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based on the results of the CIBELES &#40;ChronIc coronary occlusion treated By EveroLimus Eluting Stent&#41; trial&#44; a randomized comparison of sirolimus- and everolimus-eluting coronary stents in 207 patients with CTO&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study population</span><p id="par0015" class="elsevierStylePara elsevierViewall">The CIBELES trial &#40;Clinicaltrials&#46;gov identifier <a href="ctgov:NCT00793221">NCT00793221</a>&#41; included 207 patients with a coronary CTO with an estimated duration of occlusion &#62;2 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> The patients were randomly allocated to everolimus-eluting &#40;Xience V&#44; Abbott Vascular&#41; or sirolimus-eluting &#40;Cypher&#44; Cordis&#44; Johnson &#38; Johnson&#41; coronary stents&#46; In the latest guidelines on the treatment of CTO&#44; CTO was defined as a total occlusion with an estimated duration of occlusion &#62;3 months&#46; However&#44; in the CIBELES study an estimated duration of occlusion &#62;2 weeks was used&#44; for two reasons&#46; First&#44; most studies comparing different strategies to reduce restenosis in CTO included patients with an estimated duration of occlusion &#62;2 weeks&#46; Second&#44; in the CIBELES study&#44; two different types of drug-eluting stents were compared&#44; taking late loss as the primary endpoint&#44; and duration of occlusion has more impact on the probability of crossing the occlusion than on the risk of restenosis&#46; Despite these two considerations&#44; estimated duration of occlusion in the CIBELES study was &#62;3 months in 80&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Other inclusion and exclusion criteria have been previously published&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Thirteen centers in Spain and Portugal participated in the study&#44; all of them with a high volume of percutaneous coronary interventions on CTO&#46; The Spanish Society of Cardiology sponsored the study&#44; which was partly funded by an unrestricted grant from Abbott Vascular&#46; The study was monitored by Chiltern International&#44; and had an independent clinical events committee&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data collection</span><p id="par0025" class="elsevierStylePara elsevierViewall">For every patient&#44; data were collected on approach &#40;anterograde or retrograde&#44; femoral or radial&#41;&#44; material and techniques used &#40;types of guidewires&#44; balloons&#44; microcatheters&#44; intravascular ultrasound&#44; rotational atherectomy&#44; etc&#46;&#41;&#44; type of anticoagulation and amount of contrast&#46; All these aspects were left to the operators&#8217; discretion&#44; respecting local practice&#44; and hence the data obtained reflect standard practice in each center&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">The statistical analysis was performed with SPSS version 12&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; Continuous variables are presented as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; and qualitative variables as proportions &#40;percentages&#41;&#46; Means were compared with the Student&#39;s t test&#44; and proportions were compared using the chi-square test &#40;with Fisher&#39;s correction when necessary&#41;&#46; Differences were considered statistically significant with a p value &#60;0&#46;05&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In order to evaluate variability between different participating centers&#44; the variation coefficient was calculated for different study variables &#40;standard deviation&#47;mean&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Baseline characteristics of the study population &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">The patients&#8217; mean age was 64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10 years&#44; and 83&#37; were male&#46; About 36&#37; of patients were diabetic&#46; Due to the inclusion criteria&#44; all treated lesions were de novo and located in native vessels&#46; The treated vessel was the left anterior descending artery&#44; right coronary artery&#44; and left circumflex artery in 41&#37;&#44; 39&#37;&#44; and 19&#37;&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Techniques and devices used &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">A radial approach was used in 23&#37; of cases&#59; a retrograde approach was used in only 5&#37; of patients&#46; The use of radial &#40;0&#37;-92&#37;&#41; and retrograde approaches &#40;0&#37;-18&#37;&#41; both showed considerable variability between participating centers &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The mean number of guidewires used was 2&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2&#46; Asahi guidewires were the most frequently used &#40;34&#46;6&#37;&#41;&#44; followed by Abbott &#40;21&#46;2&#37;&#41; and Terumo &#40;10&#46;6&#37;&#41; guidewires&#46; In 33&#46;8&#37; of cases&#44; guidewires specifically designed for CTO were not used&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A large number of balloons &#40;2&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9 per patient&#41; were used&#46; Of these balloons&#44; most were pre-dilatation balloons &#40;1&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7 per patient&#41;&#46; Post-dilatation balloons were used in only 25&#37; of patients&#44; the number used per patient being 0&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#46; Microcatheters were used in 33&#37; of patients &#40;74 in 68 patients&#41;&#44; the most frequent type being Finecross &#40;Terumo&#41; &#40;77&#37;&#41;&#44; followed by Corsair &#40;Asahi&#41; &#40;16&#37;&#41;&#46; Due to the study design&#44; all patients received drug-eluting stents&#46; The mean number of stents implanted per patient was 2&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;0&#44; with