Chronic Total Occlusions: The Road Less Traveled
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Transcript of Chronic Total Occlusions: The Road Less Traveled
The Road Less Travelled: Update on Percutaneous Coronary Interventions (PCI)
for Chronic Total Occlusions (CTO)
M Nicholas Burke, MDMinneapolis Heart Institute and Foundation
Chronic Total OcclusionsBackground
NHLBI Dynamic Registry and BARI Study 1997-1999, n=1,761
•Presence of Total Occlusion 31%•Attempted Total Occlusion 7.5%
Srinivas et al. Circ 2002
Chronic Total OcclusionsEffect on therapy
Christofferson AJC 2005
CTO PCI: Why don’t we do it?
•Because the artery is closed•Because the damage is done•Because it can’t get any worse•Because restenosis rates are
high•Because it’s no big deal
Kleisli T. et al.; J Thorac Cardiovasc Surg 2005;129:1283-1291
Cumulative unadjusted survival from all-cause and cardiac death in surgical patients with CRV and IRV
Incomplete Revascularization with PCIIncomplete Revascularization with PCIWhat is the effect?What is the effect?
Long term outcomes of ‐ complete versus incomplete revascularization after drug eluting ‐stent implantation in patients with multivessel coronary disease
Catheterization and Cardiovascular Interventions16 APR 2013 DOI: 10.1002/ccd.24799
Chronic Total Occlusions PCI
Most frequently heard arguments against doing CTO’s:
1: I don’t need to do it because it’s well collateralized
Collaterals Are Rarely Sufficient To Substantially Reduce Ischemia In CTO
Modified from Werner GS et al, European Heart Journal 2006, courtesy Werner GS
Chronic Total Occlusions PCI
Most frequently heard arguments against doing CTO’s:
1: I don’t need to do it because it’s well collateralized
2: I’ve turned multivessel disease into single vessel disease
CTO of Non IRA and STEMI-CTO of Non IRA and STEMI-Double JeopardyDouble Jeopardy
J. Am. Coll. Cardiol. Intv. 2009;2;1128-1134
Hannan E L et al. Circulation 2006;113:2406-2412
Impact of completeness of revascularization and/or presence of CTO on mortality
21954 Patients without acute MI or LMD between 1997-2000
Chronic Total Occlusions PCI
Most frequently heard arguments against doing CTO’s:
1: I don’t need to do it because it’s well collateralized
2: I’ve turned multivessel disease into single vessel disease
3: CTO’s represent “stable coronary disease” (ie COURAGE patients)
Courage Trial Rates of Death or MI by Residual Ischemia
De
ath
or
MI
Ra
te (
%)
0%(n=23)
p=0.023
p=0.063
1%-4.9% (n=141)
5%-9.9%(n=88)
>10%(n=62)
Shaw et al, Circ 2008;117
P=0.002
Chronic Total Occlusions PCI
Most frequently heard arguments against doing CTO’s:
1: I don’t need to do it because it’s well collateralized
2: I’ve turned multivessel disease into single vessel disease
3: CTO’s represent “stable coronary disease” (ie COURAGE patients)4: There isn’t randomized data showing benefit
Chronic Total Occlusions PCI
Really?
Really?
THEN WHY HAVE YOU BEEN DOING PCI ON STABLE PATIENTS
FOR ALL OF THESE YEARS?
Did you have randomized data showing benefit ?
CTOs: What are we trying to do?
1. Make People Feel Better (improve symptoms)
2. Make People Live Longer (avoid future events)
CTOs: What are we trying to do?
Medical therapy
Let’s look at the evidence
Myocardial IschemiaTherapy: NitratesMyocardial IschemiaTherapy: NitratesTo Improve SymptomsTo Improve Symptoms
Am J Cardiol 72 1993
Long-Term Nitrate Use in CAD
AHJ 138(3) 1999
Myocardial IschemiaTherapy: NitratesTo Reduce Future Events (?)To Reduce Future Events (?)
Myocardial IschemiaTherapy: CCBTo Reduce Future Events (?)To Reduce Future Events (?)
Myocardial IschemiaTherapy: CCBTo Reduce Future Events (?)
Circ. Vol. 90 (2) 1994
Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future Events To Reduce Future Events
Wait for It….
Yup, that’s all there is
Myocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
Editorial conclusion:
“BB are of no use in stable CAD Patients”
And remember, these are INTERNISTS talking
Chronic Total Occlusion Revascularization:To Improve Mortality
73.5%
65%
71.9%
Per
cen
t S
urv
ivin
g50
SuccessMatched SuccessFailure
70
80
90
100
P = 0.002
60
“A successful revascularized [CTO] confers a significant 10-year survival advantage compared with failed revascularization.”Suero et al., J Am Coll Cardiol 2001.
