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Chronic Total Occlusion
Revascularization: Why, When and
How?
Mitul Patel MD, FACC, FSCAIAssociate Clinical Professor of Medicine
Interventional Cardiology, Division of Cardiovascular Medicine
Director of Endovascular Interventions, Cardiovascular Institute
UC San Diego Sulpizio Cardiovascular Center and VA Medical Center San Diego
Disclosures
• Abbott Vascular – Consultant, Advisory Board, Speaker’s Bureau• Boston Scientific – Consultant, Advisory Board• Cardiovascular Systems, Inc. – Consultant, Speaker’s Bureau• Chiesi – Consultant, Speaker’s Bureau• Medtronic – Consultant, Speaker’s Bureau• Terumo – Consultant, Speaker’s Bureau
CTO Prevalence and Treatment
Christofferson, et al. Am J Cardiol 2005;95:1088–1091 4
Fefer et al. JACC 2012.
18.4%
CTO PCI - Why?
• Complete Revascularization
• Improve Quality of Life
• Improve LV Function
• Reduce Mortality
Farooq. J Am Coll Cardiol 2013;61:282–94
Post hoc Analysis of SYNTAX All-Comers
Farooq. J Am Coll Cardiol 2013;61:282–94
PCI
Farooq. J Am Coll Cardiol 2013;61:282–94
Prevalence of complete
revascularization
% o
f p
at
ien
ts
P
RevascularizationCABG vs. PCI
Courtesy: Ali Pourdjabbar, MD
Death
(PCI vs CABG)
MI
(PCI vs CABG)
Repeat
Revascularization
(PCI vs CABG)
Stroke
(PCI vs CABG)
ARTSII 5.4 vs 7.1 4.4 vs 4.0 14.5 vs 7.0 2.8 vs 2.2
Syntax 4.4 vs 3.5 4.8 vs 3.3 13.5 vs 5.9 0.6 vs 2.2
Freedom 16.3 vs 10.9 13.9 vs 6.0 12.6 vs 4.8 2.4 vs 5.2
BEST 6.6 vs 5.0 4.8 vs 2.7 11.0 vs 5.4 2.5 vs 2.9
Independent Predictors of ICR
Farooq. J Am Coll Cardiol 2013;61:282–94
Quality of Life
Improved Symptom Control and Quality of Life
Safley, Grantham, et al. 2013. Cathet. Cardiovasc. Intervent.
• 10- center prospective PCI registry• N= 167 CTO cases
Joyal D, Afilalo J, Rinfret S. Am Heart J, 2010.
Improved Symptom Control and Quality of LifeMeta Analysis of > 7,000 patients
• Prospective, Randomized 2:1, Open-label
• 26 centers in Europe
• Primary Endpoints– Efficacy: Health Status as measured by EQ-5D and SAQ @ 12-Months
– Safety: Death and Non-fatal MI @ 36-Months
• CTO PCI success rate: 86.3%
G.S. Werner, Euro PCR 2017
20
40
60
80
100
12 month results• Procedural Success: 86.3%
• Crossover rate for OMT: 7%• PCI Complication Rate: 2.9%
G.S. Werner, Euro PCR 2017
ti
Improvement in LV Function
Improvement in LV function with CTO-PCI
Paul et al, Heart 2011.
Ejection Fraction (EF) Segmental Wall Thickening (SWT)
MRI assessment at baseline and at 6 months shows an improvement in EF and SWT in patients who had successful CTO-PCI
L.P. Hoebers et al. International Journal of Cardiology 187 (2015) 90–96
Improvement in LV function with CTO-PCI
Impact on Mortality…
Claessen et al. JACC Intv. Nov. 2009 Impact of a CTO in a Non-IRA After STEMI
Impact of the Presence of a CTO after Primary PCI for STEMI3,277 consecutive pts
Mortality Reduction
R. Valenti et al. CTO–PCI and Survival. EHJ. 2008
2003-2006486 consec pts
+ viabilityAll attemptedAll antegrade2 yr f/u71% success rate
Mortality Reduction
13,443 pts14,439 CTO PCI’s
George, et al. Long-Term Follow-Up of Elective Chronic Total Coronary Occlusion Angioplasty. JACC 2014;235-43.
Meta-Analysis of CTO PCI
All-Cause Mortality
Joyal D, et al. Am Heart J. 2010; 160: 179-.‐87
UC San Diego CTO Patient Selection Algorithm
Functional ?
YesNo
Mortality Benefit ?
Yes
NoMedical Therapy
Proceed with CTO PCISymptomatic and
Optimized on GDMT ?Yes
No
Optimize Medical Rx& Lifestyle Modifications
Complete Revascularization?Mortality Benefit?
Yes
No
LV Dysfunction ?Inducible Ischemia ?
Proximal LAD ?
How?
Strategy
Have a plan or algorithm… But always be prepared…Sometimes things don’t go as planned…
Clear Proximal CapGood Distal Target
Dissection Re-EntryWire Escalation
Length < 20mm
RetrogradeAntegrade
Wire Escalation
Dissection Re-Entry(CrossBoss™- Stingray™)
NOYES
YES
Dissection Re-Entry(Reverse CART)
Dissection Re-Entry(Reverse CART)
YES NONO
FAILFAIL
FAIL FAIL
Brilakis ES, et al. A Percutaneous Treatment Algorithm for Crossing Coronary Chronic Total Occlusions. J Am Coll Cardiol Intv. 2012;5(4):367-379.
Hybrid Algorithm
Equipment
Crossing Strategy Success by J-CTO ScoreUK Hybrid Registry
Dissection re-entry (antegrade or retrograde) more highly utilized in more complex cases
Wilson WM, et al. Heart 2016;0:1–8. doi:10.1136/heartjnl-2015-308891
Dual Injection
Antegrade Wire Escalation
Antegrade Wire Escalation
Antegrade Dissection / Re-EntryAntegrade Dissection / Re-Entry
Antegrade Dissection / Re-Entry
Antegrade Dissection / Re-Entry
Antegrade Dissection / Re-EntryAntegrade Dissection / Re-Entry
Antegrade Dissection / Re-EntryAntegrade Dissection / Re-Entry
Antegrade Dissection / Re-Entry
Retrograde
Patient returns 5 years later with unstable angina…
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
Retrograde # 2
Antegrade Dissection / Re-Entry
The Algorithm
The Algorithm…
AWE Subintimal Stingray
Antegrade Dissection / Re-Entry
The Algorithm
Retro STAR
Post PTCA
Antegrade Dissection / Re-Entry
The Algorithm
12 weeks later... AWE
Antegrade Dissection / Re-Entry
The Algorithm
Disaster Preparedness
• Know where these items are stored:• Graftmasters• Coils• Snares• Pericardiocentesis
kits • Make sure they’re not
expired!
Thank You