CTO Re vascularization in 2013

Transcription

1 CTO Re vascularization in 2013 Is it safe to use/stent the sub intimal space? Dimitri Karmpaliotis, MD, FACC, FSCAI Interventional Cardiology Piedmont Heart Institute Atlanta, Georgia SCAI, CTO Training Series, June,

2 Disclosures As a faculty member for this program, I disclose the following relationships with industry: Speakers Bureau for Abbott Vascular, MDT vascular, Asahi, and Boston Scientific (BPM) PHI has received educational grant from Bridgepoint Medical/Boston Scientific PHI has recdeived research grant from MDT vascular

3 Hybrid Strategy Treatment Algorithm Brilakis, Karmpaliotis, Lembo, Kandzari, Burke,Grantham, Thompson, Lombardi, et al.

4 Bridgepoint device

5 A successful subintimal tracking and re entry technique was associated with a 57% of reocclusion rate. J Am Coll Cardiol. 2013;61(5): doi: /j.jacc

6 Sub intimal wiring/stenting How accurate are we in predicting it while it`s happening? Are all dissections created equally? How relevant are the data from STAR registries? What are the available outcomes data for contemporary CTO PCI? Is the presence or absence of sub intimal stenting the only possible predictor of acute or long term outcome? Is there a difference whether a dissection is created Antegrade or Retrograde? How does sub intimal stenting affect the safety and the durability of the CTO PCI?

7 Sub intimal wiring/stenting How good are we are in predicting it while it happens?

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25 Which case resulted in stent deployment within the sub intimal space? ALL OF THEM!

26 You re there whether you plan it or not 48 CTO s crossed predilated with 1.5 or 2.0mm balloon then IVUS passed 9% of all antegrade cases had subintimal wire passage 40% of all retrograde wiring cases had subintimal wire passage JACC Cardiovasc JACC Cardiovasc Int Sep;2(9): Int Sep;2(9):846 54

27 Not all dissections are created equally!

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48 Why is the following antegrade dissection/reentry different from a retrograde Reverse CART?

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56 ACE CTO 100 Patients NCT Baseline 1 m 6 m 8 m 12 m Successful CTO crossing and stenting with EES (n=100) FU angiography + IVUS +OCT Clinical FU Clinical FU Clinical FU Brilakis et al TCT 2013 Primary endpoint 8 month incidence of in stent binary angiographic restenosis

57 CTO PCI approach All pts n = 100 Antegrade dissection/re-entry crossing 44 attempt (%) Retrograde crossing attempt (%) 35 Final successful crossing technique (%) - Antegrade wire escalation 51 - Antegrade dissection/re-entry 24 - Retrograde 25 IVUS guidance (%) 68 Brilakis et al TCT 2013

58 Procedural information All pts n = 100 Number of stents implanted* 3.3 ± 1.3 Patients with overlapping stents (%) 94 Total stent length (mm)* 85 ± 34 Stent diameter (mm)* 2.8 ± 1.1 Maximum dilatation pressure (mmhg)* 19.5 ± 4.5 Total procedure time (min)* 159 ± 76 Total fluoroscopy time (min)* 42 ± 24 Total air kerma radiation exposure (Gray)* 4.7 ± 2.1 Total contrast volume (ml)* 373 ± 169 Brilakis et al TCT 2013 * mean ± standard deviation

59 Restenosis type 80 lesions with angiographic FU Occlusive 10% Diffuse 16% Focal 19% No restenosis 55% Brilakis et al TCT 2013

60 Limitations Single center study Nearly all men Highly complex lesion and patient group No other stent comparator arm Losses to angiographic FU Follow up angiography could increase revascularization rates IVUS/OCT analysis pending Brilakis et al TCT 2013

61 Dissection and Re entry Techniques Kimura and Katoh, Toyohashi CCT patients total 79 cases by CART (52%), 11 by reverse CART (7%). 12 month clincal follow up (83%): TLR: 13% TVR: 16% Death: 3 (non cardiac 3) MACE: 2.9% Angiographical follow up (61%) Restenosis : 24% Re occlusion: 4%

