gerald s. werner, md, fesc, facc klinikum darmstadt, germany · chronic total occlusions update a...

Gerald S. Werner, MD, FESC, FACC

Klinikum Darmstadt, Germany

BSIC, Manchester, September 15, 2006

Chronic total occlusions update

A European perspective

Gerald S. Werner, MD, FESC, FACC

Klinikum Darmstadt, Germany

BSIC, Manchester, September 15, 2006

CTO – The European perspective

• What you may want to know about collaterals

• Why should we open a CTO ?

• The past and presence of CTO treatment

• CTOs in the DES era

• The remaining challenges in CTOs

Pathophysiology of collaterals in CTOs

• How to assess collaterals ?

• What happens to collaterals after PCI ?

• Can collaterals replace an open artery ?

Assessment of collaterals: pressure and flow

PAo

POccl APVOccl

RColl

RP

PAo

POccl APVOccl

RCollPressure/Doppler Wire

Pressure/Doppler Wire

Before recanalization Reocclusion after PTCA

TCO Balloon

RA RA

RP

Baseline collateral function

PAo

POccl APVOccl

RColl

RP

PAo

POccl APVOccl

RCollPressure/Doppler Wire

Pressure/Doppler Wire

Before recanalization Reocclusion after PTCA

TCO Balloon

RA RA

RP

Recruitable collateral function

Werner et al. Circulation 2001;104:2784-90

Collateral function in CTOs

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7

0

5

10

15

20N

um

be

r o

f pa

tie

nts

Collateral pressure index

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7

0

5

10

15

20

Num

ber

of patients


79% 46%


Before PCI After PCI

Loss of collateral function not due to embolization

0 25 50 75

Rcoll [mmHg/(cm*sec)]

0,0

0,5

1,0

1,5

2,0

ma

xim

ale

CK

[µ

mo

l/(L

*se

c)]

R-Quadrat = 0,01

Bahrmann et al. Z Kardiol 2002;91:937-945

Collateral function in CTOs

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7

0

5

10

15

20N

um

be

r o

f pa

tie

nts


0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7

0

5

10

15

20

Num

ber

of patients


79% 46%

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7

0

5

10

15

20

Num

ber

of patients


18%



6 mo FUP

Evidence for preformed collaterals in man

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7

0

5

10

15

20N

um

be

r o

f pa

tie

nts


0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7

0

5

10

15

20

Num

ber

of patients


79% 46%

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7

0

5

10

15

20

Num

ber

of patients


18%

20%

Wustmann et al. Circulation 2003;107:2213-20 Werner et al. Circulation 2003;108:2877-82


6 mo FUP

Can good collaterals replace an open artery ?

Collateral function assessed as collateral flow reserve

In 98 Pat. with CTO during adenosine stress

Adapted from Werner et al. JACC 2006;48:51-8

Can good collaterals replace an open artery ?

95% of collaterals are no

substitute for the open artery

CTOs – Should we treat them all ?

• Improvement of symptoms (angina, dyspnea)

• Improvement of LV function

• Improvement of prognosis

Benefit of recanalisation on LV function

Werner et al. Am Heart J 2005;149:129-37

No improvement in case of

Reocclusion !!!

Indication for revascularization: MRI function and

vitality

LV recovery after recanalization of CTOs - MRI

Baks T et al. JACC 2006;47:721-5

PCI success and survival

Suero et al. JACC 2001;38:409-14

Ramanathan & Buller, ACC 2003

2000 Pat, 74% successful

1458 Pat, 77% successful

871 Pat, 65% successful Hoye et al. Eur Heart J 2005;26:2630-6

If PCI fails … at least consider CABG

Suero et al. JACC 2001;38:409-14

But CABG seems to be

only the second best option

A CTO left occluded makes life more dangerous

Leaving a CTO alone means taking risks in low risk

patients

0

1

2

3

4

5

6

7

8

Periprocedural

MACE

Death within 12

months

CTO (n= 122)

Non-CTO (n= 88)

No PCI (n= 451)

STAR Registry, Institute for infarct research, Ludwigshafen

PCI of

CTOs in the cathlab routine in 2003

• In a German registry (STAR – Stable Angina

pectoris Registry - IHF, Ludwigshafen) 2002

consecutive diagnostic angiographies were

evaluated:

• 33% had at least one CTO

• CTO pts had more severe symptoms, and LV

dysfunction

• the 1-year mortality with CTOs was 5.5% vs. 3.1%

• Only one third of CTOs underwent PCI

• Half of all CTOs were referred to CABG

Why bother, you can‘t open it … most times CTO success rates – historical perspective