a mean stent length of 49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24 mm&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Other devices and techniques used were Tornus penetration catheters &#40;Abbott Vascular&#41; in 4&#37; of patients&#44; rotational atherectomy &#40;Boston Scientific&#41; in 2&#37;&#44; and cutting balloon &#40;Boston Scientific&#41; in 1&#37;&#46; Importantly&#44; intracoronary ultrasound during the procedure or after stent implantation was used in only 6&#37; of procedures&#44; also with considerable variability between participating centers &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Antithrombotic treatment</span><p id="par0065" class="elsevierStylePara elsevierViewall">Antiplatelet therapy consisted of aspirin and clopidogrel in all patients&#46; Additionally&#44; 4&#37; of patients received glycoprotein IIb&#47;IIIa inhibitors&#46; Anticoagulation during the procedure was performed with unfractionated heparin in most cases &#40;87&#37;&#41;&#44; followed by bivalirudin &#40;12&#37;&#41; and enoxaparin &#40;1&#37;&#41;&#46; In eight of the 13 centers &#40;62&#37;&#41;&#44; unfractionated heparin was the only anticoagulation used&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Variability between participating centers</span><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows the variability between participating centers&#46; The greatest variability was observed in the use of intracoronary ultrasound &#40;variation coefficient 2&#46;14&#41;&#44; and the least was found in the use of guidewires specific for CTO &#40;variation coefficient 0&#46;37&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Comparison between patients with a duration of occlusion &#62;3 months vs&#46; &#60;3 months</span><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the comparison between patients with an estimated duration of occlusion &#62;3 months and &#60;3 months&#46; Of the 207 patients&#44; 165 &#40;80&#37;&#41; had an estimated duration of occlusion &#62;3 months&#46; These patients had higher rates of specific techniques for CTO &#40;specific guidewires&#44; microcatheters&#44; etc&#46;&#41;&#44; but the differences were statistically significant only in the use of a radial approach &#40;20&#37; vs&#46; 36&#37;&#59; p&#61;0&#46;031&#41;&#46; A retrograde approach was used in 6&#37; of patients with duration of occlusion &#62;3 months&#44; compared to 0&#37; in patients with estimated duration of occlusion of between 2 weeks and 3 months&#46; A trend for a higher rate of use of plaque modification devices &#40;rotational atherectomy&#44; cutting balloon&#44; Tornus catheter&#41; was found in patients with &#62;3 months since occlusion &#40;9&#37; vs&#46; 0&#37;&#44; p&#61;0&#46;078&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Among patients undergoing coronary angiography&#44; 13-18&#37; have one or more CTO&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;9</span></a> Treatment of CTO constitutes one of the most complex tasks for interventional cardiologists&#44; due mainly to difficulty in recanalizing the vessel&#44; but also to the high risk of restenosis&#44; reocclusion and new revascularization procedures in patients with an initial successful result&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> This explains why only about 10&#37; of CTO are scheduled for percutaneous revascularization&#44; and most cases are managed either with medical treatment alone or with surgical revascularization&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Several studies have shown that successful treatment of CTO is associated with improvement in left ventricular ejection fraction and clinical outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;11</span></a> Thus&#44; in spite of the technical difficulties associated with percutaneous treatment of this type of lesion&#44; CTO is currently one of the fields of greatest interest for interventional cardiologists&#44; and consequently a wide variety of devices&#44; recommendations&#44; and techniques have been developed specifically to treat these lesions&#46; As a result&#44; the variability between different centers in the treatment of CTO is greater than with other types of lesions&#44; and therefore data obtained from a single center are difficult to apply to other centers&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The CIBELES trial was performed in 13 centers in Spain and Portugal&#44; in which 207 patients with CTO were randomized to sirolimus- or everolimus-eluting stents&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> This study has provided valuable information on how CTO are currently treated&#46; As no specific recommendations were given regarding approach &#40;femoral vs&#46; radial&#41;&#44; use of retrograde techniques&#44; types of guidewires&#44; or different devices&#44; the results represent the daily practice of the participating centers&#46; The study has afforded some interesting insights&#46; First&#44; the number of devices used &#40;including balloons&#44; stents&#44; and guidewires&#41; was high&#44; suggesting that the treatment of this type of lesion is expensive and therefore cost-effectiveness analyses of non-CTO lesions might not be applicable to CTO&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Second&#44; the total stent length was high &#40;nearly 50 mm&#41;&#46; In some previous randomized studies of patients with CTO&#44; total stent length was less&#44; probably reflecting patient selection&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> However&#44; other studies showed a similarly high stent length to CIBELES&#44; which probably reflects the fact that CTO are frequently associated with long-segment disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;14</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Third&#44; a relatively high proportion of patients did not receive any