Access the full text.
Sign up today, get DeepDyve free for 14 days.
D. Cutlip, S. Windecker, R. Mehran, A. Boam, D. Cohen, G. Es, P. Steg, M. Morel, L. Mauri, P. Vranckx, E. Mcfadden, A. Lansky, M. Hamon, M. Krucoff, P. Serruys (2007)
Clinical End Points in Coronary Stent Trials: A Case for Standardized DefinitionsCirculation, 115
S. Rathore, H. Matsuo, M. Terashima, Y. Kinoshita, M. Kimura, E. Tsuchikane, K. Nasu, M. Ehara, Y. Asakura, O. Katoh, Takahiko Suzuki (2009)
Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008: impact of novel guidewire techniques.JACC. Cardiovascular interventions, 2 6
(2019)
Two-year clinical outcomes of medical therapy vs. revascularization for patients with coronary chronic total occlusion,”Hellenic
(1998)
and S
C. Godino, G. Bassanelli, F. Economou, K. Takagi, M. Ancona, S. Galaverna, A. Mangieri, V. Magni, A. Latib, A. Chieffo, M. Carlino, M. Montorfano, A. Cappelletti, A. Margonato, A. Colombo (2013)
Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI.International journal of cardiology, 168 2
A. Ladwiniec, V. Allgar, S. Thackray, F. Alamgir, A. Hoye (2015)
Medical therapy, percutaneous coronary intervention and prognosis in patients with chronic total occlusionsHeart, 101
Lei Guo, Shanfeng Zhang, Jian Wu, Lei Zhong, Huaiyu Ding, Jia-ying Xu, Xuchen Zhou, Rongchong Huang (2019)
Successful recanalisation of coronary chronic total occlusions is not associated with improved cardiovascular survival compared with initial medical therapyScandinavian Cardiovascular Journal, 53
R. Wolff, P. Fefer, M. Knudtson, A. Cheema, P. Galbraith, J. Sparkes, G. Wright, H. Wijeysundera, B. Strauss (2016)
Gender differences in the prevalence and treatment of coronary chronic total occlusionsCatheterization and Cardiovascular Interventions, 87
A. Toma, B. Stähli, M. Gick, Miroslaw Ferenc, K. Mashayekhi, H. Buettner, F. Neumann, C. Gebhard (2018)
Temporal changes in outcomes of women and men undergoing percutaneous coronary intervention for chronic total occlusion: 2005–2013Clinical Research in Cardiology, 107
B. Stähli, C. Gebhard, M. Gick, Miroslaw Ferenc, K. Mashayekhi, H. Buettner, F. Neumann, A. Toma (2017)
Comparison of Outcomes in Men Versus Women After Percutaneous Coronary Intervention for Chronic Total Occlusion.The American journal of cardiology, 119 12
H. Gada, P. Whitlow, T. Marwick (2012)
Establishing the cost-effectiveness of percutaneous coronary intervention for chronic total occlusion in stable angina: a decision-analytic modelHeart, 98
Aaas News, E. Lu, Min-Min Zhou, Rong Mocsai, A. Myers, E. Huang, B. Jackson, Davide Ferrari, V. Tybulewicz, V. Lowell, Clifford Lepore, J. Koretzky, Gary Kahn, M. L., F. Achard, H. Eva, Ernst-Detlef Schulze, J. Acharya, U. Acharya, U. Acharya, Shetal Patel, E. Koundakjian, K. Nagashima, Xianlin Han, J. Acharya, D. Adams, Jonathan Horton, Blood, M. Adams, M. McVey, J. Sekelsky, J. Adamson, G. Kochendoerfer, A. Adeleke, A. Kamdem-Toham, Alan Aderem, C. Picard, Aeschlimann, G. Haug, G. Agarwal, M. Scully, H. Aguilaniu, L. Gustafsson, M. Rigoulet, T. Nyström, Asymmetric Inheri, Ferhaan Ahmad, J. Schmitt, M. Aida, S. Ammal, J. Aizenberg, D. Muller, J. Grazul, D. Hamann, J. Ajioka, C. Su, A. Akella, M. Alam, F. Gao, A. Alatas, H. Sinn, Titus Albu, P. Zuev, M. Al-Dayeh, J. Dwyer, A. Al-ghonaium, Sami Al-Hajjar, S. Al-Jumaah, A. Allakhverdov, V. Pokrovsky, Allen, A. Brown, James Allen, A. Brown, James Gillooly, James (1893)
Book ReviewsBuffalo Medical and Surgical Journal, 33
P. Fefer, P. Fefer, M. Knudtson, A. Cheema, P. Galbraith, Azriel Osherov, S. Yalonetsky, Sharon Gannot, M. Samuel, Max Weisbrod, Daniel Bierstone, J. Sparkes, G. Wright, B. Strauss (2012)
Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry.Journal of the American College of Cardiology, 59 11
Lei Guo, Jian Wu, Lei Zhong, Huaiyu Ding, Jia-ying Xu, Xuchen Zhou, Rongchong Huang (2019)
Two-year clinical outcomes of medical therapy vs. revascularization for patients with coronary chronic total occlusion.Hellenic journal of cardiology : HJC = Hellenike kardiologike epitheorese
R. Mehran, B. Claessen, C. Godino, G. Dangas, K. Obunai, Sunil Kanwal, M. Carlino, J. Henriques, C. Mario, Young-Hak Kim, Seung‐Jung Park, G. Stone, M. Leon, J. Moses, A. Colombo (2011)
Long-term outcome of percutaneous coronary intervention for chronic total occlusions.JACC. Cardiovascular interventions, 4 9
William Boden, Robert O’Rourke, Koon Teo, P. Hartigan, D. Maron, William Kostuk, M. Knudtson, Marcin Dada, P. Casperson, Crystal Harris, B. Chaitman, Leslee Shaw, Gilbert Gosselin, Shah Nawaz, Lawrence Title, Gerald Gau, Alvin Blaustein, David Booth, E. Bates, J. Spertus, D. Berman, G. Mancini, William Weintraub (2007)
Optimal medical therapy with or without PCI for stable coronary disease.The New England journal of medicine, 356 15
P. Rattanawong, Tanawan Riangwiwat, W. Vutthikraivit, P. Putthapiban, W. Sukhumthammarat, C. Kanitsoraphan, Pakawat Chongsathidkiet (2018)
GENDER DIFFERENCE AND OUTCOME AFTER PERCUTANEOUS INTERVENTION IN PATIENTS WITH CHRONIC TOTAL OCCLUSION: A SYSTEMATIC REVIEW AND META-ANALYSISJournal of the American College of Cardiology, 71
Gender difference and outcome after percutaneous intervention in patients with chronic total occlusion : a sys - temmatic and meta - analysis
G. Sianos, G. Werner, A. Galassi, Michail Papafaklis, J. Escaned, D. Hildick-Smith, E. Christiansen, A. Gershlick, M. Carlino, A. Karlas, Nikolaos Konstantinidis, S. Tomasello, C. Mario, N. Reifart (2012)
Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club.EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, 8 1
(2016)
Gender differences in the prevalence and treatment of coronary chronic total Journal of Interventional Cardiology 7 occlusions
P. Sirnes, Y. Myreng, P. Mølstad, V. Bonarjee, S. Golf (1998)
