Debate #4: CTO Revascularization

Samin K Sharma, MD, FACC, FSCAIDirector Clinical & Interventional Cardiology

Zena and Michael a Weiner Professor of Medicine

Mount Sinai Hospital, NY

Most CTO Should be Opened: Samin K Sharma, MDOnly Limited CTO Should be Opened: Carlo Di Mario, MD

CCCSymposium 2014

I will make my point for;Most CTOs Should be Opened

Chronic Total Occlusion (CTO)

Presence of CTO in CAD Imparts Adverse Prognosis

NUnadjusted HR

Compared with CR [95%CI]

Adjusted HR Compared with CR

[95%CI]

Complete Revascularization 6817 1.00 1.00

1 IR vessel with no CTO 8518 1.20 [1.04-1.38] 1.00 [0.87-1.15]

2 IR vessel with no CTO 2057 1.88 [1.57-2.27] 1.25 [1.03-1.50]

1 IR vessel CTO 3232 1.81 [1.53-2.13] 1.35 [1.14-1.59]

2 IR vessels at least 1 CTO 1321 2.77 [2.29-3.35] 1.36 [1.12-1.66]

Impact of Completeness of PCI Revascularization on Long-Term Outcomes in the Stent Era

Hannah, Holmes, King, Sharma et al. Circulation 2006;113:2406

HRs for Mortality for Various Subgroups of Incomplete Revascularization

Hannan, Sharma et al. JACC Cardio Interv 2009;2:17

Incomplete Revascularization in the Era of DES: NY State Database Report

Conclusion: Pts with ≥2 IR vessels with a CTO, have the worst long-term prognosis and greater need for CABG or re-PCI

Effect of a Concurrent CTO on Long-Term Mortality and LVEF in Pts After Primary PCI in AMI

Claessen et al. JACC Cardio Interv 2009;2:1128.

3277 STEMI pts 1997-05: SVD 65%, MVD 22%, MVD + CTO 13%

Endpoint: Survival at 5 yrs, LVEF at 12 mo (median F/U 3.1 yrs)

Landmark Survival Analysis

Patel et al., JACC Cardiovasc Interv 2013;6:128

Temporal Trends in Cumulative Angiographic Success Rates and Major Procedural Complication Rates

80%

0.5%

Patel et al., JACC Cardiovasc Interv 2013;6:128

Incidence of Procedural Complications in Successful vs. Unsuccessful CTO PCI

MACE (%) 3.7 4.3 0.68

Death (%) 0.4 1.5 <0.0001

Emergent CABG (%) 0.03 0.17 0.74

Stroke (%) 0.07 0.4 0.04

MI (%) 2.8 3.0 0.87

Q-wave MI (%) 0.3 0.5 0.26

Coronary perforation (%) 3.7 10.7 <0.0001

Tamponade (%) 0.0 1.7 <0.0001

Vascular complication (%) 1.7 0.9 0.20

Contrast nephropathy (%) 5.0 4.6 0.86

Successful Unsuccessful p value Complications

CTO: Anatomic Descriptors of Procedural Success

In the current ERA;Severe calcification

Why Bother to do PCI?Chronic Total Occlusion (CTO)

Because successful CTO recanalization may result in

Angina/Ischemia relief

Freedom from subsequent CABG

Improved LV function

Improvement in event-free survival

Presence of CTO in CAD Imparts Adverse Prognosis

SeriesName/Year

Successful PCI (N)

FU (months)

Asymptomatic(%)

Olivari, 2003 248 12 89

Berger, 1996 139 6 87

Ivanhoe, 1992 264 36 69

Ruocco, 1992 160 24 69

Bell, 1992 234 32 76

TOTAL >1000 >24 mo >80%

CTO Recanalization and Angina Relief

Chronic Total Occlusion (CTO)

TOAST-GISE1 Year Clinical Status of Complication Free Patients

CTO Success (n = 248)

CTO Failure(n = 60) P Value

No angina 220 (88.7%) 45 (75.0%) 0.008

ETT performed 210 (84.7%) 42 (70.0%) 0.010

Maximal ETT 155 (62.5%) 20 (33.3%) <0.0001

Negative ETT 181 (73.0%) 28 (46.7%) 0.0001

Olivari Z et al, J Am Coll Cardiol 2003;41:1672Olivari Z et al, J Am Coll Cardiol 2003;41:1672

Meta-Analysis of CTO Outcomes

Joyal et al., Am Heart J 2010;160:179.

13 Observational Studies, 7288 patients weighted averaged follow-up 6 years

OR for Success vs. Failure

95% Cl p Value

Mortality 0.56 0.43-0.72 <0.001

MI 0.74 0.44-1.25 0.26

Subsequent CABG 0.22 0.17-0.27 <0.001

Residual Angina 0.45 0.30-0.67 0.001

Evaluation of LV Function 3-Yrs after Percutaneous Recanalization of CTO

Kirschbaum S et al, Am J Cardiol 2008;101:179

Changes in LV Volume Indexes and EF between Baseline and 3-Yr FU Measured Using Magnetic Resonance Imaging (N=21)

Mean ejection fraction improved slightly, but end-systolic and end-diastolic volume indexes decreased significantly.