device&#44; material or technique developed specifically for the treatment of CTO&#46; For example&#44; retrograde techniques were used in only 5&#37; of patients&#44; demonstrating that they have a low penetration in daily practice in Spain and Portugal&#46; In some CTO registries&#44; mainly Japanese&#44; this percentage is around 25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The use of devices recommended by CTO expert groups<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> was also relatively low&#46; Microcatheters were used in one third of patients&#44; 34&#37; of patients did not require specific guidewires&#44; and the procedure was guided by intracoronary ultrasound in only 6&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; In patients with &#62;3 months since vessel occlusion&#44; the use of these devices was slightly more frequent&#44; but also less than expected&#46; On the other hand&#44; the use of a radial approach &#40;frequently not recommended in CTO because it provides less support than a femoral approach&#41; was relatively high &#40;23&#37;&#41;&#44; even in patients with duration of occlusion &#62;3 months&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> These data suggest that recommendations by CTO expert groups may not be applicable to the routine treatment of these lesions&#46; However&#44; this does not necessarily imply suboptimal use of resources&#44; but perhaps that the recommendations of these expert groups are unrealistic&#46; All physicians participating in the CIBELES trial were experienced interventional cardiologists with wide experience in the treatment of CTO&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Four&#44; post-dilatation balloons were used in only 25&#37; of patients&#46; This could be considered a low figure&#44; given the expected high proportion of underexpanded and&#47;or malapposed stents in such long stented segments&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Five&#44; other issues&#44; such as the use of other techniques &#40;e&#46;g&#46; rotational atherectomy&#41;&#44; antithrombotic treatment&#44; and the amount of contrast dye&#44; were consistent with other CTO series&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;16</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Finally&#44; due to its study design&#44; all patients included in the CIBELES trial received drug-eluting stents&#46; Recent recommendations on the treatment of CTO do not clearly indicate the routine use of drug-eluting stents in these lesions&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> but we believe that&#44; unless there is an absolute contraindication for prolonged double antiplatelet therapy&#44; all CTO should be treated with drug-eluting stents&#44; particularly with sirolimus- or everolimus-eluting stents&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;12&#44;13&#44;17</span></a> In fact&#44; the use of drug-eluting stents was &#62;95&#37; in some recent registries on CTO&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Study limitations</span><p id="par0120" class="elsevierStylePara elsevierViewall">This study has some limitations&#46; First&#44; the main objective of the CIBELES trial was to compare two different types of drug-eluting stents&#44; and did not include analysis of the material and techniques used in the trial&#39;s endpoints&#46; However&#44; this in fact reinforces the findings related to the techniques and material used&#58; since no specific recommendations were given in the study&#44; the data in this article reflect the daily practice of the participating centers&#46; Second&#44; due to the study design&#44; in all included patients the guidewire successfully crossed the vessel occlusion&#44; and this may have influenced the study&#39;s results&#46; However&#44; we believe this may be only applicable to guidewires&#44; and not to other devices used in CTO&#46; Third&#44; the centers participating in the CIBELES trial were only in Spain and Portugal&#44; and treatment of CTO may differ in other countries&#46; Despite these limitations&#44; we believe that the findings probably reflect daily practice in most countries and centers treating CTO&#44; at least in Europe and the USA&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Ethical disclosures</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Protection of human and animal subjects</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Confidentiality of data</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Right to privacy and informed consent</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Funding</span><p id="par0140" class="elsevierStylePara elsevierViewall">Unrestricted grant from Abbott Vascular&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent years&#44; various specific techniques and materials have been developed for the treatment of coronary chronic total occlusions &#40;CTO&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To evaluate the current situation in the treatment of CTO &#40;techniques and material&#41; in our setting&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We evaluated data on techniques and material used in the CIBELES &#40;ChronIc coronary occlusion treated By EveroLimus Eluting Stent&#41; trial&#44; a randomized comparison of sirolimus- and everolimus-eluting stents in 207 patients with CTO in 13 centers in Spain and Portugal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A radial approach was used in 23&#37; of patients&#44; and retrograde techniques were used in only 5&#37;&#46; A high number of balloons were used &#40;2&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9 per patient&#41;&#46; Microcatheters were used in 33&#37; of patients&#44; and post-dilatation balloons in only 25&#37;&#46; The mean number of stents implanted per patient was 2&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;0&#44; with a mean total stent length of 