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Which CTO should be treated by PCI orCABG
&The specific problems of PCI for post
CABG patients
Gerald S. Werner FESC, FACC, FSCAI
Medizinische Klinik I
Klinikum Darmstadt GmbH
1807
Coronary artery chronic total occlusions (CTOs) are an
exacerbation of stable coronary artery disease (CAD) with
advanced calcification. CTOs are defined as 100% coronary
occlusions with Thrombolysis in Myocardial Infarction grade
0 flow persisting for >3 months.1 National database registries
and large single-center series suggest that in patients with
CAD the overall incidence of CTOs may vary from 16% to
19% in Japan2 and 29% to 33% in North America,3 making
this a common problem globally. Treatment of CTOs should
be considered if associated with symptoms or viable/ischemic
myocardial territories. Historically, treatments have been via
coronary artery bypass grafting (CABG) or medical therapy.3–9
Response by Weintraub and Garratt on p 1817
The use of percutaneous coronary intervention (PCI) to
treat CTOs (CTO-PCI) against established practice is contro-
versial.10 This controversy is facilitated by the poor evidence
available and by lack of clarity in the European and American
guidelines for revascularization, including those for patients
with stable CAD.11–15 The lack of robust evidence and the
unclear guidelines can lead to ill-defined clinical indications
determining serious geographical discrepancies in CTO-PCI
medical practice. In a recent report from Japan, >61% of
patients diagnosed with CTOs (19% of all CAD patients) were
treated with CTO-PCI.2 This is a significant increase com-
pared with a previous report from North America in which
only 6% to 9% of all CTOs (29%–33% of all CAD cases)
were treated with CTO-PCI (range, 1%–16% by geographi-
cal area/center).3 The report by Yamamoto and coworkers2
suggests widespread use of CTO-PCI in patients with multi-
vessel CAD. This is likely to be at the expense of more estab-
lished treatments such as CABG. The difference in CTO-PCI
practice observed between Japan and North America is not
easily explained. Contributing factors may be differences in
study period, unclear guidelines, misrepresentation of safety/
efficacy evidence supporting the use of CTO-PCI, neglect of
the evidence supporting more established treatments, gate-
keeper effect, and lack of policies by health authorities.
In this article, we provide evidence to support the view
that CABG surgery remains the gold standard for the treat-
ment of CTOs in patients with isolated left main stem (LMS)
CTOs, left anterior descending (LAD) CTOs, or CTOs in the
context of multivessel CAD. In addition, we explore safety
and efficacy concerns behind the widespread use of CTO-PCI.
Baseline Determinants of Health Outcome
and Decision Making in Patients With CTOsFor patients with CTO, the decision-making process should
be based on a meticulous evaluation of the coronary anatomy,
the complexity of each patient risk profile, the support of the
heart team, the reference to evidence-based medicine, and a
fully informed patient.
Clinical and Cardiac-Specific Variability of Patients
With CTOs
Patients with CTOs may have a complex risk profile with
a higher incidence of diabetes mellitus, multivessel disease
(Circulation. 2016;133:1807-1817. DOI: 10.1161/CIRCULATIONAHA.115.017797.)
© 2016 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.115.017797
From University of Bristol, UK.This article is Part I of a 2-part article. Part II appears on p 1818.Correspondence to Raimondo Ascione, FRCS, FRCS-CTh equiv, MD, ChM, Faculty of Health Sciences, University of Bristol, Bristol Heart Institute,
Bristol Royal Infirmary, Level 7, Upper Maudlin St, Bristol, UK BS2 8HW. E-mail [email protected]
Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting?
Chronic Total Occlusion Should Be Treated With Coronary
Artery Bypass GraftingMustafa Zakkar, PhD, MRCS; Sarah J. George, PhD; Raimondo Ascione, FRCS, FRCS-CTh equiv, MD, ChM
CONTROVERSIES IN
CARDIOVASCULAR MEDICINE
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Should chronic total occlusions (CTOs) of coronary arteries
be revascularized by coronary artery bypass graft (CABG)
surgery? It would seem that this is not a question that is often
asked, yet CTOs are common and are more commonly revas-
cularized by CABG than by percutaneous coronary interven-
tion (PCI). In this article, we review the epidemiology of
CTOs; discuss issues and viability of the subtended zone, how
viability could be assessed, indications for revascularization
of CTOs, and the literature on CABG for CTO; and conclude
with recommendations for future research. The fundamental
positions put forward here are that the literature on CABG for
CTOs is not strong enough to justify this common procedure
on a routine basis, that decisions on care still need to be made,
and that additional research is needed.