3530

86 636078

MRI Predicts LV EF & Wall Motion Improvement with CTO Revascularization (N=21) with prior MI

Seg

men

tal

wal

l th

icke

nin

g (

%)

Transmural extent of infarction

-20

-10

0

10

20

30

40

50

60

70

80

90

<25% 25-75% >75% Remote

SWT at Baseline (n=21)

SWT 5 mths post Stent Implantation

SWT 3 yrs post stent ImplantationP<0.001P<0.001

P<0.05P<0.05

P<0.001P<0.001P<0.05P<0.05

P<0.05P<0.05

P=nsP=ns

P=nsP=nsP=nsP=ns

P<0.05P<0.05

P=nsP=ns

P<0.05P<0.05P=nsP=ns

Kirschbaum et al, Am J Cardiol 2008;101:179Kirschbaum et al, Am J Cardiol 2008;101:179

Effect of Successful vs. Failed CTO PCI in All-Cause Mortality During Long-Term Follow-up

Moses et al., JACC Cardio Interv 2012;5:389

Author, Year Yr Follow-up PCI Success (n) PCI Failure (n) OR/HR, 95% CIFinci, et al., 1990 2 100 100 OR: 1.70, 0.40 - 7.32

Warren et al., 1990 2.6 26 18 N/A

Ivanhoe et al., 1992 4 317 163 OR: 0.21, 0.05 - 0.83

Angioi et al., 1995 3.6 93 108 OR: 0.37, 0.10 - 1.40

Noguchi et al., 2000 4.3 134 92 OR: 0.28, 0.11 – 0.72

Suero et al., 2001 10 1,491 514 OR: 0.67, 0.54 – 0.83

Olivari et al., 2003 1 289 87 OR: 0.19, 0.03 – 1.14

Hoye et al., 2005 4.5 567 304 OR: 0.52, 0.32 – 0.84

Drozd et al., 2006 2.5 298 161 OR: 0.74, 0.23 – 2.37

Aziz, et al.,2007 1.7 377 166 OR: 0.31, 0.13 – 0.76

Prasad et al., 2007 10 914 348 OR: 0.82, 0.62 – 1.08

Valenti et al., 2008 1 344 142 OR: 038, 0.19 – 0.77

de Labriolle et al., 2008

2 127 45 OR: 1.25, 0.25 – 6.27

Mehran et al., 2011 2.9 1,226 565 HR: 0.63, 0.40 – 1.0

Jones et al., 2012 3.8 582 254 HR: 0.28, 0.15 – 0.52

Joyal et al., 2010 5,056 2,236 OR: 0.56, 0.43 – 0.72

Jones et al., JACC Cardio Interv 2012;5:380

Successful Recanalization of CTO Associated with Improved Long-Term Survival

Advanced Techniques for Chronic Total OcclusionJapanese Specialized Technique

• Anchor balloon technique• Mother-Child catheter technique• Parallel wire• IVUS guidance• Retrograde approach

Retrograde Wire Technique for Chronic Total Occlusion Recanalization

Four Patterns of Success in Retrograde CTO Recanalization

Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.

Increased Use of Retrograde Approach and Technical Success Rate Over Time

Michael et al., Am J Cardiol 2013;112:488

%

20062007

201020092008

2011

≈35%

ACCF/SCAI/STS/AATS/AHA/ASNC 2012Appropriateness Criteria for Coronary Revascularization

Patel et al. JACC 2012;53:530-553

Chronic Total Occlusions: Indications for PCI

INDICATION

Appropriateness Score (1-9)

CCS Angina Class

Asymptomatic I or II III or IV

• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Low-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy

I I I• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Low-risk findings on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy

I U U

• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Intermediate-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy

I U U

• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Intermediate-risk criteria on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy

U U A

• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• High-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy

U U A

• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• High-risk criteria on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy

U A A

PCI of a CTO in patients with appropriate clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise

Chronic Total Occlusions

I IIaIIb III

Procedural Steps of Current CTO-PCI

Fundamental Wire Technique and Current Strategy for Chronic Total Occlusion PCI

CTO - PCI

Antegrade approach x2

Retrograde approach (ostial)

IVUS guide re-entry

Single Wire Technique

Parallel Wire Technique

Retrograde Wire Cross

Kissing Wire Cross

CART

Reverse CARTSuccess Failure

Cotralateral Dual Injection

Procedural Success of CTO PCI at MSH

0

20

40

60

80

100

%

2003-2005 2006-2008 2009-10 2011-12

397 806 665 782

9386

78

68

Asahi wires

Retrogradetechnique

Planned 2nd (18%) or 3rd (8%) attempt

EXPERT CTOUS Trial:90+ success

Conclusions:Rationale for CTO Recanalization in ALL

Presence of a CTO imparts adverse prognosis.

Therefore developing technical skills (dedicated centers and dedicated Interventionalists) is essential to tackle this “last frontier of Interventional Cardiology” to improve overall outcomes of our complex CAD pts.

Non randomized data support improved overall CV outcomes (including mortality) with successful CTO procedures. A randomized trial will be needed to establish the PCI efficacy in CTO pts.

KEY to better CTO outcomes is successful recanalization