cto revascularization in 2015 - incathlab.com · cto revascularization in 2015 jeffrey w. moses, md...
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CTO Revascularization in 2015
Jeffrey W. Moses, MD
Professor of Medicine
Director, Interventional Cardiac Therapeutics
Columbia University Medical Center
Director Complex Coronary Interventions
St. Francis Hospital, Roslyn, LI
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Disclosure Statement of
Financial Interest
I, Jeffrey W. Moses, MD am a consultant
to BSC ,Abbott,Medtronic (minor)
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False Assumptions about Coronary Chronic
Total Occlusions
• The CTO is well collateralized and
therefore there is minimal impact on
quality of life and prognosis
• CTO is a closed vessel and therefore
not at risk for/or during ACS/AMI
• CTO outcomes are more benign than
non CTO coronary disease
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National Attempt Rates
ACC-NCDR
13.6
11.712.4 11.8
0
5
10
15
20
2004^ 2005 2006 2007*
National Attempt Rate Over Time
* Through Q3
^ Jan 1 2004-Mar 31 2005
Courtesy J Aaron Grantham and ACC/NCDR
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Clinical Indications Why Open a Chronically Occluded Coronary Artery?
• Symptom control
Angina
CHF
Fatigue
• Improve LV function
Regional
Global
• Survival
Improved tolerance of AMI
Complete revascularization
Ischemic Risk
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Collaterals are Usually not Sufficient to
Substantially Reduce Ischemia in CTO
Modified from Werner GS et al, European Heart Journal 2006,
courtesy Werner GS
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Evidence for Quality of Life Benefit
Effect of Procedural Success
- 40 - 20 0 20 40
SAQ Quality of Life
SAQ Physical Limitation
SAQ Angina Frequency
Symptomatic
SAQ Quality of Life
SAQ Physical Limitation
SAQ Angina Frequency
Asymptomatic
27 . 3 ( 16 . 5 , 38 . 0 )
15 . 9 ( 5 . 1 , 26 . 7 )
10 . 3 ( - 0 . 8 , 21 . 3 )
8 . 5 ( - 3 . 7 , 20 . 7 )
6 . 3 ( - 5 . 0 , 17 . 6 )
4 . 3 ( - 5 . 4 , 13 . 9 )
125 pts completed the Seattle Angina Questionnaire (SAQ) before and one
month after PCI. 69 procedural success (55%), 56 failures (45%)
Grantham JA. et al, Circulation: QCOR 2010;3:284-90
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Impact of Successful CTO-PCI: Angina Long-term angina benefit favors CTO-PCI success
Angioi, et al.
Drozd, et. al.
Finci, et. al.
Ivanhoe, et. al.
Olivari, et. al.
Warren, et. al.
Total (n=1030)
Joyal D, Afilalo J, Rinfret S. Am Heart J, 2010.
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Impact of Successful CTO-PCI: Mortality Long-term survival benefit favors CTO-PCI success
Joyal D, Afilalo J, Rinfret S. Am Heart J, 2010.
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0.0%
15.6%
22.3%
39.3%
0%
10%
20%
30%
40%
Death
or
MI
Rate
(%
)
COURAGE
Rates of Death or MI by Residual Ischemia
p=0.002
0%
(n=23)
p=0.023
p=0.063
1%-4.9%
(n=141)
5%-9.9%
(n=88)
>10%
(n=62)
Shaw et al, Circ 2008;117
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Residual SYNTAX Score in SYNTAX
Trial
Low Baseline SYNTAX Score (0-22) Intermediate Baseline SYNTAX Score (23-32) High Baseline SYNTAX Score (≥33)
Es
tim
ate
d E
ve
nt
Ra
te
All-Cause Death (y)
Residual
SYNTAX Score Log–rank
P value .022
23.8%
13.8%
7.7% 6.7%
0
>0–4
>4–8
>8
60%
50%
40%
30%
20%
10%
0%
0 1 2 3 4 5
All-Cause Death (y)
Log–rank
P value <.001
34.1%
12.9% 10.1% 8.2%
60%
50%
40%
30%
20%
10%
0%
0 1 2 3 4 5
All-Cause Death (y)
Log–rank
P value <.001
39.1%
11.5%
10.2% 9.3%
60%
50%
40%
30%
20%
10%
0%
0 1 2 3 4 5
Kereiakes et al, Rev Cardiovasc Med. 2014;15:24-30
Farooq Circ 2013;128:141
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Material and Methods • Retrospective analysis of coronary
angiography performed with regard to
procedure details and angiographic
completeness of revascularization
• Complete angiographic
revascularization defined as:
– No angiographically significant
stenosis in all vessels with
diameter of at least 2mm
– Significant stenosis
defined as: LM and
proximal LAD ≥ 50%
MLD and ≥70% in all
other arteries
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Results
12 Months
Variable (%)
Complete revasc
(n=222)
Incomplete revasc
(n=217) P value
Myocardial infarction 2,3% 5,5% 0,125
All-cause mortality 10,4% 18,4% 0,01
Death or MI 11,7% 23,5% 0,002
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Aorta-PD graft
Retrograde Approach
Transit™
Fielder
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CTO Crossing Successful strategy
2.2%
56.9%30.7%
10.1%Retrograde
Wire Cross
Kissing Wire
Technique
Reverse
CART
CART
~ 90%
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Reverse CART
Courtesy of Dr. Masahiko Ochiai
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Reverse CART
3.0mm rx antegrade
Corsair
Reverse CART Distal cap access
Advance corsair into antegrade guide
Exchange for viper wire
Trap prn
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IVUS Guided Identification of the Entry
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IVUS Guided Technique
for Looking For the Entry
IVUS in LA branch
CTO
*
Where is the origin?
