Chronic Total Occlusions (CTO): The Final Fron er of Coronary Interven on CTO PCI

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1 Chronic Total Occlusions (CTO): The Final Fron er of Coronary Interven on Christopher D. Nielsen, M.D. Director, Adult Cardiac Cath Labs Medical University of South Carolina CTO PCI What is a CTO and how common is it Is there clinical jus fica on for CTO PCI What are the success rates for CTO PCI What are the predictors of success What are the outcomes a er successful CTO PCI What are the complica ons of CTO PCI How do we perform these procedures 1

2 What is a CTO? Complete occlusion of a coronary artery of over 3 months dura on CTO Prevalence and Treatment Pa ents with Coronary Artery Disease N = 14,439 Treatment of Pa ents with CTOs N = 1,697 CABG 26% CTO 18.4% Medical Therapy 44% Non- CTO PCI 20% A empted CTO- PCI 10% Fefer et al. JACC

PCI U liza on Dispropor onately Low in CTOs 50% 40% 30% 20% 10% CAD Treatment Strategies PCI CABG Med Rx 0% CTO N=1,612 No CTO N=1,475 BARI Registry Substudy Christofferson et al. Am J Cardiol 2005.

3 PCI U liza on Dispropor onately Low in CTOs 50% 40% 30% 20% 10% CAD Treatment Strategies PCI CABG Med Rx 0% CTO N=1,612 No CTO N=1,475 BARI Registry Substudy Christofferson et al. Am J Cardiol CABG is Not Always an Op on SYNTAX CTO Substudy 266 CTO pa ents randomized to receive CABG Bypassed 68% Not Bypassed 32% Reason not bypassed: Not intended to treat (n=12) Diseased (n=11) Inadequate conduit (n=2) Too small (n=19) Unable to find (n=1) Other (n=36) ITT, per lesion. 49.6% overall complete revascularization in CTO subset. Courtesy Patrick Serruys, Syntax CTO substudy, TCT

What are the clinical indica ons for CTO PCI? Symptom control and quality of life (1,2) Improved LV func on (3) Improved survival and decreased MACE (4) 1 Grantham JA et al.

4 What are the clinical indica ons for CTO PCI? Symptom control and quality of life (1,2) Improved LV func on (3) Improved survival and decreased MACE (4) 1 Grantham JA et al., Circula on: Cardiovascular Quality and Outcomes Safley D, Grantham JA, Jones P, and Spertus JA, ACC Kirschbaum SW et al. American Journal of Cardiology George, et al. JACC Ischemia in Adequately Collateralized CTOs No CTOs are Adequately Collateralized FFR in 59 pts a er successful wire crossing of a CTO Werner GS et al, European Heart Journal

5 Improved Symptom Control and Quality of Life CTO Baseline CTO 6 Month Non- CTO Baseline Non- CTO 6 Month 25 0 SAQ Physicial Limita on Score SAQ Angina Frequency Score SAQ Quality of Life Score 10- center prospec ve PCI registry N= 167 CTO cases Safley, Grantham, et al Cathet. Cardiovasc. Intervent. Impact of Successful CTO- PCI: Angina Angioi, et al. Drozd, et. al. Finci, et. al. Ivanhoe, et. al. Olivari, et. al. Warren, et. al. Total (n=1030) Joyal D, Afilalo J, Rinfret S. Am Heart J,

Improvement of LV func on with CTO- PCI Ejec on Frac on (EF) Segmental Wall Thickening (SWT) MRI assessment at baseline and at 6 months shows an improvement in EF and SWT in pa ents who had

6 Improvement of LV func on with CTO- PCI Ejec on Frac on (EF) Segmental Wall Thickening (SWT) MRI assessment at baseline and at 6 months shows an improvement in EF and SWT in pa ents who had successful CTO- PCI Paul et al, Heart Long Term LV Func on Improvement with CTO- PCI Most Significant Improvement with <25% Infarc on Before stent implanta on 5 months a er revasculariza on 3 years a er stent implanta on Improvements in LV volume maintained at 3 years Degree of transmurality of scar by MRI Kirschbaum SW et al. American Journal of Cardiology