Improvement in left ventricular ejection fraction and wall motion after successful recanalization of chronic coronary occlusions.European heart journal, 19 2
(2012)
and T
Lei Guo, Lei Zhong, Kun Chen, Jian Wu, Rongchong Huang (2018)
Long-term clinical outcomes of optimal medical therapy vs. successful percutaneous coronary intervention for patients with coronary chronic total occlusions.Hellenic journal of cardiology : HJC = Hellenike kardiologike epitheorese, 59 5
(2018)
Longterm clinical outcomes of optimal medical therapy vs. successful percutaneous coronary intervention for patients with coronary chronic total occlusions
Vinoda Sharma, W. Wilson, William Smith, M. McEntegart, K. Oldroyd, N. Sidik, A. Bagnall, M. Egred, J. Irving, J. Strange, T. Johnson, S. Walsh, C. Hanratty, J. Spratt (2017)
Comparison of Characteristics and Complications in Men Versus Women Undergoing Chronic Total Occlusion Percutaneous Intervention.The American journal of cardiology, 119 4
Mariama Akodad, M. Spaziano, C. Garcia-Alonso, Y. Louvard, F. Sanguineti, P. Garot, T. Hovasse, T. Unterseeh, B. Chevalier, T. Lefévre, H. Benamer (2019)
Is sex associated with adverse outcomes after percutaneous coronary intervention for CTO?International journal of cardiology, 288
S. Tomasello, M. Boukhris, S. Giubilato, F. Marzá, R. Garbo, G. Contegiacomo, A. Marzocchi, G. Niccoli, A. Gagnor, F. Varbella, A. Desideri, P. Rubartelli, A. Cioppa, G. Baralis, A. Galassi (2015)
Management strategies in patients affected by chronic total occlusions: results from the Italian Registry of Chronic Total Occlusions.European heart journal, 36 45
B. Claessen, A. Chieffo, G. Dangas, C. Godino, Seung‐Whan Lee, K. Obunai, M. Carlino, Vaso Chantziara, Irini Apostolidou, J. Henriques, M. Leon, C. Mario, Seung‐Jung Park, G. Stone, J. Moses, A. Colombo, R. Mehran (2012)
Gender differences in long-term clinical outcomes after percutaneous coronary intervention of chronic total occlusions.The Journal of invasive cardiology, 24 10
L. Shaw, R. Shaw, C. Merz, R. Brindis, L. Klein, Brahmajee Nallamothu, P. Douglas, R. Krone, C. McKay, P. Block, K. Hewitt, W. Weintraub, E. Peterson (2008)
Impact of Ethnicity and Gender Differences on Angiographic Coronary Artery Disease Prevalence and In-Hospital Mortality in the American College of Cardiology–National Cardiovascular Data RegistryCirculation, 117
Adam Saltzman, G. Stone, B. Claessen, Amar Narula, Selene Leon-Reyes, G. Weisz, B. Brodie, B. Witzenbichler, G. Guagliumi, R. Kornowski, D. Dudek, D. Metzger, A. Lansky, E. Nikolsky, G. Dangas, R. Mehran, R. Mehran (2011)
Long-term impact of chronic kidney disease in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial.JACC. Cardiovascular interventions, 4 9
A. Grantham, S. Marso, J. Spertus, ohn House, D. Holmes, B. Rutherford (2009)
Chronic total occlusion angioplasty in the United States.JACC. Cardiovascular interventions, 2 6
Gender differences in the prevalence and treatment of coronary chronic total
S. George, J. Cockburn, T. Clayton, P. Ludman, J. Cotton, J. Spratt, S. Redwood, M. Belder, A. Belder, J. Hill, A. Hoye, N. Palmer, S. Rathore, A. Gershlick, C. Mario, D. Hildick-Smith (2014)
Long-term follow-up of elective chronic total coronary occlusion angioplasty: analysis from the U.K. Central Cardiac Audit Database.Journal of the American College of Cardiology, 64 3
(2016)
Catheterization and Cardiovascular Interventions
P. Steg, N. Greenlaw, J. Tardif, M. Tendera, I. Ford, S. Kääb, H. Abergel, K. Fox, R. Ferrari (2012)
Women and men with stable coronary artery disease have similar clinical outcomes: insights from the international prospective CLARIFY registryEuropean Heart Journal, 33
(2018)
Longterm clinical outcomes of optimal medical therapy vs
S. Rao, Connie Hess, Britt Barham, Laura Aberle, K. Anstrom, Tejan Patel, Jesse Jorgensen, E. Mazzaferri, S. Jolly, A. Jacobs, L. Newby, C. Gibson, D. Kong, R. Mehran, R. Waksman, I. Gilchrist, Brian McCourt, J. Messenger, E. Peterson, R. Harrington, Mitchell Krucoff (2014)
A registry-based randomized trial comparing radial and femoral approaches in women undergoing percutaneous coronary intervention: the SAFE-PCI for Women (Study of Access Site for Enhancement of PCI for Women) trial.JACC. Cardiovascular interventions, 7 8
Hindawi Journal of Interventional Cardiology Volume 2019, Article ID 2017958, 8 pages https://doi.org/10.1155/2019/2017958 Research Article Gender Differences in Long-Term Outcomes of Medical Therapy and Successful Percutaneous Coronary Intervention for Coronary Chronic Total Occlusions Lei Guo, Haichen Lv, Lei Zhong, Jian Wu, Huaiyu Ding, Jiaying Xu, and Rongchong Huang Department of Cardiology, e First Aliated Hospital of Dalian Medical University, Dalian City, China Correspondence should be addressed to Rongchong Huang; rchuang@ccmu.edu.cn Received 1 June 2019; Revised 21 July 2019; Accepted 22 August 2019; Published 10 September 2019 Academic Editor: ach N. Nguyen Copyright © 2019 Lei Guo et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. ere is a paucity of information about the gender diƒerences in clinical outcomes of successful percutaneous coronary intervention (PCI) compared with medical therapy (MT) in patients with coronary chronic total occlusions (CTOs). Objectives. We aimed to investigate the impact of gender on long-term clinical outcomes associated with successful CTO-PCI versus MT in patients with CTOs. Methods. Between January 2007 and December 2016, a total of 1702 patients with ≥1 CTO were enrolled. After exclusion, 1294 patients with 1520 CTOs were analyzed and were divided into the female group (n 304, 23.5%) and the male group (n 990, 76.5%). e patients in the female or male group were assigned to a MT group or successful CTO-PCI group according to the treatment strategy. In the female group, they were divided into two