Trattamento delle CTO Indicazioni e risultati

Transcription

1 Trattamento delle CTO Indicazioni e risultati Prof. Alfredo R. Galassi MD, FESC, FACC, FSCAI Department of Medical Sciences and Pediatrics, University of Catania, Italy and University Heart Center, University Hospital Zurich, Switzerland

2 Andreas Gruentzig First Percutaneous Coronary Angioplasty in humans 15 September 1977

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4 . pertanto le occlusioni totali sono un problema reale Se non risolviamo il problema delle occlusioni totali, probabilmente non saremo mai in grado di risolvere il problema dell angioplastica nel paziente multivascolare Andreas Gruentzig 2 settimane prima della sua morte avvenuta in un incidente aereo (27, Ottobre 1985) quando aveva 46 anni

5 30 anni dopo!!!!!!

6 Euro Cto Club Founding Meeting Paris Carlo Di Mario was the photographer Joachim Buettner Gerald Werner Dariusz Dudek George Sianos Alfredo R Galassi Nicolaus Reifart

7 CTOs are common and influence management Analysis of consecutive patients undergoing angiography ( ), CTO was found in 52% patients with significant (> 70% DS) coronary disease Christofferson et al, Am J Cardiol 2005

8 The Canadian Multicenter CTO Registry April July 2009 (3 centers) Patients with chronic total occlusion (CTO) n=1697 CTO prevalence 18.4% PCI n=515 30% Medical Therapy n=747 44% CABG n=435 26% Attempted CTO PCI n=162 10% Successful CTO PCI n=123 7% CTO bypassed n=388 (90% of operations) 23% Overall, 30% of CTOs revascularized! Christofferson et al, AJC Fefer 2005 P et al, JACC 2012

9 1777 patients enrolled with 1968 CTO lesions CTO prevalence 13.3% Christofferson et al, AJC % 44% PCI 776 pts Optimal medical therapy 826 pts 10% CABG 175 pts Tomasello D et al, Eur Heart J 2015

10 Galassi et al, Eur Heart J 2015

11 Indications of CTO revascularization according to symptoms, ischemia and viability Galassi et al, Eur Heart J 2015

12 Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium

13 Procedural complications and in-hospital outcome Galassi et al, EuroIntervention 2011

14 Online Registry

15 Angiographic Success %

16 Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium

17 Galassi AR et al, on behalf of the Euro CTO Club Overall Antegrade Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy Retrograde George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium

18 Galassi AR et al, on behalf of the Euro CTO Club Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium

19 Galassi AR et al, on behalf of the Euro CTO Club Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium

20 Survival free from MACCE and cardiac death in pts (No: 619) treated with PCI or medical therapy after propensity score adjustment Tomasello D et al, Eur Heart J 2015

21 Procedural Complications 2,5 2,2 2,5 2,3 2,5 2 1,9 1,5 1,5 1 0,5 1,2 1, ,8 0,8 0,6 0,5 0,5 0,5 0,3 0,9 0,3 0,3 0,3 1 0,7 0,7 0,6 0,8 0,5 1 0,8 0,5 0,6 0,6 0,5 0,5 0,5 0,5 0,4 0 0,1 0,08 0,07 0 0, Death Myocardial infarction Coronary perforation Cardiac tamponade Vascular complication Donor vessel dissection

22 Consensus on Indications and Strategy Best treatment for CTO is the result of: - Careful review of clinical history - Sensitive non-invasive assessment of myocardial ischemia and viability in CTO related territory - Patient risk profile assessment (complete revascularization in multivessel patient); patient selection is crucial - Life expectancy (younger and older youth) - LAD CTO - Non-LAD CTO but main vessel ischemic area related CTO - Radiation, contrast load and complication risk assessment (balance success vs failure) Consensus of Euro CTO Club Eurointervent 2012

23 Conclusions The European Strategy 1. Antegrade success (approx 85%) stable from 2010 onwards (last 5 years) 2. Retrograde procedures: a) mostly staged b) increased significantly from 2010 onwards (up to 30% in 2014) c) more complex lesions, more time consuming, more fluoroscopy time, more dye to be used 3. Retrograde operators higher success than non retrograde operators (90% vs 80%) 4. Severe complications < %

24 Thank you for your attention