chronic total occlusions - solaci
TRANSCRIPT
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