Why bother with PCI – you can‘t keep it open

anyhow Binary angiographic restenosis with balloon vs BMS

Woehrle CTO Workshop Munich 2005

Stenting in CTOs: long and multiple stents required

Werner et al. J Am Coll Cardiol 2003;42:219-25

1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tie

nts

[%

]

Number of implanted stents

No TVF Restenosis Reocclusion

1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tie

nts

[%

]



1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tie

nts

[%

]



1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tie

nts

[%

]



Published studies using DES in CTOs

Hoye Ge Nakamura Prison II PACTO

Stent Cypher Cypher Cypher Cypher Taxus

Patients 56 122 60 100 95

Reference diameter [mm]

2.35 2.67 3.12 3.38 2.65

Stent length 24 42 36.5 32 40

Stents per lesion 2.0 1.4 1.4 ? 1.4 1.7

TVF 9 % 9 % 3 % 8 % 10 %

Reocclusion 3 % 2.5 % 0 % 4 % 1 %

Follow-up 59 % 83 % 75 % 94 % 100 %

Events in PRISON II: BMS vs. Cypher

Suttorp et al. TCT 2005

30 90 150 0 60 120 210 180 240 270

Days Since Index Procedure

300 330 360

100%

90%

80%

70%

Fre

edom

of T

LR

TAXUS MR Control

9 mos. 12 mos.

P=0.0003

91.3 %

79.4 %

Control=bare metal stent

TAXUS= TAXUSTM stent

TAXUSTM MR stent is not available for sale

CTO vs. Complex Nonocclusive Lesions (Taxus VI)

12%

NNT 8

Werner et al. J Am Coll Cardiol 2004;44:2301-6

35%

NNT 3

Long stenting no longer a problem for recurrence

2.75x32

3.0x32

3.0x28

3.0x32 3.5x8

2214/05 471/05

6 months later

Taxus restenosis in CTOs: focal

All nonocclusive restenosis were focal at the edges and

successfully treated with another Taxus stent ->99 % patency

95 pts

85 pts.

No TVF

10 pts.

TVF

93 pts.

9 pts.

Repeat PCI

6 months

1 pt. Reoccl.

No PCI

9 pts. *)

No TVF 12 months

1 pt. Late

Reoccl.

Longterm patency

Werner GS et al; ACC 2006

0

2

4

6

8

10

12

Overall Cardiac Death

TLR MI

1.7% n=1

1.7% n=1

6.7% n=4

Inc

ide

nc

e (

%)

N = 65/778 Patients

WISDOM 12-Month TAXUS Related

Cardiac Events: Total Occlusions

3.3% n=2

Only 8.4% !!!

0

2

4

6

8

10

Overall Cardiac Death

Treated Vessel Re-intervention

MI

2.2% n=4 1.1%

n=2

4.3% n=8

Inc

ide

nc

e (

%)

N = 186/3688 Patients

MILESTONE II 12-Month TAXUS Related

Cardiac Events: Total Occlusions

1.6% n=3

Stent thrombosis = 1.0% (2/186)

Only 5% !!!

Opening a CTO …

• Improves symptoms (angina, dyspnea)

• Improves LV function

• Improves prognosis

• Can be kept open with DES

• Why are they still undertreated ?

CTO success rates

1995/96 1997/98 1999/01 2001/03

Penetration power of dedicated wires

New wire techniques

Mitsudo; www.tctmd.com

Parallel wire technique - example

230/05

Parallel wire technique with ASAHI

Miracle Bros and Conquest wires

Case example: Double blunt occlusion

12/05/06

Blunt proximal cap with 2 large sidebranches and blunt distal cap with one large side branch.


12/05/06

Bilateral approach: Confianza Pro over Spectranetics versus Miracle 3G over Transit


12/05/06

Bilateral approach: A major new option for 2nd attempts But the majority of CTOs are not treated in live courses

Determinants of procedural success

• Experience, dedication and patience

of interventionist

• Duration of occlusion

• < > 2 weeks

• < > 3 months

• < > 12 months

• Angiographic criteria … not many

• Heavy calcification

• Vessel tortuosity

PCI of CTOs is dangerous … really ?

Bahrmann et al. EuroInterv 2006;2:231-7

Why do we not apply what is possible ?

1995/96 1997/98 1999/01 2006

CTO – The European reality

• Opening a CTO …

• Costs a lot of lab time

• Costs a lot of work time

• Costs a lot of material

• Costs a lot of radiation exposure

• Requires a lot of patience

• Does not pay in our reimbursement system

gerald s. werner, md, fesc, facc klinikum darmstadt, germany · chronic total occlusions update a...

Documents