groups: 177 patients in the MT group and 127 patients in the successful CTO-PCI group. In the male group, they were divided into two groups: 623 patients in the MT group and 367 patients in the successful CTO-PCI group. e primary outcome was cardiac death. e secondary outcome was major adverse cardiac event (MACE). Results. e median overall follow-up duration was 3.6 (IQR, 2.1–5.0) years, there were no signiŸcant diƒerences between the MT and successful CTO-PCI groups with respect to the prevalence of cardiac death (MT vs. successful PCI: 6.8% vs. 3.9%, p 0.287) and MACE (20.9% vs. 21.3%, p 0.810) in female patients. In the male group, the occurrence of cardiac death (MT vs. successful PCI: 6.6% vs. 3.8%, p 0.066) was similar between the two groups. e MACE rate (30.0% vs. 18.5%, p < 0.001) was signiŸcantly higher in the MT group. Heart failure (hazard ratio 3.40, 95% conŸdence interval 1.23–9.40, p 0.018) was an independent predictor of cardiac death in female patients. Conclusions. Successful CTO-PCI was not associated with reduced risk of cardiac death compared with medical therapy alone in both female and male patients. However, men have a signiŸcant reduction in MACE rate after successful CTO-PCI. Aggressive CTO-PCI should be considered carefully among female patients. diagnostic angiography [3, 4]. Most studies reported that 1. Introduction successful CTO percutaneous coronary intervention (PCI) Gender diƒerences have long been known to exist in the is associated with symptomatic relief of angina, improve- presentation and outcome of coronary artery disease (CAD). ment in left ventricular function, quality of life, and a Multiple studies indicate that female patients are less likely reduction in mortality compared with failed CTO-PCI than male to be referred for invasive coronary angiography [5–7]. However, only approximately 10%–20.7% of CTOs and to undergo revascularization, despite almost the same are currently undergoing attempted CTO-PCI [3, 8], prevalence of coronary disease [1, 2]. mainly because CTO-PCI procedures may be with rela- Chronic total occlusions (CTOs) represent an impor- tively lower success rate, a higher risk of complication, and tant and unique subgroup of coronary lesions and have higher expense when compared with non-CTO elective PCI been identiŸed in up to 18% of all patients referred for [9, 10]. Indeed, a substantial portion of CTO patients are 2 Journal of Interventional Cardiology treated with medical therapy (MT) alone instead of PCI cardiologists and the patients and their family members’. [11, 12]. "e baseline clinical and procedural characteristics were collected from the dedicated database and medical records. Female patients with CTOs have a greater incidence of comorbidities and a higher risk of intraoperative and Clinical end points were obtained from clinical hospital postoperative complications compared with male patients records, visits, or telephone contacts with living patients or [13–15]. "erefore, clinicians are more likely to treat these family members. "e institutional review board approved female patients who have CTOs with MT alone, and a the present study. previous study also reported female patients have the lowest rate of revascularization [16]. However, current CTO studies 2.2. Treatment Strategy. MT comprised the use of anti- are typically comprised of less than 20% female patients, platelet medication, aggressive lipid-lowering therapy, which is in accordance with the overall low inclusion of blockade of the rennin-angiotensin system, β-blockers, and women in cardiovascular registries and randomized trials nitrates. Coronary interventions were performed according relevant to CTO [3, 13, 14], and there is relative paucity of to standard techniques. Beginning at least 24 hours before information about the gender differences in clinical out- the procedure, all patients were prescribed a loading dose of comes of successful CTO-PCI compared with MT for CTO aspirin (300 mg) and/or clopidogrel (300 mg) before PCI. patients. Moreover, most studies only focused on the out- For patients with more than one CTO, only one CTO vessel comes between successful and failed CTO-PCI, the patients was targeted and no further attempt was made during the who undergo MT alone and did not undergo a CTO-PCI study period. After the procedure, a dual antiplatelet therapy attempt were rarely considered previously [17]. "erefore, with aspirin (100 mg/day) and clopidogrel (75 mg/day) was this study aimed to investigate the impact of gender on long- prescribed at least 12 months. All patients underwent two- term clinical outcomes associated with successful CTO-PCI dimensional echocardiography. In presence of normal wall versus MT in patients with CTOs. motion in the territory supplied by the CTO artery, no further viability testing was performed. 2. Methods 2.1. Study Population. "e present study was a retrospective 2.3. Definitions and Study Outcomes. A “CTO lesion” was observational study. A total of 16224 patients who un- defined as an obstruction of a native coronary artery with a derwent diagnostic coronary angiography from January thrombolysis in myocardial infarction (TIMI) flow grade of 2007 to December 2016 were included at the First Affiliated 0 on angiography and estimated duration of>3 months [5]. Hospital of Dalian Medical University (Dalian, China) [18]. A successful PCI was defined as a final residual stenosis Of these patients, 1702 had at least one CTO. 47 patients who <20%, with a TIMI grade flow ≥2 after stent implantation. underwent previous CABG and presented with acute "e primary endpoint was the incidence of cardiac death myocardial infarction within 48 h were excluded. Among the during follow-up after PCI. "e secondary endpoint was 1655 patients, those who underwent CABG and