chronic total occlusions - solaci

Luis A Guzman, MD

Director, Cardiovascular Interventions

University of Florida-Jacksonville

Chronic Total Occlusions

CTO in Perspective

CTO present in 52% of patients with

significant CAD (≥70% stenosis)

1990-2000, N=3,087

Christofferson et al. Am J Cardiol 2005

49% Med Therapy 11% PCI

40% CABG

Objectives

• What is the benefit of opening a chronically occluded artery?

• What is the success rate of opening CTO?

• What are the challenges inherent to angioplasty of a CTO?

• What approaches have improved outcomes in CTO angioplasty?

Rationale for angioplasty

Indications:

• Medically refractory

Angina (I,B)

• Positive Stress Test

with large burden of

ischemia (I, B)

• LV dysfunction with

ischemic myocardium

(IIb, B)

Proven Benefits:

• Symptom improvement

• Decreased need for

CABG

• Reduced LV remodeling

Purported benefits:

• Increased survival

• Favorable risk profile

Improved Mortality? 2,007 CTO patient vs 2,007 matched control

CTO-Success %

CTO-Failure %

Matched-Success %

93.7 89.4 85.5 79.2 73.5

89.0 84.4 76.5 68.8 65.0

93.2 88.0 82.7 76.6 71.9

Years

Perc

en

t S

urv

ival

50

60

70

80

90

100

CTO-Success

CTO-Failure

Matched Success

0 2 4 6 8 10

p = 0.002

Suero JACC. 2001;38:409

CTO Success 69%

Trial Success

(n)

Failure

(n)

Duration of

follow-up (y)

Mortality (%)

Success Failure P value

British Columbia

Cardiac

Registry1 1118 340 6

Suero et al.2 1491 514 10

Total Occlusion

Angioplasty

Study—Societa

Italiana di

Cardiologia

Invasiva

(TOAST-GISE)3

286

83

1

Long-term Survival Associated with Successful CTO

Revascularization Support for the Late Open Artery Hypothesis

10.0

26.6

1.1

19.0

35.0

3.6

<0.001

0.001

0.13

1Ramanathan TCT 2003; 2Suero et al. JACC 2001; 3Olivari JACC 2003

CTOs: First, Do No Harm!

• There’s only ONE way you can help:

– Successful recanalization

• There are MANY ways you can hurt the patient:

– Dissection

– Perforation

– Disrupt functioning collaterals

– De-recruit collaterals

– Distal embolization

– Sidebranch injury

– Long procedures bleeding, vascular problems

CTO PCI Tips….. Strategies Prepare for Success

• Avoid Ad Hoc CTO PCI --

• Study the diagnostic angiogram

– Proximal and distal caps,Vessel path,Collateral sourcing

• Setup optimal imaging situation

– Nearly always need two catheter imaging

– Minimize panning

• Minimize guessing

– IVUS, etc.

• Excellent guide support

• Set safety working parameters (e.g. contrast, radiation)

• Expect prolonged procedure:

– Increased radiation exposure

– Increased contrast load

– Patience and persistence required

• Consider making first case of the day

• Consider a dedicated CTO day

CTO PCI Tips….. Strategies Prepare for Success: Timing of Case

• Evolving wire technology

• CTO wiring techniques

• CTO antegrade-retrograde

• IVUS, Multi-slice CT

CTO PCI Tips….. Strategies Prepare for Success

Procedural Success of CTO PCI

0

10

20

30

40

50

60

70

80

90

99-00 97-99 86-96 80-99

84% of failure

related to inability

to pass wire

81% of failure

related to inability

to pass wire

Oliverai et al.

n=390

Dong et al.

n=283

Noguchi et al.

n=226

Suero et al.

n=2005

59%

77% 72%

85%

CTO: Lesion Morphology

Tapered Stump

Bridging

collaterals absent

Stump absent

Occlusion at

side-branch

Bridging

collaterals present

Pre or

Post-branch occlusion

Favor Procedural

Success

Does Not Favor

Procedural Success

Innovations in CTO Revascularization An Evolution in Technology and Strategy

Guidewire

Ablative

Mechanical

Different tip: Confianza, Miracle, Filder , Sion

Steerable guidewire (Steer-It)/ catheter (Venture)

Optical coherence reflectometry (ILT)

Penetration (Tornus)

Vibrational angioplasty

Magnetic Navigation (Stereotaxis)

Re-Entry

Excimer laser (Spectranetics)

Ultrasound (Flowcardia)

Radiofrequency ablation (ILT)

Blunt microdissection (Lumend)

Fibrinolysis

Demineralization, collagenase

Percutaneous bypass

Subintimal angioplasty

Retrograde CART and Reverse CART

Support Catheter FineCross, Corsair

Innovations in CTO Revascularization An Evolution in Technology and Strategy

Guidewire

Ablative

Mechanical

Different tip: Confianza, Miracle, Filder, Sion

Steerable guidewire (Steer-It)/ catheter (Venture)

Optical coherence reflectometry (ILT)

Penetration (Tornus)

Vibrational angioplasty

Magnetic Navigation (Stereotaxis)

Re-Entry

Excimer laser (Spectranetics)

Ultrasound (Flowcardia)

