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