failed CTO- major adverse cardiac event (MACE), defined as the com- PCI were excluded. "us, 1294 patients with at least one posite of cardiac death, myocardial infarction (MI), and CTO were included for analysis (Figure 1). Patients were target vessel revascularization (TVR). Cardiac death was grouped into the female group and the male group. "e defined as a death due to cardiovascular cause in absence of patients in the female group or male group were assigned to established cardiovascular etiology. MI was defined as an a MT group or successful CTO-PCI group according to the elevation of creatine kinase-MB fraction or troponin-T/ treatment strategy. Initial PCI or MT was selected according troponin-I greater than the upper limit of normal with to the presence of symptoms, high comorbidity or high risk concomitant ischemic symptoms or electrocardiographic for revascularization, the suitability of the target distal vessel findings indicative of ischemia. TVR was defined as repeat for revascularization (diameter> 2.5 mm), and patients’ revascularization of a CTO vessel [18, 19]. economic burden [18]. In asymptomatic patients who did not have viability data available or in subjects with proved absence of viability, MT was strongly preferred. In symp- 2.4. Statistical Analysis. Data are presented as percentages and mean± standard or median (IQR) as appropriate. tomatic patients, even without information on viability or in asymptomatic patients with viability, PCI was preferred. "e Categorical data were tested with the chi-square test or decision to perform PCI for CTO patients was also de- Fisher’s exact test. Continuous variables were compared pendent on several factors, including LV function, the extent using the Student’s t-test or Mann–Whitney U test. Event- of other coronary artery disease, CTO location, and tech- free survival was calculated using the Kaplan–Meier method nical difficulty. However, several other factors, including and compared with the log-rank test. Cox proportional patient preference and their family members’ willing and hazards methods were used to estimate the independent their economic burden and doctors’ assessment, also effect of multiple independent variables on the risk of cardiac influenced the final decision of the management strategy. death. Univariate variables with p values< 0.05 were in- cluded in the multivariate model. All tests were two-tailed. A "e cost of CTO-PCI was at least thirty to fifty thousand yuan (nearly 4.3 to 7.2 thousand dollars) in our hospital and p value of<0.05 was considered significant. SPSS version 24 software (IBM, New York, USA) was used for statistical was relatively high for some families. "e decision to per- form CTO-PCI was at the discretion of the interventional analysis. Journal of Interventional Cardiology 3 Total patients who underwent coronary angiography N = 16224 Patients with at least 1 CTO N = 1702 Acute STEMI within 48 h or previous CABG N =47 Study patients N = 1655 CABG Failed PCI N = 121 N = 240 Study patients N = 1294 Male Female N = 990 N = 304 Successful PCI Medical therapy Successful PCI Medical therapy N = 367 N = 623 N = 127 N = 177 Figure 1: Flow chart of the study population. CABG, coronary artery bypass grafting; CTO, chronic total occlusion; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction. had previous MI, CKD, taking clopidogrel. Branched CTO, 3. Results CTO of left circumflex coronary artery (LCX), blunt stump, 3.1. Baseline Characteristics. After exclusion, a total of 1294 high J-CTO score, and SYNTAX score were presented more patients with 1520 CTOs were enrolled in this study. "e frequently in patients in the MTgroup compared with patients female group included 304 (23.5%) patients, and the male in the successful PCI group. In the male group, as compared group included 990 (76.5%) patients. In the female group, with patients referred for successful PCI, those referred for MT they were divided into two groups: 177 in the MTgroup and were older and more likely to have previous MI, CKD, heart 127 patients in the successful PCI group. In the male group, failure, branched CTO, CTO of LCX, blunt stump, and cal- they were divided into two groups: 623 in the MTgroup and cification, with high J-CTO score and SYNTAX score, but low 367 patients in the successful PCI group (Figure 1). left ventricular ejection fraction (LVEF), and were less likely to Table 1 shows the baseline, angiographic, and procedural have CTO of the left ascending coronary artery. characteristics and in-hospital outcome of the enrolled patients. Compared to male patients, female patients were older and had more frequently hypertension, diabetes 3.2. Clinical Outcomes. "e median overall follow-up du- mellitus, dyslipidemia, and chronic kidney disease (CKD) ration was 3.6 (IQR, 2.1–5.0) years. In the female group, no and were less likely to have smokers, previous MI, and significant differences were observed between the MT and previous PCI. Women presented with less lesion bending successful CTO-PCI groups in terms of cardiac death (MT (>45 ) and other angiographic and procedural characteris- vs. successful PCI: 6.8% vs. 3.9%, p � 0.287) and MACE tics were similar between the two groups. As for procedural (20.9% vs. 21.3%, p � 0.810). In the male group, the oc- complications and in-hospital outcomes, there were no currence of cardiac death (MT vs. successful PCI: 6.6% vs. significant differences in the prevalence of coronary dis- 3.8%, p � 0.066) was comparable between the two groups. section, coronary perforation, and in-hospital death. "e MACE rate (30.0% vs. 18.5%, p< 0.001) was signifi- Table 2 shows the baseline clinical, angiographic, and cantly higher in MT group (Table 3) (Figure 2). procedural characteristics of female and male patients in the "ere was no significant