49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24 mm&#46; Other devices and techniques used were&#58; Tornus penetration catheter in 4&#37; of patients&#44; rotational atherectomy in 2&#37;&#44; and cutting balloon in 1&#37;&#46; Intracoronary ultrasound was used in only 6&#37; of patients&#46; In 34&#37; of cases&#44; operators used guidewires that were not specifically for CTO&#46; Considerable variability between centers was detected in the use of different techniques&#44; the highest and lowest variability being observed in the use of intracoronary ultrasound and the use of CTO guidewires&#44; respectively&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In the CIBELES trial&#44; techniques and devices specifically designed for the treatment of CTO were used in a relatively low proportion of patients&#46; Considerable variability between centers was detected&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Durante os &#250;ltimos anos foram desenvolvidos materiais e t&#233;cnicas espec&#237;ficos para o tratamento de oclus&#245;es totais cr&#243;nicas &#40;OTC&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Avaliar a situa&#231;&#227;o atual no tratamento de OTC &#40;t&#233;cnicas e material&#41; na nossa realidade&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Avali&#225;mos os dados relacionados com as t&#233;cnicas e material usados no estudo CIBELES &#40;ChronIc coronary occlusion treated By EveroLimus Eluting Stent&#41; que comparou de forma aleatororizada <span class="elsevierStyleItalic">stents</span> eluidores de sirolimus e everolimus em 207 doentes com OTC em 13 centros de Espanha e Portugal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A abordagem radial foi usada em 23&#37; dos doentes e as t&#233;cnicas retr&#243;gradas foram usadas em apenas 5&#37;&#46; Foi usado um elevado n&#250;mero de bal&#245;es &#40;2&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;9 por doente&#41;&#46; Microcat&#233;teres foram usados em 33&#37; e bal&#245;es de p&#243;s-dilata&#231;&#227;o apenas em 25&#37; dos doentes&#46; O n&#250;mero m&#233;dio de <span class="elsevierStyleItalic">stents</span> implantados por doente foi de 2&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;0&#44; com um comprimento total m&#233;dio de 49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24 mm&#46; Outro material foi&#58; tornus 4&#37;&#44; aterectomia rotacional 2&#37; e <span class="elsevierStyleItalic">cutting balloon</span> em 1&#37; dos doentes&#46; Ecografia intra-coron&#225;ria foi usada em apenas 6&#37; dos doentes&#46; Em 34&#37; dos casos os operadores usaram fios-guia que n&#227;o eram espec&#237;ficos de OTC&#46; Uma alta variabilidade entre centros foi detetada no uso de diferentes t&#233;cnicas&#44; sendo a variabilidade observada mais alta e mais baixa no uso de ecografia intra-coron&#225;ria e no uso de guias de OTC&#44; respetivamente&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclus&#245;es</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">No estudo CIBELES&#44; t&#233;cnicas e material especificamente desenvolvidos para o tratamento de OTC foram usados numa propor&#231;&#227;o relativamente baixa dos doentes&#46; Foi detetada uma alta variabilidade entre centros&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">See <a class="elsevierStyleCrossRef" href="#sec0105">annex</a>&#46;</p>"
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        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Principal investigator</span>&#58; Raul Moreno&#46; <span class="elsevierStyleBold">Co-principal investigator</span>&#58; Eulogio Garcia&#46; <span class="elsevierStyleBold">Clinical Events Committee</span>&#58; Esteban Lopez de Sa&#44; Carlos Macaya&#44; Jose-Luis Lopez-Sendon&#46; <span class="elsevierStyleBold">Investigators</span>&#58; Hospital Universitario La Paz&#44; Madrid&#44; Spain&#58; Raul Moreno&#44; Guillermo Galeote&#44; Angel Sanchez-Recalde&#44; Santiago Jimenez-Valero&#44; Luis Calvo&#44; Ignacio Plaza&#44; Angela Portela &#40;42 patients&#41;&#46; Hospital de Santa Cruz&#44; Lisbon&#44; Portugal&#58; Rui Campante Teles&#44; Manuel Almeida&#44; Luis Raposo&#44; and Pedro Araujo Goncalves &#40;34 patients&#41;&#46; Hospital de Galdakao&#44; Bilbao&#44; Spain&#58; Jose-Ram&#243;n Rumoroso&#44; Mario Sabada Sagredo&#44; Asier Subinas Elorriaga &#40;28 patients&#41;&#46; Hospital de Santo Antonio&#44; Porto&#44; Portugal&#58; Henrique Cyrne Carvalho&#44; Joao Silveira&#44; and Andr&#233; Luz &#40;21 patients&#41;&#46; Hospital Puerta de Hierro&#44; Majadahonda&#44; Spain&#58; Francisco Javier Goicolea&#44; and Jose Antonio Fern&#225;ndez D&#237;az &#40;17 patients&#41;&#46; Hospital Virgen de la Salud&#44; Toledo&#44; Spain&#58; Jos&#233; Moreu&#44; and Tom&#225;s Cant&#243;n &#40;15 patients&#41;&#46; Hospital German Trias I Pujol&#44; Badalona&#44; Spain&#58; Fina Mauri&#44; and Oriol Rodriguez &#40;14 patients&#41;&#46; Hospital Santa Creu I Sant Pau&#44; Barcelona&#44; Spain&#58; Antonio Serra&#44; Manel Sabate &#40;12 patients&#41;&#46; Hospital General&#44; Alicante&#44; Spain&#58; Vicente Mainar and Javier Pineda Nodar &#40;9 patients&#41;&#46; Hospital de Santa Marta&#44; Lisboa&#44; Portugal&#58; Lino Patricio&#44; Rui Ferreira &#40;7 patients&#41;&#46; Hospital Virgen de la Arrixaca&#44; Murcia&#44; Spain&#58; Mariano Vald&#233;s&#44; Javier Lacunza &#40;5 patients&#41;&#46; Complejo Hospitalario de Le&#243;n&#44; Spain&#58; Felipe Fern&#225;ndez-V&#225;zquez&#44; Armando P&#233;rez de Prado &#40;2 patients&#41;&#46; Hospital Garc&#237;a de Orta&#44; Lisboa&#44; Portugal&#58; Helder Pereira &#40;1 patient&#41;&#46;</p>"
            "etiqueta" => "Annex"
            "titulo" => "&#40;LIST OF INVESTIGATORS&#41;"
            "identificador" => "sec0105"
          ]
        ]
      ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Proportions of patients treated with different material&#44; devices and techniques in each participating center&#46;</p>"