62 J PROCTOR Antegrade wiring 10%, Retrograde 25% Tsuchikane TCT 2012 and LM/CTO Summit 2013

63 Tsuchikane`s Conclusion No clinical negative impact by EES implantation after localized Sub intimal tracking in either antegrade or retrograde manner was demonstrated in this study. Tsuchikane TCT 2012 and LM/CTO Summit 2013

64 Hybrid Strategy Treatment Algorithm Brilakis et al.

65 Contemporary CTO Revascularization Achievement of Procedural Success Through Advanced Technique 145 Patients, 160 CTO Lesions Piedmont Hospital, 10/ /2010 Indications Karmpaliotis, Lembo, Kandzari: Catheter Cardiovasc Interv Apr 11. Angina, 60% Heart failure/arrhythmia, 18% Provocative ischemia on non invasive testing, 13% Procedural Characteristics Right coronary artery, 54% In stent occlusion, 10% Retrograde wire placement, 38% Average stent length, 64.7±30.7 mm Procedural and In Hospital Outcomes Procedural success, 85.6% Death, 0.6% Emergency bypass surgery, 0.6% Myocardial infarction, 1.9%, Tamponade 0.6%

66 Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In Hospital Procedural Outcomes from a Multicenter Registry in the United States Author Year n Prior CABG (%) Septal collaterals used (%) Reverse CART (%) Technical Success (%) Major complications (%) Fluoroscopy time, min Contrast use, ml Sianos NR ± ± 167 Rathore NR NR NR Kimura ± ± 199 Tsuchikane ± ± 169 Morino NR 79.2 NR* NR* NR* Karmpaliotis* ± ± 177 Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv Dec;5(12):

67 Summary of large contemporary registry publications of percutaneous coronary interventions of chronic total occlusions Author Year N (CTO lesions) Prior CABG Diabetes Retrograde Technical Success Major complicati ons Death Tampona de Fluoroscopy time (minutes) Contrast use, (ml) Rathore NR NR Morino NR (1-301)* 293 (53-1,097)* Galassi ± ±184 U.S ± ±158 Registry* *Tesfaldet, Karmpaliotis, Brilakis, Lembo, Lombardi, Kandzari. Am J Cardiol 2013 In Press * median (range)

68 Summary of large contemporary CTO PCI registry publications that reported outcomes for the subgroup of patients with prior CABG. Author Year N (CTO lesions) Prior CABG, (%) Prior CABG in successf ul PCI group (%) Prior CABG in unsucce ssful PCI group (%) Overall, retrogra de (%) Overall, technic al Succes s (%) Overall, major complicati ons (%) Overall, fluoroscopy time, min Overall, contrast use, ml Olivari NR NR NR Rathore NR NR Morino NR NR NR 45 (1-301)* 293 (53-1,097) Mehran NR 68.0 NR NR 448±229 Galassi NR NR ± ±184 Jones NR NR NR U.S Registry* *Tesfaldet, Karmpaliotis, Brilakis, Lombardi, Lembo, Kandzari: The Heart Journal (BMJ) 2013 In Press ± ±158

69 Hybrid Success in Complex CTOs D. Daniels US CTO/LM Summit NY, 2013

70 Anecdotally Time tested >2000 BPM cases >10,000 Reverse CART cases Millions of antegrade wiring and POBA cases Where are all the deaths, MIs, tamponades, perforations, aneurysms etc????

71 Can We Safely Use the Subintimal Space? Yes We Can We can now intentionally Improves success and efficiency We must continue to study durability but safety is not an issue What is safer? SI use or failure/long procedures and wire perforations?

72 Can We Safely Use the Subintimal Space? Length and extent of dissections should be limited (good CTO PCI technique) Maintain major side branches (the goal should be to preserve them all) Vessel size, appropriate stent sizing, securing good outflow, stent length are probably more important for the durability of the procedure Do not stent if good outflow is not secured Larger studies with systematic clinical and angiographic follow up are needed