interaction between gender and medical therapy and successful PCI groups. In the female treatment strategy in terms of cardiovascular mortality group, patients in the MT group were older and more often (p � 0.106). "e cardiovascular survival benefit after 4 Journal of Interventional Cardiology Table 1: Baseline clinical, angiographic, and procedural charac- 4. Discussion teristics and in-hospital outcome in female and male patients with CTOs. We compared the long-term clinical outcomes of medical therapy versus successful CTO-PCI in female and male Female Male p patients with CTOs. "e main findings of our study are as (n � 304) (n � 990) value follows: (1) only 23.5% of the patients with CTOs were Age, years 68.3± 8.5 62.8± 10.5 <0.001 female; (2) female patients were significantly older and had Smoking (%) 21 (6.9) 506 (51.1) <0.001 more frequent hypertension, diabetes mellitus, dyslipidemia, Hypertension (%) 246 (80.9) 634 (64.0) <0.001 and CKD; (3) successful CTO-PCI was not associated with a Diabetes mellitus (%) 145 (47.7) 319 (32.2) <0.001 reduced risk of cardiovascular mortality or MACE as Dyslipidemia (%) 235 (77.3) 693 (70.0) 0.008 Familial history of CAD compared with MT alone in female patients with CTOs; (4) 31 (10.2) 118 (11.9) 0.238 (%) successful CTO-PCI was associated with a lower rate of Previous MI (%) 120 (39.5) 481 (48.6) 0.003 MACE as compared with MT alone in male patients with Previous PCI (%) 34 (11.2) 157 (15.9) 0.024 CTOs. To the best of our knowledge, this is one of the largest CKD (%) 40 (13.2) 69 (7.0) 0.001 studies to compare the impact of gender on long-term Heart failure (%) 54 (17.8) 178 (18.0) 0.914 clinical outcomes associated with successful CTO-PCI LVEF (%) 53.5± 8.5 52.5± 9.3 0.121 versus MT in unselected CTO patients. Baseline medication Only a small minority of patients (23.5%) in the current Aspirin (%) 299 (98.4) 970 (98.0) 0.677 study were female which was consistent with previous Clopidogrel (%) 280 (92.1) 920 (92.9) 0.628 studies [13, 15]. In this high-risk patient cohort with ad- Statin (%) 287 (94.4) 945 (95.5) 0.455 β blocker (%) 235 (77.3) 757 (76.5) 0.763 vanced CAD, female patients were on average older than ACEI or ARB (%) 203 (66.8) 627 (63.3) 0.274 male patients when they first undergo invasive cardiovas- One CTO lesion (%) 268 (88.2) 840 (84.8) 0.150 cular procedures, presumably due to the potentiating pro- Two CTO lesions (%) 33 (10.9) 140 (14.1) 0.141 tective effects of oestrogen against coronary atherosclerosis LAD (%) 101 (33.2) 358 (36.2) 0.349 until menopause, so the CAD process may be delayed. LCX (%) 86 (28.3) 278 (28.1) 0.944 Furthermore, female patients were more frequently pre- RCA (%) 143 (47.0) 482 (48.7) 0.615 sented with hypertension, diabetes mellitus, dyslipidemia, Multivessel disease (%) 246 (80.9) 808 (81.6) 0.710 and CKD which increase the risks associated with PCI, and Proximal or mid these multiple comorbidities probably explain the low CTO location (%) 225 (74.0) 755 (76.3) 0.424 percentage of women recorded in our study as well as in Branched CTO 45 (14.8) 145 (14.6) 0.946 Blunt stump (%) 134 (44.1) 465 (47.0) 0.377 other studies [7, 16, 19, 20]. In addition, female patients have Calcification (%) 69 (22.7) 188 (19.0) 0.156 more intraoperative and postoperative complications, in- Bending >45 (%) 121 (39.8) 465 (47.0) 0.028 cluding coronary perforation, bleeding, and contrast-in- Length ≥20 mm (%) 175 (57.6) 629 (63.5) 0.061 duced nephropathy [15, 21]. "erefore, some interventional J-CTO score 1.59± 1.24 1.74± 1.12 0.162 cardiologists were less often to perform CTO-PCI in female SYNTAX score 20.1± 7.6 22.5± 8.7 0.073 patients [16]. Contrast volume (ml) 177± 81 179± 88 0.977 According to the Clinical Outcomes Utilizing Re- Number of stents 1.34± 0.68 1.37± 0.70 0.995 vascularization and Aggressive Drug Evaluation (COUR- Total stent length (mm) 38.1± 21.3 37.7± 22.6 0.758 AGE) trial, which conducted in patients with stable CAD, Coronary dissection (%) 0 2 (0.2) 0.999 PCI was not associated with reducing the risk of death or Coronary perforation (%) 1 (0.3) 1 (0.1) 0.999 other MACE when added to optimal medical therapy [22]. In-hospital death (%) 1 (0.3) 6 (0.6) 0.999 Similarly, our study also suggested that successful CTO-PCI Values are presented as the mean± standard deviation or n (%). ACEI, did not reduce the prevalence of cardiac death in patients angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; CAD, coronary artery disease; CKD, chronic kidney disease; CTO, with CTOs probably because a large part of our cohort had chronic total occlusion; J-CTO, Japanese-chronic total occlusion; LAD, left stable coronary disease, and a similar study population was ascending coronary artery; LCX, left circumflex coronary artery; LVEF, left also included in the COURAGE trial. ventricular ejection fraction; MI, myocardial infarction; PCI, percutaneous Several studies had compared the clinical outcomes of coronary intervention; RCA, right coronary artery. successful CTO-PCI with failed PCI among female patients with CTOs, and had mainly shown a better outcome with successful PCI was similar in female and male patients regard to successful PCI [13, 23]. In our study, patients in the (Figure 3). MT group did not undergo a CTO-PCI attempt, a pop- Table 4 shows independent predictors of cardiac death in ulation that has not been considered previously [17, 18]. female and male patients. After multivariate analysis, heart Accordingly, in contrast to previous studies, our study better failure (hazard ratio [HR] 3.40, 95% confidence interval [CI] reflects the overall risk and clinical significance of PCI 1.23–9.40, p � 0.018) was associated with a higher cardiac compared with medical therapy alone in patients with death rate in female patients; age (per-year increment) (HR coronary CTOs [18]. 