Radiofrequency ablation (ILT)

Blunt microdissection (Lumend)

Fibrinolysis

Demineralization, collagenase

Percutaneous bypass

Subintimal angioplasty

Retrograde CART and Reverse CART

Support Catheter FineCross, Corsair

Refinements in Wire Technology

• Stiffer

• Tapered End

• Hydrophillic (lubricous)

ASAHI CONFIANZA™ 9

Tapered Tip

ASAHI CONFIANZA PRO™ 9

ASAHI CONFIANZA PRO™ 12

ASAHI MIRACLEBROS™ 3

Straight Tip

ASAHI MIRACLEBROS™ 4.5

ASAHI MIRACLEBROS™ 6

ASAHI MIRACLEBROS™ 12

Treating Chronic Occlusions

Guide Wires Breakthrough Technology for Chronic Occlusions

Incre

asin

g S

up

po

rt

The ASAHI FIEDLER™ FC, XT & Sion

• ASAHI FIELDER™ FC maintains a softer tip, more intermediate support*

• ASAHI FIELDER™ XT maintains a softer tip, with a 0.009” taper*

•ASAHI FIELDER™ Sion maintains a softer tip, more support, Steerable*

Treating Chronic Occlusions

Guide Wires Tip Loads

CTO Wiring wire shaping

Primary bend ~ <30°

1-2mm from tip

Secondary bend ~ 10-15°

Primary bend ~< 30°

1-2mm from tip

Wire Techniques

• Standard single wire - drill vs.

penetrate vs. sliding for microchannels

• Parallel wiring technique

• IVUS guided wiring technique

•Retrograde wiring technique

Differences in Wire Manipulation

And Wire Selection

Wire Technique Parallel/Seesaw Wire Method with Double

Support Catheters

Parallel Wire Technique

First wire

Second wire

Catheter Support

• Monorail balloons

MicroCatheters

Finecross (Terumo)

Transit (Cordis)

Corsair (Asahi)

A stainless steel specialty catheter that is designed to

support and/or exchange a guide wire in the treatment of

Chronic Occlusions

The CrossBoss™ CTO Catheter Design

0.014” guidewire compatible (OTW)

Tracks via FAST Spin Technique

• Highly torqueable coiled-wire shaft

• FAST Spin reduces push required to cross CTO

Atraumatic 1mm rounded distal tip

Caution: Investigational Device, Limited by US Law to Investigational Use

Other technologies

Other Techniques

• Anchoring technique

• CART technique

• Reverse CART technique

• Subintimal with distal re-entry

Anchoring Technique

Using OTW Balloon

RCA CTO Pre with Contralat injection Micro catheter with 4.5 gm wire tip

CTO : Anchoring Technique

CTO : Anchoring Technique

CTO : Anchoring Technique Micro catheter with 12 gm wire tip

CTO : Anchoring Technique Micro catheter with 12 gm wire tip

Anchor balloon and 4.5 gm wire tip Micro catheter crosses CTO

CTO : Anchoring Technique

Wire exchange, Balloon inflation Final

CTO : Anchoring Technique

Retrograde Technique

CTO : Retrograde Approach

Angio Pre Antegrade Approach

CTO : Retrograde Approach

Septal Angiography Wire in Septal

Septal Crossing and Support Catheter Corsair

2 Thick Braids

③0.86mm (2.6Fr) ②0.82mm (2.5Fr) ①0.86mm (2.6Fr)

Marker coil

8 Thin Braids

Tapered Soft Polyurethane Tip

20cm Screw Head Structure

Hydrophilic Polymer Coating

PTFE Inner Layer

Counterclockwise

advancement Tschuchikane et al. JACC Intv 2010

CTO : Retrograde Approach

Antegrade-Retrograde Wiring

CART or Reverse CART Techniques

Retrograde wire

crossing

The antegrade balloon can get into CTO body and the retrograde wire can reach the antegrade balloon advanced in CTO body.

yes reverse CART

CART/ knuckle wire

no

If 1° failed

proximal distal

CTO : Retrograde Approach

Reverse CART CART

CTO : Retrograde Approach

Post Balloon Final Result

Subintimal Approach

The Stingray™ CTO Re-Entry System Design

Unique self-orienting

balloon has a flat shape

180° opposed and offset

exit ports for selective

guidewire re-entry

Re-entry probe at

guidewire tip

Compatibility:

6Fr. Guide/0.014” Wire

0.020” crossing

profile

2.9Fr. shaft

profile

Subintimal Approach

Whitlow P et al. CCI 2012:80-807

Subintimal Approach

Whitlow P et al. CCI 2012:80-807

SES: 97.4%, N=76

PES: 96.4%, N=57

BMS: 80.8%,

N=26

Follow-up (months)

12 6 0

Cu

mu

lati

ve S

urv

ival-

free o

f T

VR

(%

) 100

80

75

95

90

85

Log rank p=0.01

Hoye, Serruys et al. 2004

RESEARCH and T-SEARCH Registries

Conclusions

• CTO angioplasty remains highly challenging

• Established angiographic and clinical variable predict procedural success

• Emerging technologies and techniques have shown important improvements and promises in this field

• Stenting (DES) has overcome the hurdle of restenosis

Thank you