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Transcript of Coronary Chronic Total Occlusions: When, How and … Varghese/CTO PPT.pdf · Coronary Chronic Total...
![Page 1: Coronary Chronic Total Occlusions: When, How and … Varghese/CTO PPT.pdf · Coronary Chronic Total Occlusions: When, How and Why to Intervene . 2 ... Joyal D et al. Am Heart J 2010;](https://reader031.fdocuments.us/reader031/viewer/2022030401/5a7600b67f8b9a63638ceece/html5/thumbnails/1.jpg)
Vincent Varghese, DO, FACC, FSCAI Director, Interventional Cardiology Fellowship Program
Deborah Heart & Lung Center Browns Mills, NJ
Coronary Chronic Total Occlusions: When, How and Why to Intervene
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2
No relevant financial disclosures related to this discussion
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What is a CTO ?
Clinical Definition – Coronary CTOs are commonly encountered complex lesions defined as > 99% blockage for 3 months or more, and are responsible for a clinically significant decrease in blood flow (TIMI 0-1).
Practical Definition – Any fully occluded artery that the interventionalist can’t immediately cross with a workhorse wire
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Example
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Myths of Chronic Total Occlusions
CTO’s are a rare finding CTO’s rarely cause ischemia due to robust collaterals Medical therapy is fine CTO’s do not affect mortality CTO’s have a poor success rate
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Myth #1
CTO’s are rare
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Chronic Total Occlusions
▪ NHLBI Dynamic Registry and BARI study 1997-1999 ▪ n=1,761
▪ Presence of a total occlusion 31% ▪ Attempted total occlusion 7.5%
Srinivas et al. Circulation 2002
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CTO Canadian Registry
CTO’s identified in 1,697 (18.4%) patients with significant CAD
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Myth #2
CTO’s rarely cause ischemia
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Collaterals are usually not sufficient to significantly reduce ischemia in CTO
Werner GS et al. European Heart Journal 2006
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Effectiveness of Recanalization of CTO: A systematic review and meta-analysis
Effect on Angina55% reduction in anginal symptoms
Joyal D et al. Am Heart J 2010; 160: 179-87.
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64 year old female DM, HTN, Dyslipidemia S/P PCI DES LAD 2007 Coronary angiography for CCS class 3 angina LAD stent is patent….
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How would you treat this?
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Now, how would you treat this?
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Angioplasty Bypass Medical
Presence of a CTO influences treatment choices
With Occlusion (n=220) Without Occlusion (n=357)
Delacretaz et al, 1997
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Presence of a CTO influences treatment choices
Christofferson et al, AJC, 2005, 1088-91 and Grantham et al. JACC: 2009
BARI Registry Substudy
%
PCICABGMed Rx
11
40
49
36
28
25
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Myth #3
CTOs don’t affect mortality
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CTO PCI Success on MI rates
Joyal D et al. Am Heart J 2010; 160: 179-87.
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CTO PCI Success on mortality
Joyal D et al. Am Heart J 2010; 160: 179-87.
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Concept of “double jeopardy”
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CTO impact on (Non-CTO vessel) AMI mortality Concept of “double jeopardy”
Van der Schaaf RJ et al. Am J Cardiology 2006; 98: 1165
Mortality in 1,417 patients treated for STEMI with PCI
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0
25
50
75
100
Suero Kitano Hoye Prasad Aziz Butler
92.097.0
78.0
93.590.0
73.083.0
93.0
71.0
88.080.0
65.0
Success Failure
CTO Treatment and Improved Long-term Survival (all p <.05)
(10 y) (8 y) (8 y) (10 y) (2 y) (6 y)
Hoye et al. EHJ 2005
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Myth #4
CTO’s have a poor success rate
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Meta-analysis of 18,061 patients from 65 studies
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Success with the Hybrid Approach
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The Hybrid Algorithm for CTO PCIprovisional approaches
Dual Catheter Angiography
1. Clear proximal cap 2. Good Distal Target
3. Length < 20mm
Antegrade Retrograde
yes no
Wire escalation
Dissection Reentry (Crossboss-Stingray)
Wire escalation
Dissection Reentry (reverse CART)
yes yes nono
Dissection Reentry (reverse CART)
Dissection Reentry (Crossboss-Stingray))
fail
fail
fail
fail
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Hybrid Algorithm Angiographic Considerations
1. Proximal Cap Geometry • Clear starting point • Ambiguous/confusing • Flush Occlusion / Poor Guide Support
2. Occlusion Length • Always do Bilateral Injections • < 20mm – higher likelihood of successful guide wire
crossing • > 20 mm – lower likelihood guidewire success, higher
likelihood of entering the subintimal space
3. Distal Landing Zone • Important branch/bifurcation at distal cap • Highly diseased distal vessel
4. Presence of Interventional Collaterals • Is retrograde possible?
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Tool Box for CTO PCI
▪ Sheaths ▪ Guiding catheters ▪ Guide wires ▪ Microcatheters ▪ Snares and
externalization wires ▪ Complication
management
30
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Conclusions
1. CTO’s are not infrequent (15-30%)
2. Opening CTO’s reduce angina, collaterals insufficient.
3. Interventional Cardiologists often don’t attempt CTO (15%), but they do refer for surgery.
4. Although CTO’s likely do not cause STEMI, the presence of a CTO increases mortality during future events (NSTEMI)
5. High success rates can be achieved, with low complications, using Hybrid algorithm