Response by Zakkar et al on p 1826
Background on CTOsCTOs are common findings on coronary arteriograms.1,2
Although there has been extensive literature on the subject of
PCI for CTOs, there is less literature on CABG for CTOs.3–5
This is despite data from the early 2000s showing that patients
with CTO are treated more often with CABG than with
PCI.1 Christofferson et al1 studied 8004 consecutive patients
undergoing diagnostic catheterization at a single institution
between 1990 and 2000. CTOs were defined as 100% coro-
nary occlusion present for at least 3 months. Patients with pre-
vious CABG or recent myocardial infarctions (n=1423) were
excluded. Of the remaining 6581 patients, 3087 (47%) had
significant coronary artery disease (>70% coronary stenosis).
Of patients with significant coronary artery disease, a CTO
was present in 1612 patients (52%), of whom 375 (12%) had
>1 CTO. Among patients with significant coronary artery
disease and a CTO, 11% were treated with PCI, 40% with
CABG, and 49% with medical therapy. In comparison, among
patients with significant coronary artery disease but no CTO,
36% were treated with PCI, 28% with CABG, and 35% medi-
cally (P<0.0001). In a multivariable analysis, the presence of
a CTO was associated with reduced odds of undergoing PCI
(odds ratio, 0.26; 95% confidence interval [CI], 0.22–0.31;
P<0.0001). Multivessel disease, not a CTO, was found on
multivariable analysis to be associated with the increased
choice of CABG. However, multivessel disease and CTO are
collinear, and it difficult to know which is the main driver in
decision making.
More recently, the choice of therapy for patients under-
going coronary angiography and found to have CTOs was
studied in the Canadian Multicenter Chronic Total Occlusions
Registry.6 CTOs were identified in consecutive patients under-
going nonurgent diagnostic coronary angiography at 3 sites in
Canada between April 2008 and July 2009. CTOs were identi-
fied in 2630 of 14 439 patients (18.4%). There was a history of
myocardial infarction in 40%; 25% had Q waves correspond-
ing to the CTO artery territory; and left ventricular function
was normal in the majority. Half of the CTOs were in the
right coronary artery. Almost half of the patients with CTOs
were treated medically, and 25% underwent CABG (CTOs
bypassed in 88%). PCI was performed in 30%, although CTO
lesions were attempted in only 10%, with 70% success rate.
Although more patients with CTOs have historically been
(Circulation. 2016;133:1818-1826. DOI: 10.1161/CIRCULATIONAHA.115.017798.)
© 2016 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.115.017798
From the Christiana Care Health System, Newark, DE.This article is Part II of a 2-part article. Part I appears on p 1807.Correspondence to William S. Weintraub, MD, Cardiology Section, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Newark, DE 19718.
E-mail [email protected] g
Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting?
Chronic Total Occlusion Should Not Routinely Be Treated
With Coronary Artery Bypass GraftingWilliam S. Weintraub, MD; Kirk N. Garratt, MD
CONTROVERSIES IN
CARDIOVASCULAR MEDICINE
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CTO-PCI and CABG
• What are the results of CABG for CTOs ?
• Thesis: Should we not prefer CTO PCI over CABG and use CABG as the final resort ?
• The specific problem of CTO PCI in post CABG patients
SYNTAX Study: The only randomized study tocompare PCI and CABG for CAD including CTOs
The presence of a CTO was the main reason not to
be randomized -> CABG Registry
Patrick Serruys, MD PhDCRT 2009, March 4, 2009
SYNTAX and CTO revascularization
Farooq et al. JACC 2013; 61: 282-94
PCI
No revasc.
51%
CABG
No revasc.
32%
47 years, male: PCI or CABG ?
Impact of SYNTAX Score on PCI
Wijns W, Kolh P, et al. Eur Heart J 2010
Recently published European guidelines for revascularization
What is the actual patency rate post CABG ?
PREVENT IV JAMA. 2005;294(19):2446-2454
About 30% of all venous grafts were occluded after 1 yearIn 45% of patients at least 1 graft was occluded
8% of all LIMA(LITA) were occluded after 1 year
Venous graft patency for occluded vessels
PRAGUE IV. Circulation 2004;110:3418-3423
Study goal: compare on-pump with off-pump surgery
Venous graft patency for occluded vessels
PRAGUE IV. Circulation 2004;110:3418-3423
More than 50% of CTOs are located in the RCA, 20% in the LCX
Higher Mortality with longer CTOs post CABG
Banerjee SR et al. J Cardiac Surg 2012; 27: 662-7
605 CABG patients42% with CTO, 48% in RCA
Bypass to CTO in LAD LCX RCA100% 92% 85%
The problem of the anstomoses to occluded vessels
Werner et al. Circulation 2003;107:1972-7
The distal epicardial territory acute and at follow-up
6 months later
Epicardial diameter depends on shear stress, which is increasingwith increasing perfusion pressureand flow
Lumen increase 6 months after PCI of CTO
Park JJ et al. JACC Interv, 2012; 5:1827-36
However:Total occlusion defined with <1 month duration and TIMI 0 and I
LIMA graft patency for occluded vessels
PRAGUE IV. Circulation 2004;110:3418-3423
CTO-PCI or CABG
• We need to accept that a LIMA to LAD-CTO will still be superior to PCI especially for the long-term benefit
• We need to establish the long-term benefit of CTO PCI for our patients in the range beyond a few years
• To do CTO PCI for a LAD we should respect a future LIMA anastomoses option
CTOs are frequent in chronic CAD
0
2000
4000
6000
8000
10000
12000
14000
16000
Post-CABG STEMI Coronary angio
CTO
No CTO
Fefer P et al. J Am Coll Cardiol. 2012;59(11):991-997
Number of patients
54%10%
18%
Post CABG prevalence in the literature
Muramatsu T et al. EuroIntervention 2014
Alessandrino G et al. JACC CI 2015
Alaswad K et al. CCI 2015
CABG prevalence in CTO patients ranged from 7.5% to 36%
CTO Scores and CABG ?
