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, a coronary artery that has been completely occluded for at least 3 months
Acute Acute Myocardial Infarction Occluded Coronary Artery Gradual Formation of Collateral Channels Scarred, non-viable myocardium Viable, but ischemic myocardium
CTO of the Right Coronary Artery
CTOs in Clinical Practice Prevalence Extent of Disease 25 20 15 17% 22% Overall prevalence 34% Multivessel disease 10 5 0 CTOs Excluding normal/ minimal disease 66% Single vessel disease Strauss B, The Canadian CTO Registry, 7559 Patients, March-December 2008
Myths about CTOs The heart has bypassed the CTO Patients with CTOs are protected against future events
Ischemia in Collateralized CTOs Modified from Werner GS et al, European Heart Journal 2006, courtesy Werner GS
Symptoms of Coronary Artery Disease Sensitivity Specificity Fatigue Dyspnea Angina
Benefits of CTO Revascularization SAQ Health Status at 1 Month Angina Frequency 10 Physical Limitation 14 Quality of Life 21-30 -20-10 0 10 20 30 Effect of Procedural Success Grantham JA et al. Circ Cardiovasc Qual Outcomes 2010;3:284-290
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
Impact of Incomplete Revascularization on Long-Term Outcomes Mortality Risk Relative to Complete Revascularization 1.4 1.2 1.25 1.35 1.36 1 0.8 1 0.6 0.4 0.2 0 1 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: 2406-2412
Effect of CTOs on Survival Following STEMI J Am Coll Cardiol Intv. 2009;2(11):1128-1134.
Effect of CTOs on Survival Following STEMI J Am Coll Cardiol Intv. 2009;2(11):1128-1134.
CTO Prognosis 2972 Patients with single vessel CTO, 1993-2002 25 20 23.2 15 10 10.3 13.6 16.6 Medical Therapy PCI CABG 5 6.4 6.0 0 1 year 5 years Intermountain Health Care
CTO Intervention Effect on Survival J Am Coll Cardiol Intv. 2012;5(4):380-388.
CTO Intervention and Mortality Am Heart J 2010;160:179-87.
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
70 year old Class III angina 2 anti-anginal medications MPI: reversible inferior defect
Pre-Procedure Post-Procedure
CTOs Current Treatment 50 45 49 40 35 30 25 20 15 40 36 28 35 PCI CABG Med Tx 10 5 11 0 CTO's Non-CTO's Am J Cardiol 2005;95:1088-1091
CTO Pathology Early Late
Between a Rock and
Dissection-Reentry Crossboss Catheter Stingray Balloon & Wire
Dissection-Reentry
Dissection-Reentry
Retrograde Techniques
Reverse CART Technique Antegrade Retrograde
Reverse CART
The Hybrid CTO Approach Antegrade Guidewire Escalation Retrograde Techniques Dissection Reentry
Old: The angiogram tells you if you should attempt to open a CTO New: The angiogram tells you how to open it
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
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
Results of Contemporary CTO Intervention Procedure time Fluoro time Contrast volume 145 +/- 74.2 min 67.4 +/- 45.5 min 403.2 +/- 215 cc Stents/patient 2.6 +/- 1.1 Karmpaliotis et al., Cath Cardiovasc Interv 2012
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
Perforation Complications of CTO Intervention Target vessel Collateral Donor vessel thrombosis Contrast nephropathy Radiation injury Access site bleeding
Bypass Surgery of CTOs The Prague-4 Trial 100 90 80 70 60 50 40 30 20 10 0 100 24 22 Percent graft patency at one year Circulation 2004;110:3418-3423 LAD RCA Other branch
Restenosis after CTO Intervention The PRISON II Study 45 40 35 30 25 20 15 10 5 0 41 36 11 13 7 4 In-segment In-stent Re-occlusion BMS DES
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
CTO Intervention A Patient s Story
Should we open CTOs? Con Technically challenging Resource intensive Potential for complications Pro Patient benefit