7 Medical Therapy May Not be Enough Higher Ischemic Burden Correlated to Mortality 40% p= % Death or MI Rate 30% 20% 10% p= % p= % 0% 0.0% 0% (n=23) 1%- 4.9% (n=141) 5%- 9.9% (n=88) >10% (n=62) Ischemic Burden Shaw et al, Circula on 2008;117 Long term survival a er successful CTO PCI BCIS: Bri sh Cardiovascular Interven on Society George, et al. Long- Term Follow- Up of Elec ve Chronic Total Coronary Occlusion Angioplasty. JACC 2014;

8 Late (3 Years) Follow- Up of Successful Versus Unsuccessful Revasculariza on in Chronic Total Coronary Occlusions Treated by Drug Elu ng Stent 317 total pa ents, 196 successful Am J Cardiol 2012;110: ) Survival free of MACE Am J Cardiol 2012;110: ) 8

9 Survival free of MACE Am J Cardiol 2012;110: ) Euro Heart J

10 CTO Impact on Non- CTO Vessel AMI Mortality Higher 1- year Mortality Rate w/ CTO CTO is an independent predictor of mortality Van der Schaff RJ et al. Am J Cardiol CTO and Cardiogenic Shock CTO Is An Independent Predictor Of Mortality 100% 30 Day Mortality in Pa ents with Cardiogenic Shock 100% P < * 80% 60% 66% 40% 40% 20% 0% No CTO 1 CTO >1 CTO n=102 n=32 n=7 Bataille Y, et al. Am Heart J *comparison of event rates among 3 subgroups using Fischer s exact test 10

11 When is CTO- PCI Appropriate? Based on Pa ent Risk, Angina, and Medical Management Maximum Medical Therapy Class 0 Angina Class I/II Class III/IV No Maximum Medical Therapy Class 0 Angina Class I/II Class III/IV High Risk No Rx U U A High Risk Max Rx U A A Int Risk No Rx I U U Int Risk Max Rx U U A Risk Low Risk No Rx I I I Risk Low Risk Max Rx I U U Single vessel CTO Modified from Patel et al J Am Coll Cardiol 2009;53: ACC CTO- PCI Guidelines 2011 by the American College of Cardiology Founda on and the American Heart Associa on, Inc. All rights reserved. 11

12 Success rates Success rates vary by operator and experience J Am Coll Cardiol Intv 2015; 12

13 Factors associated with Cto PCI success J Am Coll Cardiol Intv 2015; J Am Coll Cardiol Intv 2015; 13

14 Complica ons 14

15 Factors associated with Cto PCI complica ons J Am Coll Cardiol Intv 2015; J INVASIVE CARDIOL

16 J INVASIVE CARDIOL 2014 J INVASIVE CARDIOL

TCTMD 2013 From: Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions: A Weighted

1016/j.jcin.2012.10.011 Figure Legend: Pooled Complication Rates Pooled complication rates of chronic total occlusion percutaneous coronary interventions.

17 TCTMD 2013 From: Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions: A Weighted Meta-Analysis of 18,061 Patients From 65 Studies J Am Coll Cardiol Intv. 2013;6(2): doi: /j.jcin Figure Legend: Pooled Complication Rates Pooled complication rates of chronic total occlusion percutaneous coronary interventions. CABG = coronary artery bypass graft; CN = contrast nephropathy; MACE = major adverse cardiac events; MI = myocardial infarction; QWMI = Q-wave myocardial infarction. Copyright The American College of Cardiology. All rights reserved. 17

