Chronic Total Occlusions. Stephen Cook, MD Medical Director, Cardiac Catheterization Laboratory Oregon Heart & Vascular Institute

Transcription

1 Chronic Total Occlusions Stephen Cook, MD Medical Director, Cardiac Catheterization Laboratory Oregon Heart & Vascular Institute

2 Financial Disclosures

3 /see -tee-oh / abbr. Med. Chronic Total Occlusion, a coronary artery that has been completely occluded for at least 3 months

4 Acute Acute Myocardial Infarction Occluded Coronary Artery Gradual Formation of Collateral Channels Scarred, non-viable myocardium Viable, but ischemic myocardium

5 CTO of the Right Coronary Artery

6 CTOs in Clinical Practice Prevalence Extent of Disease % 22% Overall prevalence 34% Multivessel disease CTOs Excluding normal/ minimal disease 66% Single vessel disease Strauss B, The Canadian CTO Registry, 7559 Patients, March-December 2008

7 Myths about CTOs The heart has bypassed the CTO Patients with CTOs are protected against future events

8 Ischemia in Collateralized CTOs Modified from Werner GS et al, European Heart Journal 2006, courtesy Werner GS

9 Symptoms of Coronary Artery Disease Sensitivity Specificity Fatigue Dyspnea Angina

10 Benefits of CTO Revascularization SAQ Health Status at 1 Month Angina Frequency 10 Physical Limitation 14 Quality of Life Effect of Procedural Success Grantham JA et al. Circ Cardiovasc Qual Outcomes 2010;3:

11 CTOs and Prognosis What s the Data? Incomplete revascularization New York State PCI database SYNTAX trial ACUITY trial Tolerance of acute ischemic events HORIZON AMI study Results of CTO intervention

12 Impact of Incomplete Revascularization on Long-Term Outcomes Mortality Risk Relative to Complete Revascularization vessel disease with no CTO 2 or more vessel disease with no CTO 1 CTO 2 vessel disease with at least 1 CTO Hannan EL et al. Circulation 2006; 113:

13 Effect of CTOs on Survival Following STEMI J Am Coll Cardiol Intv. 2009;2(11):

14 Effect of CTOs on Survival Following STEMI J Am Coll Cardiol Intv. 2009;2(11):

15 CTO Prognosis 2972 Patients with single vessel CTO, Medical Therapy PCI CABG year 5 years Intermountain Health Care

16 CTO Intervention Effect on Survival J Am Coll Cardiol Intv. 2012;5(4):

17 CTO Intervention and Mortality Am Heart J 2010;160:

18 Benefits of CTO Intervention Relief of angina Improved tolerance for future ischemic events Potential for mortality benefit Improvement of ischemic burden Improvement in LV function Freedom from CABG

19 70 year old Class III angina 2 anti-anginal medications MPI: reversible inferior defect

20 Pre-Procedure Post-Procedure

21 CTOs Current Treatment PCI CABG Med Tx CTO's Non-CTO's Am J Cardiol 2005;95:

22 CTO Pathology Early Late

23 Between a Rock and

24 Dissection-Reentry Crossboss Catheter Stingray Balloon & Wire

25 Dissection-Reentry

26 Dissection-Reentry

27 Retrograde Techniques

28 Reverse CART Technique Antegrade Retrograde

29 Reverse CART

30 The Hybrid CTO Approach Antegrade Guidewire Escalation Retrograde Techniques Dissection Reentry

31 Old: The angiogram tells you if you should attempt to open a CTO New: The angiogram tells you how to open it

32 The Hybrid CTO Approach Initial Planning Lesion Length <20mm, Good Distal Target Good Collaterals Lesion Length > 20mm Good Distal Target Good Collaterals Lesion Length<20mm Poor Distal Target Poor Collaterals Lesion Length>20mm Poor Distal Target, Good Collaterals or Ambiguous Antegrade Wire Escalation Dissection- Reentry Antegrade Wire Escalation Proximal cap Retrograde Dissection Reentry Retrograde Retrograde Antegrade wire escalation/last Dissection- Reentry Retrograde Antegrade Wire Escalation Reentry

33 The OHVI CTO Program Physicians Stephen Cook Sudeshna Banerjee William Lombardi Cath Lab Staff Administration Jade McAllister Chris Berry Nursing Staff Cath Prep & Recovery PCU

34 Results of Contemporary CTO Intervention Procedure time Fluoro time Contrast volume 145 +/ min / min /- 215 cc Stents/patient 2.6 +/- 1.1 Karmpaliotis et al., Cath Cardiovasc Interv 2012

35 Results of Contemporary CTO Intervention Lesion success 85.6% Major adverse cardiac events 2.8% Emergency CABG 0.6% Death 0.6% Karmpaliotis et al., Cath Cardiovasc Interv 2012

36 Perforation Complications of CTO Intervention Target vessel Collateral Donor vessel thrombosis Contrast nephropathy Radiation injury Access site bleeding

37 Bypass Surgery of CTOs The Prague-4 Trial Percent graft patency at one year Circulation 2004;110: LAD RCA Other branch

38 Restenosis after CTO Intervention The PRISON II Study In-segment In-stent Re-occlusion BMS DES

39 CTO Intervention A Patient s Story 1988 Myocardial Infarction Cath: Multivessel disease, including CTO of RCA CABG 1989 Recurrent angina Cath: Occlusion of Graft to RCA Medical therapy: Nothing can be done 2011 Moved to Oregon MPI: Large, severe reversible inferior defect Cath: CTO of RCA Class III angina despite medical therapy

40 CTO Intervention A Patient s Story

41 Should we open CTOs? Con Technically challenging Resource intensive Potential for complications Pro Patient benefit