Complication management and long-term outcome after percutaneous coronary intervention

Transcription

1 Complication management and long-term outcome after percutaneous coronary intervention ESC meeting 2012, Munich, Germany Session: Chronic total occlusion: a challenge for percutaneous coronary intervention Sunday 26 Aug 2012 (Room 62 - Village 6) Georgios Sianos, MD, PhD, FESC 1 st Department of Cardiology AHEPA University Hospital Thessaloniki Greece

2 I have nothing to disclose.

3 CTO PCI Complications Frequency Centre n Death QMI NQMI ecabg MACE MAHI**** MAYO*** TOAST-GISE** Toyohashi* *** Suero JACC 2001: 38,409 ( ) **Prasad JACC 2007:49:1611 **Olivari, et al, JACC 2003;41:1672. TOAST-GISE *Rathore JACC Card Int 2009:2,6:489 ( )

4 Frequency Annualized event rate similar to non-cto cohort Suero, et al, JACC 2001;38:409. In-Hospital Complications CTO n=2007 Non-CTO n=2007 p-value Death 27 (1.3) 17 (0.8) 0.13 Q-wave MI 10 (0.5) 12 (0.6) 0.67 Non-Q-wave MI 38 (1.9) 48 (2.4) 0.27 Urgent CABG 15 (0.7) 22 (1.1) 0.25 Urgent Re-PCI 30 (1.5) 40 (2.0) 0.23 CVA 1 (0.01) 3 (0.1) 0.63 Vascular 34 (1.7) 50 (2.5) 0.08 MACE 76 (3.8) 75 (3.7) 0.9

5 What can go wrong during CTO PCI Dissection of the occluded artery Vessel perforation Aortic dissection Contrast Induced Nephropathy (CIN) Radiation complications

6 CTO dissection Frequency Suero, et al, JACC 2001;38:409. In-Hospital Complications CTO n=2007 Non-CTO n=2007 p-value Death 27 (1.3) 17 (0.8) 0.13 Q-wave MI 10 (0.5) 12 (0.6) 0.67 Non-Q-wave MI 38 (1.9) 48 (2.4) 0.27 Urgent CABG 15 (0.7) 22 (1.1) 0.25 Urgent Re-PCI 30 (1.5) 40 (2.0) 0.23 Any Dissection 357 (17.8) 267 (13.3) <0.001 CVA 1 (0.01) 3 (0.1) 0.63 Vascular 34 (1.7) 50 (2.5) 0.08 MACE 76 (3.8) 75 (3.7) 0.9

7 CTO artery dissection Wire dissections are an inherent part of CTO recanalisation procedure and not necessary a complication STAR Subintimal connection techniques Guiding catheter dissections are mostly unintended and should be avoided

8 GC CTO artery dissection PREVENTION: Prefer sideholes (for the right) and limit antegrade injection in proximal occlusions

9 Perforation: Classification Ellis Circulation 1992, 88 : I-787 Class Definition 1 Extraluminal crater without contrast extravasation 2 Pericardial or myocardial blush without contrast jet extravasation 3 Contrast jet extravasation through > 1mm perforation

10 CTO : Perforation

11 CTO Perforation Frequency Centre n Type 1 Type2 Total Tamp MAHI*** % 0.5% MAYO** % Toyohashi* % 1.4% 27.6% 1.5% *** Suero JACC 2001: 38,409 ** Prasad JACC 2007:49:1611 *Rathore JACC Card Int 2009:2,6:489

12 CTO : Perforation Causes Culprit Incidence Guidewire tip 88% Balloon inflation 6% Stent deployment 4% Rotablator 2%

13 Type 1 Perforation Management Watchful waiting

14 Type 2 Perforation Management Hydrophilic / CTO wires Distal perforation Reverse anticoagulation (partially) Embolisation : gelfoam /microshperes coils blood clot thrombin subcutaneous fat negative pressure suction via microcatheter

15 Type 3 Perforation Management Reverse anticoagulation Prolonged balloon inflation (tolerated) Cardiac Tamponade - echo Pericardiocentesis : pigtail Inotropes Access left femoral : 2 nd guiding catheter/ptfe stent Surgery

16 CTO Perforation Avoidance CTO wire : exchange for floppy wire after crossing CTO Hydrophilic wire : watch distal wire tip Avoid balloon oversizing : BA ratio < 1.2 : 1.0 Avoid stent oversizing : IVUS Calcified vessel preparation : Rotablator

17 Aortic Dissection CTO PCI Complications Frequency Centre Ao Dis Dissec Perf Tamp MAHI MAYO Toyohashi 1.0%

18 Iatrogenic Aortic Dissection Classification* Class Definition 1 Limited to ipsilateral coronary cusps 2 Cusps & prox ascending aorta (<40mm) 3 Cusps to aortic arch ( >40mm ) *William Beaumont Hospital 9 / 4314 patients ( ) Frequency 0.02% *Dunning CAthet Cardiovasc Intervent 2000;51:387

19 Aortic Dissection

20 Iatrogenic Coronary Aorto Dissection Causes Guide catheter trauma Injection of contrast : wedged catheter Balloon rupture Retrograde progression RCA dissection

21 Coronary Aorto Dissection Management Type 1 and 2 Dissection Minimise contrast injection Reverse anticoagulation Consider 5f Child catheter Stent intracoronary entry point dissection - coventional stent - covered stent Assess progression : TEE MSCT

