
• the Japan chronic total occlusion (J-
CTO) score that estimates the
likelihood of successful guidewire
crossing within the first 30 minutes
based on 5 variables:
1. Blunt stump
2. Calcification
3. Lesion tortuosity
4. Prior failed attempt
5. Occlusion length >=20 mm
• Morino Y, Abe M, Morimoto T,
Kimura T, Hayashi Y, Muramatsu T,
Ochiai M, Noguchi Y, Kato K,
Shibata Y, et al; J-CTO Registry
Investigators. Predicting successful
guidewire crossing through chronic
total occlusion of native coronary
lesions within 30 minutes: the J-
CTO (Multicenter CTO Registry in
Japan) Score as a difficulty grading
and time assessment tool. JACC
Cardiovasc Interv. 2011;4:213-221.

6. PROGRESS-
CTO score
1. moderate/severe
proximal vessel tortuosity
2. proximal cap ambiguity
3. circumflex coronary
artery CTO
4. absence of interventional
collaterals to predict
technical
• Christopoulos G, Kandzari DE,
Yeh RW, Jaffer FA, Karmpaliotis
D, Wyman MR, Alaswad K,
Lombardi W, Grantham JA,
Moses J, et al. Development
and validation of a novel
scoring system for predicting
technical success of chronic
total occlusion percutaneous
coronary interventions: the
PROGRESS CTO (Prospective
Global Registry for the Study of
Chronic Total Occlusion
Intervention) Score. JACC
Cardiovasc Interv. 2016;9:1-9.

7. The EuroCTO
CASTLE score
• 6 variables for assessing the
likelihood of success
1. Prior Coronary artery
bypass graft surgery
2. Age (>=70 years)
3. Stump anatomy
(blunt or invisible)
4. Tortuosity degree
(severe or unseen)
5. Length of occlusion
(>=20 mm)
6. Extent of calcification
(>50% of the
segment)
• Szijgyarto Z, Rampat R,
Werner GS, Ho C, Reifart
N, Lefevre T, Louvard Y,
Avran A, Kambis M,
Buettner HJ, et al.
Derivation and validation
of a chronic total coronary
occlusion intervention
procedural success score
from the 20,000-Patient
EuroCTO Registry: the
EuroCTO (CASTLE) Score.
JACC Cardiovasc Interv.
2019;12:335-342.

9. Conclusion
• the PROGRESS-CTO, the J-CTO, and the CASTLE CTO scores perform
moderately well in predicting the technical success of CTO PCI with
the J-CTO score having the best overall performance