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                  \t\t\t\t">53&#177;13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">13&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">24&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6 French&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7 French&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8 French&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Post-dilatation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49&#177;24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Maximum stent diameter &#40;mm&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Minimum stent diameter &#40;mm&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;6&#177;0&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7 French&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;6&#177;0&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;1&#177;1&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Use of specific guidewires &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">57&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">68&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;165&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Use of microcatheters &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;463&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Number of balloons</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;0&#177;0&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;133&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Number of stents</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;9&#177;0&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;1&#177;1&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Total stent length &#40;mm&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45&#46;2&#177;22&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Maximum stent diameter &#40;mm&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Minimum stent diameter &#40;mm&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&#46;8&#177;0&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;6&#177;0&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;109&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Use of post-dilatation balloons &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;874&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Intracoronary ultrasound &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">4&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;858&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Other techniques &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;078&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rotational atherectomy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;585&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cutting balloon&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tornus catheter&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;209&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Amount of contrast dye &#40;ml&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">286&#177;129&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">284&#177;131&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;926&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antithrombotic treatment &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unfractionated heparin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">95&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">85&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;293&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bivalirudin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enoxaparin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;000&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparison between patients with estimated duration of occlusion &#62;3 months and &#60;3 months&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#46;40&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Use of microcatheters&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Use of post-dilatation balloons&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Plaque modification devices&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Intracoronary ultrasound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#177;15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Specific guidewires&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">82&#177;30&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Proportions &#40;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#41; of the use of different material&#44; devices&#44; and techniques and variability between participating centers&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:17 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Primary stenting versus balloon angioplasty in occluded coronary arteries&#58; the Total Occlusion Study of Canada &#40;TOSCA&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "C&#46;E&#46; Buller"
                            1 => "V&#46; Dzavik"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
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                        "volumen" => "100"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10411846"
                            "web" => "Medline"
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Coronary perspectives on coronary chronic total occlusions&#46; The Canadian Multicenter Chronic Total Occlusions Registry"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Fefer"
                            1 => "M&#46;L&#46; Knudtson"
                            2 => "A&#46;N&#46; Cheema"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2011.12.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