1.07, 95% CI 1.04–1.11, p< 0.001) and calcification (HR 3.57, Until now, due to the relative paucity of literature re- 95% CI 2.05–6.25, p< 0.001) were independent predictors of garding sex-related differences in CTO outcomes, clinical cardiac death in male patients. outcome of CTO-PCI in this population is unknown. In the Journal of Interventional Cardiology 5 Table 2: Baseline clinical, angiographic, and procedural characteristics of female and male patients in the medical therapy and successful PCI groups. Female Male Medical therapy Successful PCI p value Medical therapy (n � 623) Successful PCI (n � 367) p value (n � 177) (n � 127) Age, years 69.6± 8.5 66.6± 8.2 0.001 63.5± 10.8 61.8± 9.9 0.014 Smoking (%) 11 (6.2) 10 (7.9) 0.574 315 (50.6) 191 (52.0) 0.652 Hypertension (%) 140 (79.1) 106 (83.5) 0.339 408 (65.5) 226 (61.6) 0.216 Diabetes mellitus (%) 91 (51.4) 54 (42.5) 0.126 199 (31.9) 120 (32.7) 0.806 Dyslipidemia (%) 140 (79.1) 95 (74.8) 0.407 437 (70.1) 256 (69.8) 0.901 Familial history of CAD (%) 15 (8.5) 16 (12.6) 0.241 78 (12.5) 40 (10.9) 0.447 Previous MI (%) 80 (45.2) 40 (31.5) 0.016 326 (52.3) 155 (42.2) 0.002 Previous PCI (%) 20 (11.3) 14 (11.0) 0.940 96 (15.4) 61 (16.6) 0.637 CKD (%) 30 (16.9) 10 (7.9) 0.022 53 (8.5) 16 (4.4) 0.011 Heart failure (%) 37 (20.9) 17 (13.4) 0.091 133 (21.3) 45 (12.3) <0.001 LVEF (%) 52.7± 9.3 54.7± 7.2 0.338 51.4± 9.6 54.3± 8.3 <0.001 Baseline medication Aspirin (%) 174 (98.3) 125 (98.4) 0.935 609 (97.8) 361 (98.4) 0.508 Clopidogrel (%) 158 (89.3) 122 (96.1) 0.030 572 (91.8) 348 (94.8) 0.074 Statin (%) 167 (94.4) 120 (94.5) 0.959 591 (94.9) 354 (96.5) 0.245 β blocker (%) 132 (74.6) 103 (81.1) 0.180 480 (77.0) 277 (75.5) 0.574 ACEI or ARB (%) 118 (66.7) 85 (66.9) 0.962 405 (65.0) 222 (60.5) 0.154 One CTO lesion (%) 157 (88.7) 111 (87.4) 0.730 528 (84.8) 312 (85.0) 0.911 Two CTO lesions (%) 18 (10.2) 15 (11.8) 0.650 88 (14.1) 52 (14.2) 0.985 LAD (%) 56 (31.6) 45 (35.4) 0.488 207 (33.2) 151 (41.1) 0.012 LCX (%) 58 (32.8) 28 (22.0) 0.041 198 (31.8) 80 (21.8) 0.001 RCA (%) 81 (45.8) 62 (48.8) 0.599 309 (49.6) 173 (47.1) 0.455 Multivessel disease (%) 141 (79.7) 105 (82.7) 0.509 511 (82.0) 297 (80.9) 0.667 Proximal or mid CTO location (%) 126 (71.2) 99 (78.0) 0.185 482 (77.4) 373 (74.4) 0.287 Branched CTO 33 (18.6) 12 (9.5) 0.026 104 (16.7) 41 (11.2) 0.018 Blunt stump (%) 95 (53.7) 39 (30.7) <0.001 333 (53.5) 132 (36.0) <0.001 Calcification (%) 46 (26.0) 23 (18.1) 0.106 144 (23.1) 44 (12.0) <0.001 Bending >45 (%) 72 (40.7) 49 (38.6) 0.713 296 (47.5) 169 (46.0) 0.656 Length ≥20 mm (%) 108 (61.0) 67 (52.8) 0.151 401 (64.4) 228 (62.1) 0.479 J-CTO score 1.75± 1.29 1.37± 1.13 0.017 1.87± 1.21 1.52± 1.06 <0.001 SYNTAX score 21.7± 7.2 18.4± 7.8 0.046 23.7± 9.3 20.1± 6.9 0.003 Contrast volume (ml) 144± 67 222± 77 <0.001 148± 73 230± 87 <0.001 Number of stents 0 1.34± 0.68 — 0 1.37± 0.77 — Total stent length (mm) 0 38.1± 21.3 — 0 37.7± 22.6 — Values are presented as the mean± standard deviation or n (%). ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; CAD, coronary artery disease; CKD, chronic kidney disease; CTO, chronic total occlusion; J-CTO, Japanese-chronic total occlusion; LAD, left ascending coronary artery; LCX, left circumflex coronary artery; LVEF, left ventricular ejection fraction; MI, myocardial infarction; PCI, percutaneous coronary intervention; RCA, right coronary artery. Table 3: Clinical outcomes in female and male patients during follow-up. Female Male Medical therapy Successful PCI (n � 127) p value Medical therapy (n � 623) Successful PCI (n � 367) p value (n � 177) Cardiac death (%) 12 (6.8) 5 (3.9) 0.287 41 (6.6) 14 (3.8) 0.066 MI (%) 13 (7.3) 8 (6.3) 0.723 52 (8.3) 22 (6.0) 0.174 TVR (%) 17 (9.6) 16 (12.6) 0.408 119 (19.1) 49 (13.4) 0.020 MACE (%) 37 (20.9) 28 (21.3) 0.810 187 (30.0) 68 (18.5) <0.001 Values are presented as n (%). MACE, major adverse cardiovascular events; MI, myocardial infarction; PCI, percutaneous coronary intervention; TVR, target vessel revascularization. present study, we found that successful PCI is not associated consistent with the finding of previous studies [1, 2]. Our with reduced prevalence of cardiac death, as compared with previous study also suggested that successful CTO-PCI did MT alone among female and male patients with CTOs, not reduce cardiac death or MACE compared with MT 6 Journal of Interventional Cardiology 100 100 p = 0.087 p < 0.001 p = 0.195 p = 0.829 70 50 02468 02468 Years Years Men-successful PCI Women-successful PCI Men-successful PCI Women-successful PCI Men-medical therapy Women-medical therapy Men-medical therapy Women-medical therapy (a) (b) Figure 2: Kaplan–Meier curves for cardiac death (a) and MACE (b) during follow-up for successful CTO-PCI versus medical therapy in male and female patients. CTO, chronic total occlusion; MACE, major adverse cardiovascular events; PCI, percutaneous coronary intervention. HR (95% CI) p value p value for interaction Female 0.51 (0.18 – 1.45) 0.204 (n = 304) 0.106 Male 0.59 (0.32 – 1.09) 0.092 (n = 990) 0.125 0.25 0.5 1 2 Medical therapy better Successful PCI better Figure 3: Sex subgroup analysis for cardiovascular mortality. CI, confidence interval(s); HR, hazard ratio; PCI, percutaneous coronary intervention. Table 4: Multivariable predictors of cardiac death in female and score and were also unsuitable for PCI. "ese findings male patients. suggest that, considering multiple comorbidities, the high prevalence of intraoperative and postoperative complica- HR (95% CI) p value tions and prognosis, as well as high expense, aggressive Female CTO-PCI should be considered carefully in female patients Heart failure 3.40 (1.23–9.40) 0.018 with coronary CTOs. CKD 2.10 (0.69–6.39) 0.190 Interestingly, the present study showed only a reduced Male Age (per-year increment) 