Download - Debate #4: CTO Revascularization
Debate #4: CTO Revascularization
Samin K Sharma, MD, FACC, FSCAIDirector Clinical & Interventional Cardiology
Zena and Michael a Weiner Professor of Medicine
Mount Sinai Hospital, NY
Most CTO Should be Opened: Samin K Sharma, MDOnly Limited CTO Should be Opened: Carlo Di Mario, MD
CCCSymposium 2014
I will make my point for;Most CTOs Should be Opened
Chronic Total Occlusion (CTO)
Presence of CTO in CAD Imparts Adverse Prognosis
NUnadjusted HR
Compared with CR [95%CI]
Adjusted HR Compared with CR
[95%CI]
Complete Revascularization 6817 1.00 1.00
1 IR vessel with no CTO 8518 1.20 [1.04-1.38] 1.00 [0.87-1.15]
2 IR vessel with no CTO 2057 1.88 [1.57-2.27] 1.25 [1.03-1.50]
1 IR vessel CTO 3232 1.81 [1.53-2.13] 1.35 [1.14-1.59]
2 IR vessels at least 1 CTO 1321 2.77 [2.29-3.35] 1.36 [1.12-1.66]
Impact of Completeness of PCI Revascularization on Long-Term Outcomes in the Stent Era
Hannah, Holmes, King, Sharma et al. Circulation 2006;113:2406
HRs for Mortality for Various Subgroups of Incomplete Revascularization
Hannan, Sharma et al. JACC Cardio Interv 2009;2:17
Incomplete Revascularization in the Era of DES: NY State Database Report
Conclusion: Pts with ≥2 IR vessels with a CTO, have the worst long-term prognosis and greater need for CABG or re-PCI
Effect of a Concurrent CTO on Long-Term Mortality and LVEF in Pts After Primary PCI in AMI
Claessen et al. JACC Cardio Interv 2009;2:1128.
3277 STEMI pts 1997-05: SVD 65%, MVD 22%, MVD + CTO 13%
Endpoint: Survival at 5 yrs, LVEF at 12 mo (median F/U 3.1 yrs)
Landmark Survival Analysis
Patel et al., JACC Cardiovasc Interv 2013;6:128
Temporal Trends in Cumulative Angiographic Success Rates and Major Procedural Complication Rates
80%
0.5%
Patel et al., JACC Cardiovasc Interv 2013;6:128
Incidence of Procedural Complications in Successful vs. Unsuccessful CTO PCI
MACE (%) 3.7 4.3 0.68
Death (%) 0.4 1.5 <0.0001
Emergent CABG (%) 0.03 0.17 0.74
Stroke (%) 0.07 0.4 0.04
MI (%) 2.8 3.0 0.87
Q-wave MI (%) 0.3 0.5 0.26
Coronary perforation (%) 3.7 10.7 <0.0001
Tamponade (%) 0.0 1.7 <0.0001
Vascular complication (%) 1.7 0.9 0.20
Contrast nephropathy (%) 5.0 4.6 0.86
Successful Unsuccessful p value Complications
CTO: Anatomic Descriptors of Procedural Success
In the current ERA;Severe calcification
Why Bother to do PCI?Chronic Total Occlusion (CTO)
Because successful CTO recanalization may result in
Angina/Ischemia relief
Freedom from subsequent CABG
Improved LV function
Improvement in event-free survival
Presence of CTO in CAD Imparts Adverse Prognosis
SeriesName/Year
Successful PCI (N)
FU (months)
Asymptomatic(%)
Olivari, 2003 248 12 89
Berger, 1996 139 6 87
Ivanhoe, 1992 264 36 69
Ruocco, 1992 160 24 69
Bell, 1992 234 32 76
TOTAL >1000 >24 mo >80%
CTO Recanalization and Angina Relief
Chronic Total Occlusion (CTO)
TOAST-GISE1 Year Clinical Status of Complication Free Patients
CTO Success (n = 248)
CTO Failure(n = 60) P Value
No angina 220 (88.7%) 45 (75.0%) 0.008
ETT performed 210 (84.7%) 42 (70.0%) 0.010
Maximal ETT 155 (62.5%) 20 (33.3%) <0.0001
Negative ETT 181 (73.0%) 28 (46.7%) 0.0001
Olivari Z et al, J Am Coll Cardiol 2003;41:1672Olivari Z et al, J Am Coll Cardiol 2003;41:1672
Meta-Analysis of CTO Outcomes
Joyal et al., Am Heart J 2010;160:179.
13 Observational Studies, 7288 patients weighted averaged follow-up 6 years
OR for Success vs. Failure
95% Cl p Value
Mortality 0.56 0.43-0.72 <0.001
MI 0.74 0.44-1.25 0.26
Subsequent CABG 0.22 0.17-0.27 <0.001
Residual Angina 0.45 0.30-0.67 0.001
Evaluation of LV Function 3-Yrs after Percutaneous Recanalization of CTO
Kirschbaum S et al, Am J Cardiol 2008;101:179
Changes in LV Volume Indexes and EF between Baseline and 3-Yr FU Measured Using Magnetic Resonance Imaging (N=21)
Mean ejection fraction improved slightly, but end-systolic and end-diastolic volume indexes decreased significantly.