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            2 => array:3 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusion&#58; data from a multicenter&#44; prospective&#44; observational study &#40;TOAST-GISE&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Z&#46; Olivari"
                            1 => "P&#46; Rubartelli"
                            2 => "F&#46; Piscione"
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                      ]
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                  "host" => array:1 [
                    0 => array:1 [
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            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "In-hospital outcomes of contemporary percutaneous coronary intervention in patients with chronic total occlusions&#46; Insights from the J-CTO Registry &#40;Multicenter CTO Registry in Japan&#41;"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Y&#46; Morino"
                            1 => "T&#46; Kimura"
                            2 => "T&#46; Hayashi"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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            4 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recanalization strategy for chronic total occlusions with tapered and stiff-tip guidewire&#46; The results of CTO New technique for Standard procedure &#40;CONQUEST&#41; trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "K&#46; Mitsudo"
                            1 => "T&#46; Yamashita"
                            2 => "Y&#46; Asakura"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Invasive Cardiol"
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            5 => array:3 [
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              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current perspectives on coronary chronic total occlusions&#46; The Canadian Multicenter Chronic Total Occlusions Registry"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Fefer"
                            1 => "M&#46;L&#46; Knudtson"
                            2 => "A&#46;N&#46; Cheema"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2011.12.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2012"
                        "volumen" => "59"
                        "paginaInicial" => "991"
                        "paginaFinal" => "997"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22402070"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized comparison between everolimus-eluting stent and sirolimus-eluting stent in chronic coronary total occlusions&#46; Rationale and design of the CIBELES &#40;non-acute Coronary occlusion treated by Everolimus eluting Stent&#41; trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Moreno"
                            1 => "E&#46; Garcia"
                            2 => "R&#46;C&#46; Teles"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "EuroIntervention"
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                        "volumen" => "6"
                        "paginaInicial" => "12"
                        "paginaFinal" => "16"
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            7 => array:3 [
              "identificador" => "bib0040"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized comparison of sirolimus-eluting and everolimus-eluting coronary stents in the treatment of total coronary occlusions&#58; results from the chronic coronary occlusion treated by everolimus-eluting stent randomized trial"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "CIBELES investigators"
                          "etal" => true
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                            1 => "E&#46; Garc&#237;a"
                            2 => "R&#46; Teles"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCINTERVENTIONS.112.000076"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circ Cardiovasc Interv"
                        "fecha" => "2013"
                        "volumen" => "6"
                        "paginaInicial" => "21"
                        "paginaFinal" => "28"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23403384"
                            "web" => "Medline"
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            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prognostic impact of a chronic occlusion in a non-infarct vessel in patients with acute myocardial infarction and multivessel disease undergoing primary percutaneous coronary intervention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Moreno"
                            1 => "C&#46; Conde"
                            2 => "M&#46;J&#46; Perez"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Invasive Cardiol"
                        "fecha" => "2006"
                        "volumen" => "18"
                        "paginaInicial" => "16"
                        "paginaFinal" => "19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16391378"
                            "web" => "Medline"
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              "etiqueta" => "10"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized trial comparing coronary angioplasty with coronary bypass surgery&#46; Emory Angioplasty versus Surgery Trial &#40;EAST&#41;"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46;B&#46; King 3rd"
                            1 => "N&#46;H&#46; Lembo"
                            2 => "W&#46;S&#46; Weintraub"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199410203311602"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1994"
                        "volumen" => "331"
                        "paginaInicial" => "1044"
                        "paginaFinal" => "1050"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8090163"
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            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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