22 Coronary Aorto Dissection Type 3 Dissection Management Surgical Intervention

23 Coronary Aorto Dissection Avoidance Amplatz guide : exercise caution Wedged catheter : do not inject contrast side hole catheter

24 Scheme to define contrast-induced nephropathy (CIN) risk score Mehran, R. et al. J Am Coll Cardiol 2004;44:

25 Avoidance of CIN Awareness of risk factors Optimize pre-procedure creatinine, hemodynamics Use of NAC, Bicarb drip, diuretics Appropriate contrast volume ~flouroscopic/guidewire clues ~microcatheter contralateral injections ~Biplane ~IVUS

26 Radiation: Differences between institutions Suzuki et al CCI 2008; 71: Technical factors Flat panel Biplane Projection plane Frame rate 2 patients of 72 with skin injury after 6.8 and 7.4 Gy, both with preferred projection 30 LAO 25 cranial, both 25 fr/s!!!

27 Protect your patient, and yourself Use every available physical shielding Avoid angulation for most of the time Use collimation as much as possible!!! Reduce frame rate but do not stop after 60 min fluoro if progressing, all the risk were wasted Adapted from G Werner

28 Limitations and complications of the current retrograde approach Occluded artery Retrograde perforation Retrograde dissection Collaterals Rupture/hematoma of the septal collaterals Perforation to the RV/LV Septal wire trapping Epicardial collateral rupture/perforation Epicardial flow disruption with ischemia Donor artery Spasm Dissection/thrombosis Others Inability to cross the collaterals Peri-procedural infarction

29 Summary PCI of a CTO is stable CAD treatment and must remain a safe procedure Some complications such as dissections are inherent in the procedure Perforations can be avoided by complete control of the wire position contralateral injection is essential!!! Contrast media induced damage Set a limit depending on the patients renal function, rather try again later Radiation induced damage Frequent change of projections and angulation/use collimation

30 Initial Success and Long-Term Follow-Up of Percutaneous Transluminal Coronary Angioplasty in Chronic Total Occlusions Versus Conventional Stenoses (retrospective study, n=982, CTO PCI technical success rate 51%) Group 1: 169 patients with CTO Group 2: 102 patients with functional total (99%) occlusion Group 3: 711 patients with conventional (70 to 95 % ) stenoses At 2 years of follow up41%( of patients in group 1 had sustained a late cardiac event (death, MI, CABG or repeat PTCA) compared with only 28% of patients in groups 2 and 3 {p <0.001). Safian et al, Am J Cardiol 1988;61:23G-28G

31 CTO PCI; Primary Success, Restenosis, and Long-term Clinical Follow-up (n=480, patients enrolled between , clinical success rate 66%) Freedom from cardiac death and the combined events of death, MI, and CABG over 48 months Ivanhoe et al, Circulation 1992;85:

32 CTO PCI; Primary Success, Restenosis, and Long-term Clinical Follow-up (n=480, patients enrolled between , clinical success rate 66%) Freedom from cardiac death or MI for patients with successful and unsuccessful procedures over 48 months Ivanhoe et al, Circulation 1992;85:

33 CTO PCI; Primary Success, Restenosis, and Long-term Clinical Follow-up (n=480, patients enrolled between , clinical success rate 66%) Freedom from CABG for patients with successful and unsuccessful procedures over 48 months Ivanhoe et al, Circulation 1992;85:

34 CTO PCI; determinants of Primary Success and Long Term (4.3 ±3.1 years ) Clinical Outcome (retrospective study, n=226, technical success rate 59.2%, procedures were undergone during ) A B C A: Freedom from cardiac death after PTCA B: Freedom from cardiac events after PTCA C: Freedom from the need for coronary CABG after PTCA Noguchi et al, Cathet. Cardiovasc. Intervent. 49: , 2000.

35 Procedural Outcomes and Long-Term Survival Among Patients Undergoing CTO PCI in Native Coronary Arteries: A 20-Year Experience (n=2007, patients enrolled between , technical success rate 72.3%) Suero et al, J Am Coll Cardiol 2001;38:409 14

36 Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience (retrospective study, n=874, CTO PCI technical success rate 65.1%) Hoye et al, European Heart Journal (2005) 26,

37 Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience (retrospective study, n=874, CTO PCI technical success rate 65.1%) Hoye et al, European Heart Journal (2005) 26,

38 Trends in Outcomes After Percutaneous Coronary Intervention for Chronic Total Occlusions. A 25-Year Experience From the Mayo Clinic (n=1262, Procedural success rates were 51%, 72%, 73%, and 70% (p 0.001) for the 4 groups) Prasad et al, J Am Coll Cardiol 2007;49:1611 8

39 Trends in Outcomes After Percutaneous Coronary Intervention for Chronic Total Occlusions. A 25-Year Experience From the Mayo Clinic (n=1262, Procedural success rates were 51%, 72%, 73%, and 70% (p 0.001) for the 4 groups) Prasad et al, J Am Coll Cardiol 2007;49:1611 8

40 5-year clinical outcomes of DES versus BMS implantation in patients with successful CTO recanalization (non-randomized study, BMS group as historical control, n=1184) Kaplan-Meier survival curves at 5 years. A: Cumulative survival rates. (90.3% for DES group vs 89.6% for BMS group, Log-rank P=0.38) B: TVR-free survival rates. (81.6% for DES group vs 73.5% for BMS group, Log-rank P <0.001). C: MACE-free survival rates. (80.6% for DES group vs 71.5% for BMS group, Log-rank P <0.001). Han Ya-ling, et al Chin Med J 2009;122(6):

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