Complex CTO
of MLCX
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The Stingray™ CTO Re-Entry System
Unique self-orienting
balloon has a flat shape for
true lumen targeting
180° opposed and offset
exit ports for selective
guidewire re-entry
Re-entry probe at
Stingray
Guidewire tip
Compatibility:
Coronary: 0.014” Wire
The StingRay™ System (Catheter and Guidewire) is
designed to accurately target and re-enter the true lumen
from a subintimal position.
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• Multi-wire coiled shaft
• Tracks via FAST Spin Technique
– Highly torqueable coiled-wire shaft
– FAST Spin reduces push required to cross CTO
• Atraumatic distal tip advanced across a CTO ahead of the guidewire
• OTW 0.014” guidewire compatible
The CrossBoss™ CTO Crossing
Catheter The CrossBoss™ catheter is an OTW stainless steel
catheter designed to quickly and safely pass through the
CTO to gain access to the distal true lumen or enter
subintimal pathways. The catheter is advanced by using
rapid bi-directional rotation.
Ratchet Handle for
FAST-Spin Technique
Atraumatic 1 mm
Distal Tip
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Brilakis et al.
Hybrid Strategy Treatment Algorithm
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Antegrade Paradigm
• 48 year old man with hypertension,
hyperlipidemia, known coronary artery disease
3 months prior to admission presented to
outside hospital with acute chest pain, STEMI,
and underwent thrombus aspiration and PCI to
RCA
LAD CTO intervention attempted but
abandoned due to vessel perforation
Continued to have exertional chest pain, so he
was referred to Columbia for second opinion
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Dual Injection
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Antegrade – Crossing the lesion
• Corsair
• Attempted wires: Asahi Gaia 1, 2, 3
• Confianza Pro 12 used to pierce
• Gaia 2 used to cross lesion
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Confienza
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Corsair Tip In
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Gaia 2nd Advancing
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Aligning
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Crossing
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In Distal Vessel
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LAD lesion prep
• Gaia exchanged for
BMW wire
• Corsair removed with
trapping balloon
• Mid-LAD dilated with
NC 2.5 and 3.0 x 8mm
balloons
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Final picture
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Typical Retrograde Wire Sequence
• 78 year old man with hypertension, prior tobacco use,
prostate cancer, carotid stenosis and coronary artery
disease
1987: Cardiac catheterization via brachial approach in
with PTCA to unknown vessel complicated by
endocarditis
2014: Presented with one month of worsening exertional
chest pain to outside hospital
Echocardiogram: normal systolic function, no wall
motion or valvular abnormalities
Coronary angiogram: complex multi-vessel disease
including chronic total occlusion of the PDA for which
he was transferred to Columbia-Presbyterian
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Initial dual injection
8F bright-tip sheaths
8F JR4
5F diagnostic JL4
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Left coronary intervention
• 7F FL 4.0 Guide for antegrade left coronary
intervention
• BMW, Prowater wires
• Angiosculpt 3 x 10mm in left main 18atm
• NC 3 x 12mm balloon in mid LAD
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Left coronary intervention
• Premier 3 x 12mm stent in LAD
• Premier 4 x 8mm stent in LM
• NC 4.5 x 8mm in LM stent post-dilation
• IVUS
• NC 4 x 8mm post-dilate
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Retrograde RCA CTO Intervention
• 150cm Corsair
• Prowater used to access septal collaterals
• Sion wire for collateral surfing, successfully
accessed RPDA
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Setup for reverse CART
• Miracle 6 in corsair antegrade
• Pilot 200 retrograde
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Retrograde RCA CTO Intervention
• 2.5 x 30 balloon in distal RCA
• 8F Guideliner entered with Confienza Pro
12 and exchanged for Viper wire
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• Resolute 2.5 x 30mm stent in distal RCA
• Resolute 3 x 38mm stent in mid RCA
• Resolute 3.5 x 22mm stent in proximal RCA
RCA stents
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Final pictures
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Antegrade Dissection Reentry
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J-CTO Score Sheet
Morino Y et al. JACC Interv, 2011;4: 213-221
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Predicting Success: The J-CTO Score
Morino Y et al. JACC Interv, 2011;4:213-221
Fin
al G
W s
uc
cess,
%
Risk groups:
J-CTO Score: 1 0 2 >=3
Patient number 130 494 138 135 91
Easy Intermediate Difficult Very difficult
73.3
88.4 92.3 97.8
>90 min
60-90 min
30-60 min
=<30 min
100
90
80
70
60
50
40
30
20
10 0
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Revascularization for CTO
Conclusions
• CTOs negatively impact our patients quality
of life as well as prognosis
• Patients with symptoms, multivessel CAD,
and moderate to large CTO-mediated
ischemic burden derive clinical benefit
• We under treat these patients
• Great opportunity exists to benefit public
health by expanding CTO revascularization