1.07 (1.04–1.11) <0.001 MACE after successful CTO-PCI in male patients, which Calcification 3.57 (2.05–6.25) <0.001 was in accordance with previous one [25]. One possible Heart failure 1.58 (0.86–2.91) 0.139 explanation may be the relatively small sample size of the CKD 1.68 (0.83–3.41) 0.146 female cohort in this study. Moreover, a previous study from CI, confidence interval(s); CKD, chronic kidney disease; HR, hazard ratio. the multinational CTO registry and meta-analysis had turned out that gender was not independently associated with adverse outcomes [26, 27]. [11, 24]. Furthermore, there was also no significant re- Several limitations should be taken into consideration. duction in MACE rate after successful CTO-PCI in female First, this was not a randomized trial and selection bias could patients. "ose female patients who had medical therapy have occurred. Second, a relatively low number of women alone tended to be older and more often had CKD, CTO of were included. "ird, the amount of viable myocardium was left LCX, blunt stump, high J-CTO score, and SYNTAX not routinely evaluated, which may affect the results. "e Survival free from cardiac death (%) Survival free from MACE (%) Journal of Interventional Cardiology 7 disease prevalence and in-hospital mortality in the American expense of the test was relatively high for most families, and college of cardiology-national cardiovascular data registry,” many CTO patients refused to accept the test, even after Circulation, vol. 117, no. 14, pp. 1787–1801, 2008. doctors’ explanation. However, all patients in this study [3] P. Fefer, M. L. Knudtson, A. N. Cheema et al., “Current underwent two-dimensional echocardiography which was perspectives on coronary chronic total occlusions the Ca- relatively cheap and acceptable for most patients and we nadian multicenter chronic total occlusions registry,” Journal used it to evaluate LV function. In presence of normal wall of the American College of Cardiology, vol. 59, no. 11, motion in the territory subtended by the CTO artery, no pp. 991–997, 2012. further viability testing was performed. Fourth, since this [4] J. A. Grantham, S. P. Marso, J. Spertus, J. House, was a retrospective cohort study, routine collection of D. R. Holmes, and B. D. Rutherford, “Chronic total occlusion postprocedural cardiac enzymes was not performed in every angioplasty in the United States,” JACC: Cardiovascular In- patient from the study beginning, only in the case that terventions, vol. 2, no. 6, pp. 479–486, 2009. patients suffered intraoperative myocardial or vascular in- [5] G. Sianos, G. S. Werner, A. R. Galassi et al., “Recanalisation of chronic total coronary occlusions: 2012 consensus document jury or were present with sustained angina after operation. from the EuroCTO club,” EuroIntervention, vol. 8, no. 1, However, postoperative electrocardiogram was performed pp. 139–145, 2012. in every patient. Randomized controlled trials are needed to [6] P. Sirnes, Y. Myreng, P. Mølstad, V. Bonarjee, and S. Golf, investigate clinical outcomes of medical therapy and suc- “Improvement in left ventricular ejection fraction and wall cessful percutaneous coronary intervention in both female motion after successful recanalization of chronic coronary and male patients. occlusions,” European Heart Journal, vol. 19, no. 2, pp. 273– 281, 1998. 5. Conclusions [7] S. George, J. Cockburn, T. C. Clayton et al., “Long-term follow-up of elective chronic total coronary occlusion an- A minority of CTO patients (23.5%) were women. Successful gioplasty analysis from the UK central cardiac audit database,” CTO-PCI was not associated with reduced the risk of cardiac Journal of the American College of Cardiology, vol. 64, no. 3, death compared with medical therapy alone in both female pp. 235–243, 2014. and male patients. However, successful CTO-PCI reduced [8] A. Ladwiniec, V. Allgar, S. "ackray, F. Alamgir, and A. Hoye, the rate of MACE in male patients. Aggressive CTO-PCI “Medical therapy, percutaneous coronary intervention and should be considered carefully among female patients. prognosis in patients with chronic total occlusions,” Heart, vol. 101, no. 23, pp. 1907–1914, 2015. Larger randomized controlled trials are needed to support [9] S. Rathore, H. Matsuo, M. Terashima et al., “Procedural and these findings. in-hospital outcomes after percutaneous coronary in- tervention for chronic total occlusions of coronary arteries Data Availability 2002 to 2008 impact of novel guidewire techniques,” JACC: Cardiovascular Interventions, vol. 2, no. 6, pp. 489–497, 2009. "e data used to support the findings of this study are [10] H. Gada, P. L. Whitlow, and T. H. Marwick, “Establishing the available from the corresponding author upon request. cost-effectiveness of percutaneous coronary intervention for chronic total occlusion in stable angina: a decision-analytic Conflicts of Interest model,” Heart, vol. 98, no. 24, pp. 1790–1797, 2012. [11] L. Guo, L. Zhong, K. Chen, J. Wu, and R.-C. Huang, “Long- "e authors declare that they have no conflicts of interest. term clinical outcomes of optimal medical therapy vs. suc- cessful percutaneous coronary intervention for patients with Authors’ Contributions coronary chronic total occlusions,” Hellenic Journal of Car- diology, vol. 59, no. 5, pp. 281–287, 2018. Lei Guo and Haichen Lv contributed equally to this study. [12] S. D. Tomasello, M. Boukhris, S. Giubilato et al., “Management strategies in patients affected by chronic total occlusions: results Acknowledgments from the Italian registry of chronic total occlusions,” European Heart Journal, vol. 36, no. 45, pp. 3189–3198, 2015. "e authors acknowledge and thank Ying Liu and Kun Chen [13] B. E. Stahli, ¨ C. Gebhard, M. Gick et al., “Comparison of for their invaluable assistance. "is study was supported by the outcomes in men versus women after percutaneous coronary China Cardiovascular Disease Alliance VG Youth Fund Project intervention for chronic total occlusion,” e American (no. 2017-CCA-VG-046), Beijing United Heart Foundation Journal of Cardiology, vol. 119, no. 12, pp. 1931–1936, 2017. (no. BJUHFCSOARF201801-02), and Beijing Lisheng Car- [14] B. E. Claessen, A. Chieffo, G. D. Dangas et al., “Gender differences in long-term clinical outcomes after percutaneous diovascular Health Foundation (no. LHJJ20158521). coronary intervention of chronic total occlusions,” e Journal of Invasive Cardiology, vol. 24, no. 10, pp. 484–488, References [1] P. G. Steg, N. Greenlaw, J.