Years
0.001
Chronic Total Occlusion Revascularization:To Improve Mortality
META ANALYSIS Successful vs Failed CTO PCI
Joyal D, Afilalo J, Rinfret S. Am Heart J 2010
Favors Failure
PCI success PCI failure Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total WeightM-H. Random,
95% Cl M-H, Random,
95% CI Angioi et al. 3 93 9 108 3.4% 0.37 [0.10, 1.40]Aziz et al. 9 377 12 166 6.7% 0.31 [0.13, 0.76]Drozd et al. 7 280 5 149 4.3% 0.74 [0.23, 2.37]Finci et al. 5 100 3 100 2.9% 1.70 [0.40, 7.32]Hoye et al. 37 567 36 304 14.4% 0.52 [0.32, 0.84]Ivanhoe et al. 3 317 7 163 3.2% 0.21 [0.05, 8.83]Labriolle et al. 7 127 2 45 2.4% 1.25 [0.25, 6.27]Noguchi et al. 7 134 15 92 6.1% 0.28 [0.11, 0.72]Olivari et al. 2 286 3 83 1.9% 0.19 [0.03, 1.14]Prasad et al. 229 914 101 348 21.6% 0.82 [0.62, 1.08]Suero et al. 395 1491 180 514 23.8% 0.67 [0.54, 0.83] Valenti et al. 17 344 17 142 9.3% 0.38 [0.19, 0.77] Warren et al. 0 26 0 18 Not estimable
Total (95% CI) 5056 2232 100.0% .56 [0.43, 0.72]Total events 721 390
Heterogeneity: Taux = 0.06; Chix = 18.74, df = 11 (P= .07); P= 41%Test for overall effect: Z = 4.39 (P< .0001) 0.1 1 10 100
Favors Success
Source: American Heart Journal ©2010 Elsevier
CTO PCI: Why don’t we do it?(the REAL reason)
BECAUSEIT’S
HARD TO DO(and Interventionalists hate to fail)
CTO PCI: why is it so difficult?
• All PCI is predicated on getting a wire from the proximal to distal lumen to deliver balloons and stents
• Wires follow the path of least resistance• CTOs are very sclerotic and calcified• The path of least resistance is generally
between layers of vessel wall in a dissection
• It is extremely difficult to exit a dissection
Chronic Total Occlusion RevascularizationNew Tools and Technology
Things that have not worked:• Drills• Jackhammers• Lasers• RFA• IR• Blunt micro-dissection• Lytics
Chronic Total Occlusion RevascularizationBasic Precept of the Hybrid Strategy
The ultimate crossing goal in CTO PCI is to have a single wire connecting the proximal and distal true lumens. It
doesn’t matter whether: 1) the wire is true lumen or subintimal
within the body of the CTO2) the wire is coming from an antegrade or
retrograde direction
Chronic Total Occlusion RevascularizationThe CrossBoss™ CTO Catheter DesignThe CrossBoss™ CTO Catheter Design
• Multi-wire coiled shaft
• Tracks via FAST Spin Technique
– Highly torqueable coiled-wire shaft
– FAST Spin reduces push required to cross CTO
• Atraumatic distal tip advanced across a CTO ahead of the guidewire
• OTW 0.014” guidewire compatible
CrossBoss is designed to quickly and safely deliver a guidewire via true lumen or subintimal pathways
Chronic Total Occlusion RevascularizationThe Stingray™ CTO Re-Entry System Design
Unique self-orienting balloon has a flat shape for
true lumen targeting
180° opposed and offset exit ports for selective
guidewire re-entry
Re-entry probe at Stingray
Guidewire tip
Compatibility:6Fr. Guide/0.014” Wire
2.9Fr. shaft profile
Stingray System (catheter and guidewire) is designed to accurately target and re-enter the true lumen from a subintimal position
BridgePoint System
Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: Retrograde
Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART
Surmely JF: J Invasive Cardiol. 2006 Jul 18(7):33408
Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART
Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART
Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART
Case Presentation: SD
• 42 yo pt WF with FH and Tobacco Abuse
• Admitted 12/12 with NSTEMI
• Angiogram:
SD continued
SD continued
SD continued
SD continued
• Discharged to Home on Medical Therapy
• Try to Quit Smoking
SD continued
• Readmitted 3/13 with USA
• ECG with CP: Inferior ST depression
• Angiogram: NO CHANGE
• TIME to FIX THIS THING
SD continued
SD continued
SD continued
SD continued
SD continued
Case Presentation: TL
• 42 yo pt w/Hx PE
• Referred for c/o DOE
• Stress Echocardiogram EF 35% global•7’35” SOB, worsening inferior wall function
• Angiogram:
Case Presentation: TL
TL continued
• Cardiac Rehab
– Exercise induced VT
TL continued: PCI
TL continued: PCI
TL contiued: PCI
TL continued
• Exercise stress test 2 weeks after PCI:
– 13’30” no VT
• Echo approximately 2 months after PCI:
– EF ~55%