18 The technique for CTO interven on New Approach to Treat CTOs The Hybrid Strategy Retrograde Techniques Antegrade Dissec on Re- Entry Antegrade Wiring FOUR ANGIOGRAPHIC CHARACTERISTICS DICTATE STRATEGY Proximal cap ambiguity Lesion length Quality of distal target Suitability of interventional collaterals HYBRID STRATEGY PRINCIPLES Consistent evalua on approach Emphasizes procedural safety, success, and efficiency Minimizes radia on and contrast Quick transi on to alternate plans when failure mode occurs 18

19 The Hybrid Algorithm Clear Proximal Cap Good Distal Target YES NO Antegrade Retrograde YES NO Length < 20mm YES NO Wire Escalation FAIL Dissection Re- Entry (CrossBoss - Stingray ) Wire Escalation FAIL Dissection Re- Entry (Reverse CART) FAIL FAIL Dissection Re-Entry (Reverse CART) Dissection Re-Entry (CrossBoss - Stingray ) Antegrade Wire Escala on Soft-tipped polymerjacketed Excellent Steerability Poor Penetration Moderate stifftipped polymerjacketed Good Steerability Moderate Penetration Excellent Penetration Easier Perforation Heavy tipped non-polymerjacketed 19

20 Antegrade Dissec on Re- Entry CTO crossing through the subintimal space, advancing across the occlusion, re-entering into the distal true lumen Coronary CTO Crossing and Re- entry System CrossBoss Catheter Designed to quickly and safely deliver a guidewire via true lumen or subin mal pathways S ngray Catheter Designed to accurately target and re- enter the true lumen from a subin mal posi on

21 1. 2. Microcatheters VascularPerspec ves Images provided by Boston Scientific. Results from case studies are not predictive of results in other cases. Results in other cases may vary.

22 Retrograde Techniques Dissec on Re- Entry Techniques: Reverse CART Illustra on by Dr. J C Spra / VascularPerspec ves, 22

23 Procedural Success Rates Over Time Operators with Retrograde Skills >90% Success Retrograde Operators Antegrade Operators Dartmouth North Cascade Mul center CTO Registry, Thompson CA, Lombardi WL Predictors of success 23

24 J Am Coll Cardiol Intv Int J Cardiovasc Imaging (2013) 24

Int J Cardiovasc Imaging (2013) Coronary ComputedTomographic Prediction Rule for Time-Efficient Guidewire Crossing Through Chronic Total Occlusion Insights From the CT-RECTOR Multicenter Registry

25 Int J Cardiovasc Imaging (2013) Coronary ComputedTomographic Prediction Rule for Time-Efficient Guidewire Crossing Through Chronic Total Occlusion Insights From the CT-RECTOR Multicenter Registry (Computed Tomography Registry of Chronic Total Occlusion Revascularization) Maksymilian P. Opolski, MD,*y Stephan Achenbach, MD,z Annika Schuhbäck, MD,z Andreas Rolf, MD,* Helge Möllmann, MD,* Holger Nef, MD,x Johannes Rixe, MD,x Ma hias Renker, MD,x Adam Witkowski, MD,y Cezary Kepka, MD,k Claudia Walther, MD,* Chris an Schlundt, MD,z Artur Debski, MD,y Michal Jakubczyk, MSC,{ Chris an W Hamm MD*x 25

26 JACC Interven ons Feb 2015 JACC Interven ons Feb

27 JACC Interven ons Feb 2015 JACC Interven ons Feb

28 JACC Interven ons Feb 2015 JACC Interven ons Feb

29 Chronic Total Occlusions (CTO): The Final Fron er of Coronary Interven on Christopher D. Nielsen, M.D. Director, Adult Cardiac Cath Labs Medical University of South Carolina 29

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

Chronic Total Occlusions. Stephen Cook, MD Medical Director, Cardiac Catheterization Laboratory Oregon Heart & Vascular Institute Chronic Total Occlusions Stephen Cook, MD Medical Director, Cardiac Catheterization Laboratory Oregon Heart & Vascular Institute Financial Disclosures /see -tee-oh / abbr. Med. Chronic Total Occlusion,