-C. Tardif et al., “Women and men [15] V. Sharma, W. Wilson, W. Smith et al., “Comparison of characteristics and complications in men versus women un- with stable coronary artery disease have similar clinical outcomes: insights from the international prospective dergoing chronic total occlusion percutaneous intervention,” e American Journal of Cardiology, vol. 119, no. 4, pp. 535– CLARIFY registry,” European Heart Journal, vol. 33, no. 22, pp. 2831–2840, 2012. 541, 2017. [16] R. Wolff, P. Fefer, M. L. Knudtson et al., “Gender differences [2] L. J. Shaw, R. E. Shaw, C. N. B. Merz et al., “Impact of ethnicity and gender differences on angiographic coronary artery in the prevalence and treatment of coronary chronic total 8 Journal of Interventional Cardiology occlusions,” Catheterization and Cardiovascular In- terventions, vol. 87, no. 6, pp. 1063–1070, 2016. [17] C. Godino, G. Bassanelli, F. I. Economou et al., “Predictors of cardiac death in patients with coronary chronic total occlu- sion not revascularized by PCI,” International Journal of Cardiology, vol. 168, no. 2, pp. 1402–1409, 2013. [18] L. Guo, J. Wu, L. Zhong et al., “Two-year clinical outcomes of medical therapy vs. revascularization for patients with cor- onary chronic total occlusion,” Hellenic Journal of Cardiology, [19] D. E. Cutlip, S. Windecker, R. Mehran et al., “Clinical end points in coronary stent trials a case for standardized defi- nitions,” Circulation, vol. 115, no. 17, pp. 2344–2351, 2007. [20] A. J. Saltzman, G. W. Stone, B. E. Claessen et al., “Long-term impact of chronic kidney disease in patients with ST-segment elevation myocardial infarction treated with primary percu- taneous coronary intervention the horizons-ami (harmo- nizing outcomes with revascularization and stents in acute myocardial infarction) trial,” JACC: Cardiovascular In- terventions, vol. 4, no. 9, pp. 1011–1019, 2011. [21] S. V. Rao, C. N. Hess, B. Barham et al., “A registry-based randomized trial comparing radial and femoral approaches in women undergoing percutaneous coronary intervention: the SAFE-PCI for women (study of access site for enhancement of PCI for women) trial,” JACC: Cardiovascular Interventions, vol. 7, no. 8, pp. 857–867, 2014. [22] W. E. Boden, R. A. O’Rourke, K. K. Teo et al., “Optimal medical therapy with or without PCI for stable coronary disease,” New England Journal of Medicine, vol. 356, no. 15, pp. 1503–1516, 2007. [23] M. Akodad, M. Spaziano, C. J. Garcia-Alonso et al., “Is sex associated with adverse outcomes after percutaneous coro- nary intervention for CTO?,” International Journal of Car- diology, vol. 288, pp. 29–33, 2019. [24] L. Guo, S. F. Zhang, J. Wu et al., “Successful recanalisation of coronary chronic total occlusions is not associated with improved cardiovascular survival compared with initial medical therapy,” Scandinavian Cardiovascular Journal, 2019. [25] A. Toma, B. E. Stahli, ¨ M. Gick et al., “Temporal changes in outcomes of women and men undergoing percutaneous coronary intervention for chronic total occlusion: 2005– 2013,” Clinical Research in Cardiology, vol. 107, no. 6, pp. 449–459, 2018. [26] R. Mehran, B. E. Claessen, C. Godino et al., “Long-term outcome of percutaneous coronary intervention for chronic total occlusions,” JACC: Cardiovascular Interventions, vol. 4, no. 9, pp. 952–961, 2011. [27] P. Rattanawong, T. Riangwiwat, W. Vutthikraivit et al., “Gender difference and outcome after percutaneous in- tervention in patients with chronic total occlusion: a sys- temmatic and meta-analysis,” Journal of the American College of Cardiology, vol. 71, no. 11, p. 1057, 2018. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Hindawi Publishing Corporation Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 http://www www.hindawi.com .hindawi.com V Volume 2018 olume 2013 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 International Journal of Journal of Immunology Research Endocrinology Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Submit your manuscripts at www.hindawi.com BioMed PPAR Research Research International Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2013 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Neurology Research and Treatment Cellular Longevity Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018
Journal of Interventional Cardiology – Hindawi Publishing Corporation
Published: Sep 10, 2019
You can share this free article with as many people as you like with the url below! We hope you enjoy this feature!
Read and print from thousands of top scholarly journals.
Already have an account? Log in
Bookmark this article. You can see your Bookmarks on your DeepDyve Library.
To save an article, log in first, or sign up for a DeepDyve account if you don’t already have one.
Copy and paste the desired citation format or use the link below to download a file formatted for EndNote
Access the full text.
Sign up today, get DeepDyve free for 14 days.
All DeepDyve websites use cookies to improve your online experience. They were placed on your computer when you launched this website. You can change your cookie settings through your browser.