J-CTO score PROGRESS score
Morino Y et al. JACC Interv 2011; 4: 213 Christopoulos G et al. JACC Interv 2016; 9: 1
Post CABG CTO PCI success
Michael TT et al. Heart 2013;99:1515-18
Post CABG CTO PCI success (RECHARGE)
Maeremans J et al. JACC 2016; 68: 1958-70
CTO Scores and CABG ?
Alessandrino G et al. JACC CI 2015; 8: 1540
RECHARGE score(based on 880 lesions)
Maeremans et al CCI 2018; 91: 192-202
The EURO CTO “CASTLE” Score
Previous CABG
No 1.00
Yes 1.42 (1.25 – 1.61) <0.0001
Based on 17238 procedures
CASTLE:CABGAge>70Stump (non-tapered)Tortuosity (proximal to CTO)Length>20Calcification severe
Risk groupsRisk scores 0-1 2 3 4-6
0.0
0.1
0.2
0.3
0.4
Pro
bab
ility
of
failu
re o
f P
CI
1 2 3 4
observed
predicted
Failure rate
Szijgyarto et al JACCInterv 2019
Post CABG CTOs are unpredictable ?A personal experience
• If CTO developed post CABG the CTO is often functional, and can be easily passed
• If it is a prior CTO it often is also compromised by long-term calcification
• Remember that an occluded venous graft may still be a viable option for a retrograde access
Disease progression after CABG
Pereg et al JACC Interv. 2014;7:761-7
Pre-op lesion severity and post op CTO
Pereg et al JACC Interv. 2014;7:761-7
20 years Post CABG: Ostial RCA CTOWhat is the best strategy ?
Retrograde options are challenging
Moderate calcification -> medium-strengh wire
OPEN CTO Registry – High prevalence of CABG
Considerable Mortality
SafetyIn Hospital Frequency
Death 0.9%*
MI 2.4%
Emergent surgery 0.6%
Perforation 6.0%
Clinical perforation 4.9% (82%)
Bleeding Access 4.0%
Radiation injury 0.1%
30 Day Frequency
Death 1.3%
Rehospitalization 14.7%
Unplanned 12.1% (82%)
Revascularization 2.6%
Planned 2.6%
PCI 2.3%
CABG 0.3%
Skin change 3.1%
6 Month Frequency
Death 2.8%
Rehospitalization 32.65%
Skin change 3.4%
*STS risk estimate for OPEN patients 1.67%
Not Adjudicated
Be aware of perforations in post CABG patients
Deaths and Adverse EventsPatient In Hosp Perforation Periproc MI Post CABG
1 Yes Yes Yes Yes
2 Yes Yes Yes No
3 Yes Yes No No
4 Yes Yes No Yes
5 Yes Yes No No
6 Yes Yes No No
7 Yes Yes No Yes
8 Yes Yes No Yes
9 Yes Yes No Yes
5/9 deaths associated with perforation were in post CABG patients
similar mortality of perforation with and without prior CABG
(1.1% vs. 0.8%, p=0.62)
All 9 deaths were associated with a perforation
Sapontis et al. JACC CI. 2017;10(15):1523.
Conclusion: The post CABG patient with a CTO
• Post CABG patients with CTO are found in about 10-15% in Europe, >30% in US
• A post CABG patient is often more difficult to treat, especially if the CTO was preexistent
• The complication from a perforation during CTO PCI may be even higher than with non-CABG patients due to the restriction of the pericardium and difficulty to drain
Final thoughts
• Should we not stop referring non-proximal LAD CTOs to surgery ?
• We would minimize the problem of post CABG CTO PCI after graft failure
• And we could reserve non-LAD bypass surgery to failed CTO PCI cases with then an urge for an arterial revascularization
Final thoughts
• Should we not stop referring non-proximal LAD CTOs to surgery ?
• We would minimize the problem of post CABG CTO PCI after graft failure
• And we could reserve non-LAD bypass surgery to failed CTO PCI cases with then an urge for an arterial revascularization