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Trattamento delle CTO
Indicazioni e risultati Prof. Alfredo R. Galassi MD, FESC, FACC, FSCAI
Department of Medical Sciences and Pediatrics,
University of Catania, Italy
and University Heart Center,
University Hospital Zurich, Switzerland
Andreas Gruentzig
First Percutaneous Coronary
Angioplasty in humans
15
September
1977
…. pertanto le occlusioni totali sono un problema reale
Se non risolviamo il problema delle occlusioni totali,
probabilmente non saremo mai in grado di risolvere il
problema dell’angioplastica nel paziente multivascolare
Andreas Gruentzig
2 settimane prima della sua morte avvenuta in un
incidente aereo
(27, Ottobre 1985) quando aveva 46 anni
……30 anni dopo!!!!!!
Euro Cto Club
Founding Meeting
Paris 14.12.2006
Joachim Buettner
Gerald Werner
Dariusz Dudek
George Sianos
Alfredo R Galassi
Nicolaus Reifart
Carlo Di Mario was
the photographer
Christofferson et al, Am J Cardiol 2005
CTOs are common and influence
management
Analysis of 6.581 consecutive patients undergoing
angiography (1990-2000), CTO was found in 52%
patients with significant (> 70% DS) coronary disease
Patients with chronic total occlusion (CTO)
n=1697
CTO prevalence 18.4%
Medical Therapy
n=747
44%
PCI
n=515
30%
CABG
n=435
26%
CTO bypassed
n=388 (90% of operations)
23%
Attempted CTO PCI
n=162
10%
Successful CTO PCI
n=123
7%
The Canadian Multicenter CTO Registry April 2008 - July 2009 (3 centers)
Overall, 30% of CTOs revascularized!
Fefer P et al, JACC 2012 Christofferson et al, AJC 2005
1777 patients enrolled with 1968 CTO lesions
CTO prevalence 13.3%
Optimal medical
therapy 826 pts
PCI 776 pts CABG 175 pts
46%
44% 10%
Tomasello D et al, Eur Heart J 2015
Christofferson et al, AJC 2005
Galassi et al, Eur Heart J 2015
Indications of CTO revascularization according to
symptoms, ischemia and viability
Galassi et al, Eur Heart J 2015
Course Directors
Nicolaus Reifart
Main Taunus Kliniken
Bad Soden, Germany
Gerald S. Werner
Medizinische Klinik
Klinikum Darmstadt
Darmstadt, Germany
Co-Directors
Alfredo R. Galassi
Ferrarotto Hospital
University of Catania
Catania, Italy
George Sianos
AHEPA University Hospital
Thessaloniki, Greece
Hans Bonnier
University Hospital Brussels
Brussels, Belgium
Procedural complications
and in-hospital outcome
Galassi et al, EuroIntervention 2011
0
500
1000
1500
2000
2500
3000
2008 2009 2010 2011 2012 2013 2014
1303
1724
2189
2634 2603 2660 2615
Online Registry 2008-2014
0
20
40
60
80
100
2006 2007 2008 2009 2010 2011 2012 2013 2014
75 77 80 82
85.3 85 85.3 87 85.8
Angiographic Success
%
Course Directors
Nicolaus Reifart
Main Taunus Kliniken
Bad Soden, Germany
Gerald S. Werner
Medizinische Klinik
Klinikum Darmstadt
Darmstadt, Germany
Co-Directors
Alfredo R. Galassi
Ferrarotto Hospital
University of Catania
Catania, Italy
George Sianos
AHEPA University Hospital
Thessaloniki, Greece
Hans Bonnier
University Hospital Brussels
Brussels, Belgium
Course Directors
Nicolaus Reifart
Main Taunus Kliniken
Bad Soden, Germany
Gerald S. Werner
Medizinische Klinik
Klinikum Darmstadt
Darmstadt, Germany
Co-Directors
Alfredo R. Galassi
Ferrarotto Hospital
University of Catania
Catania, Italy
George Sianos
AHEPA University Hospital
Thessaloniki, Greece
Hans Bonnier
University Hospital Brussels
Brussels, Belgium
Antegrade Retrograde Overall
Galassi AR et al, on behalf of the Euro CTO Club
Course Directors
Nicolaus Reifart
Main Taunus Kliniken
Bad Soden, Germany
Gerald S. Werner
Medizinische Klinik
Klinikum Darmstadt
Darmstadt, Germany
Co-Directors
Alfredo R. Galassi
Ferrarotto Hospital
University of Catania
Catania, Italy
George Sianos
AHEPA University Hospital
Thessaloniki, Greece
Hans Bonnier
University Hospital Brussels
Brussels, Belgium
Galassi AR et al, on behalf of the Euro CTO Club
Course Directors
Nicolaus Reifart
Main Taunus Kliniken
Bad Soden, Germany
Gerald S. Werner
Medizinische Klinik
Klinikum Darmstadt
Darmstadt, Germany
Co-Directors
Alfredo R. Galassi
Ferrarotto Hospital
University of Catania
Catania, Italy
George Sianos
AHEPA University Hospital
Thessaloniki, Greece
Hans Bonnier
University Hospital Brussels
Brussels, Belgium
Galassi AR et al, on behalf of the Euro CTO Club
Tomasello D et al, Eur Heart J 2015
Survival free from MACCE and cardiac death
in pts (No: 619) treated with PCI or medical
therapy after propensity score adjustment
0
0,5
1
1,5
2
2,5
2008 2009 2010 2011 2012 2013 2014
0,5 0,5
0,3
0 0,03 0,08 0,07
0,8
1,1
0,9
1
0,8
0,5
0,4
2,2
1
2,5
1,5
1,9
2,3
2,5
0,1
0,6
0,3
0,6
0,5
0,6
0,5
1
0,8
0,3
0,7
1
0,5 0,5 0,5
1,2
0,3
0,7
0,8
0,6
0,5
Death
Myocardial infarction Vascular complication
Donor vessel dissection
Cardiac tamponade
Coronary perforation
Procedural Complications
Consensus on Indications and Strategy
Best treatment for CTO is the result of:
- Careful review of clinical history
- Sensitive non-invasive assessment of myocardial ischemia
and viability in CTO related territory
- Patient risk profile assessment (complete revascularization
in multivessel patient); patient selection is crucial
- Life expectancy (younger and older youth)
- LAD CTO
- Non-LAD CTO but main vessel ischemic area related CTO - Radiation, contrast load and complication risk assessment
(balance success vs failure)
Consensus of Euro CTO Club Eurointervent 2012
Conclusions
The European Strategy
1. Antegrade success (approx 85%) stable from 2010
onwards (last 5 years)
2. Retrograde procedures:
a) mostly staged
b) increased significantly from 2010 onwards (up
to 30% in 2014)
c) more complex lesions, more time consuming,
more fluoroscopy time, more dye to be used
3. Retrograde operators higher success than non
retrograde operators (90% vs 80%)
4. Severe complications <1.5-2.0%
Thank you
for your attention
argalassi@gmail.com
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