3530
86 636078
MRI Predicts LV EF & Wall Motion Improvement with CTO Revascularization (N=21) with prior MI
Seg
men
tal
wal
l th
icke
nin
g (
%)
Transmural extent of infarction
-20
-10
0
10
20
30
40
50
60
70
80
90
<25% 25-75% >75% Remote
SWT at Baseline (n=21)
SWT 5 mths post Stent Implantation
SWT 3 yrs post stent ImplantationP<0.001P<0.001
P<0.05P<0.05
P<0.001P<0.001P<0.05P<0.05
P<0.05P<0.05
P=nsP=ns
P=nsP=nsP=nsP=ns
P<0.05P<0.05
P=nsP=ns
P<0.05P<0.05P=nsP=ns
Kirschbaum et al, Am J Cardiol 2008;101:179Kirschbaum et al, Am J Cardiol 2008;101:179
Effect of Successful vs. Failed CTO PCI in All-Cause Mortality During Long-Term Follow-up
Moses et al., JACC Cardio Interv 2012;5:389
Author, Year Yr Follow-up PCI Success (n) PCI Failure (n) OR/HR, 95% CIFinci, et al., 1990 2 100 100 OR: 1.70, 0.40 - 7.32
Warren et al., 1990 2.6 26 18 N/A
Ivanhoe et al., 1992 4 317 163 OR: 0.21, 0.05 - 0.83
Angioi et al., 1995 3.6 93 108 OR: 0.37, 0.10 - 1.40
Noguchi et al., 2000 4.3 134 92 OR: 0.28, 0.11 – 0.72
Suero et al., 2001 10 1,491 514 OR: 0.67, 0.54 – 0.83
Olivari et al., 2003 1 289 87 OR: 0.19, 0.03 – 1.14
Hoye et al., 2005 4.5 567 304 OR: 0.52, 0.32 – 0.84
Drozd et al., 2006 2.5 298 161 OR: 0.74, 0.23 – 2.37
Aziz, et al.,2007 1.7 377 166 OR: 0.31, 0.13 – 0.76
Prasad et al., 2007 10 914 348 OR: 0.82, 0.62 – 1.08
Valenti et al., 2008 1 344 142 OR: 038, 0.19 – 0.77
de Labriolle et al., 2008
2 127 45 OR: 1.25, 0.25 – 6.27
Mehran et al., 2011 2.9 1,226 565 HR: 0.63, 0.40 – 1.0
Jones et al., 2012 3.8 582 254 HR: 0.28, 0.15 – 0.52
Joyal et al., 2010 5,056 2,236 OR: 0.56, 0.43 – 0.72
Jones et al., JACC Cardio Interv 2012;5:380
Successful Recanalization of CTO Associated with Improved Long-Term Survival
Advanced Techniques for Chronic Total OcclusionJapanese Specialized Technique
• Anchor balloon technique• Mother-Child catheter technique• Parallel wire• IVUS guidance• Retrograde approach
Retrograde Wire Technique for Chronic Total Occlusion Recanalization
Four Patterns of Success in Retrograde CTO Recanalization
Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.
Increased Use of Retrograde Approach and Technical Success Rate Over Time
Michael et al., Am J Cardiol 2013;112:488
%
20062007
201020092008
2011
≈35%
ACCF/SCAI/STS/AATS/AHA/ASNC 2012Appropriateness Criteria for Coronary Revascularization
Patel et al. JACC 2012;53:530-553
Chronic Total Occlusions: Indications for PCI
INDICATION
Appropriateness Score (1-9)
CCS Angina Class
Asymptomatic I or II III or IV
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Low-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy
I I I• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Low-risk findings on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy
I U U
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Intermediate-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy
I U U
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Intermediate-risk criteria on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy
U U A
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• High-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy
U U A
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• High-risk criteria on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy
U A A
PCI of a CTO in patients with appropriate clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise
Chronic Total Occlusions
I IIaIIb III
Procedural Steps of Current CTO-PCI
Fundamental Wire Technique and Current Strategy for Chronic Total Occlusion PCI
CTO - PCI
Antegrade approach x2
Retrograde approach (ostial)
IVUS guide re-entry
Single Wire Technique
Parallel Wire Technique
Retrograde Wire Cross
Kissing Wire Cross
CART
Reverse CARTSuccess Failure
Cotralateral Dual Injection
Procedural Success of CTO PCI at MSH
0
20
40
60
80
100
%
2003-2005 2006-2008 2009-10 2011-12
397 806 665 782
9386
78
68
Asahi wires
Retrogradetechnique
Planned 2nd (18%) or 3rd (8%) attempt
EXPERT CTOUS Trial:90+ success
Conclusions:Rationale for CTO Recanalization in ALL
Presence of a CTO imparts adverse prognosis.
Therefore developing technical skills (dedicated centers and dedicated Interventionalists) is essential to tackle this “last frontier of Interventional Cardiology” to improve overall outcomes of our complex CAD pts.
Non randomized data support improved overall CV outcomes (including mortality) with successful CTO procedures. A randomized trial will be needed to establish the PCI efficacy in CTO pts.
KEY to better CTO outcomes is successful recanalization