BSIC, Manchester, September 15, Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany

Transcription

1 BSIC, Manchester, September 15, 2006 Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany

2 BSIC, Manchester, September 15, 2006 Chronic total occlusions update A European perspective Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany

3 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

4 Pathophysiology of collaterals in CTOs How to assess collaterals? What happens to collaterals after PCI? Can collaterals replace an open artery?

5 Assessment of collaterals: pressure and flow P Ao P Ao TCO Balloon Pressure/ Doppler Wire R Coll Pressure/ Doppler Wire R Coll P Occl APV Occl P Occl APV Occl R P R P RA Before recanalization Baseline collateral function RA Reocclusion after PTCA Recruitable collateral function Werner et al. Circulation 2001;104:

6 Number of patients Number of patients Collateral function in CTOs Before PCI 20 After PCI 20 79% 46% ,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 Collateral pressure index 0 0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 Collateral pressure index Werner et al. Circulation 2003;108:

7 Loss of collateral function not due to embolization Rcoll [mmhg/(cm*sec)] 0,0 0,5 1,0 1,5 2,0 maximale CK [µmol/(l*sec)] R-Quadrat = 0,01 Bahrmann et al. Z Kardiol 2002;91:

8 Number of patients Number of patients Number of patients Collateral function in CTOs Before PCI 20 After PCI 20 79% 46% ,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 Collateral pressure index 5 6 mo FUP ,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 15 Collateral pressure index 18% ,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 Collateral pressure index Werner et al. Circulation 2003;108:

9 Number of patients Number of patients Number of patients Evidence for preformed collaterals in man Before PCI 20 After PCI 20 79% 46% ,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 Collateral pressure index 5 6 mo FUP ,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 15 Collateral pressure index 18% 10 20% 5 0 0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 Collateral pressure index Wustmann et al. Circulation 2003;107: Werner et al. Circulation 2003;108:

10 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

11 Can good collaterals replace an open artery? 95% of collaterals are no substitute for the open artery

12 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

13 CTOs Should we treat them all? Improvement of symptoms (angina, dyspnea) Improvement of LV function Improvement of prognosis

14 Benefit of recanalisation on LV function No improvement in case of Reocclusion!!! Werner et al. Am Heart J 2005;149:129-37

15 Indication for revascularization: MRI function and vitality

16 LV recovery after recanalization of CTOs - MRI Baks T et al. JACC 2006;47:721-5

17 PCI success and survival 2000 Pat, 74% successful Suero et al. JACC 2001;38: Pat, 77% successful 871 Pat, 65% successful Hoye et al. Eur Heart J 2005;26: Ramanathan & Buller, ACC 2003

18 If PCI fails at least consider CABG But CABG seems to be only the second best option Suero et al. JACC 2001;38:409-14

19 A CTO left occluded makes life more dangerous

20 Leaving a CTO alone means taking risks in low risk patients PCI of CTO (n= 122) Non-CTO (n= 88) No PCI (n= 451) 0 Periprocedura l MACE Death within 12 months STAR Registry, Institute for infarct research, Ludwigshafen

21 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

22 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

23 Why bother, you can t open it most times CTO success rates historical perspective

24 Why bother with PCI you can t keep it open anyhow Binary angiographic restenosis with balloon vs BMS Woehrle CTO Workshop Munich 2005

25 Patients [%] Stenting in CTOs: long and multiple stents required No TVF Restenosis Reocclusion >2 Number of implanted stents Werner et al. J Am Coll Cardiol 2003;42:219-25

26 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

27 Published studies using DES in CTOs Hoye Ge Nakamura Prison II PACTO Stent Cypher Cypher Cypher Cypher Taxus Patients Reference diameter [mm] Stent length Stents per lesion ? TVF 9 % 9 % 3 % 8 % 10 % Reocclusion 3 % 2.5 % 0 % 4 % 1 % Follow-up 59 % 83 % 75 % 94 % 100 %

28 Events in PRISON II: BMS vs. Cypher Suttorp et al. TCT 2005

29 Freedom of TLR CTO vs. Complex Nonocclusive Lesions (Taxus VI) 100% 9 mos. 12 mos % 90% 80% 70% TAXUS MR Control P= Days Since Index Procedure 12% 35% NNT % TAXUS TM MR stent is not available for sale TAXUS= TAXUS TM stent Control=bare metal stent Werner et al. J Am Coll Cardiol 2004;44:2301-6

30 Long stenting no longer a problem for recurrence 3.0x32 3.5x8 3.0x28 3.0x x32 6 months later 2214/05 471/05

31 Taxus restenosis in CTOs: focal All nonocclusive restenosis were focal at the edges and successfully treated with another Taxus stent ->99 % patency

32 Longterm patency 95 pts 6 months 85 pts. No TVF 10 pts. TVF 9 pts. Repeat PCI 1 pt. Reoccl. No PCI 12 months 9 pts. *) No TVF 93 pts. 1 pt. Late Reoccl. Werner GS et al; ACC 2006

33 Incidence (%) WISDOM 12-Month TAXUS Related Cardiac Events: Total Occlusions N = 65/778 Patients Only 8.4%!!! % n=1 3.3% n=2 1.7% n=1 6.7% n=4 0 Cardiac Death MI TLR Overall

34 Incidence (%) MILESTONE II 12-Month TAXUS Related Cardiac Events: Total Occlusions 10 8 N = 186/3688 Patients Only 5%!!! % n=2 1.6% n=3 2.2% n=4 4.3% n=8 0 Cardiac Death MI Treated Vessel Re-intervention Overall Stent thrombosis = 1.0% (2/186)

35 Opening a CTO Improves symptoms (angina, dyspnea) Improves LV function Improves prognosis Can be kept open with DES Why are they still undertreated?

36 CTO success rates 1995/ / / /03

37 Penetration power of dedicated wires

38 New wire techniques Mitsudo;

39 Parallel wire technique - example Parallel wire technique with ASAHI Miracle Bros and Conquest wires 230/05

40 Case example: Double blunt occlusion Blunt proximal cap with 2 large sidebranches and blunt distal cap with one large side branch. 12/05/06

41 Case example: Double blunt occlusion Bilateral approach: Confianza Pro over Spectranetics versus Miracle 3G over Transit 12/05/06

42 Case example: Double blunt occlusion Bilateral approach: A major new option for 2nd attempts But the majority of CTOs are not treated in live courses 12/05/06

43 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

44 PCI of CTOs is dangerous really? Bahrmann et al. EuroInterv 2006;2:231-7

45 Why do we not apply what is possible? 1995/ / /

46 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

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