Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in...
-
Upload
vuongnguyet -
Category
Documents
-
view
223 -
download
0
Transcript of Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in...
![Page 1: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/1.jpg)
Optimal Revascularization
in Multivessel Disease
and Coronary CTO
Dr Simon Walsh MD FRCP FSCAI
Consultant Cardiologist
Belfast Trust
![Page 2: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/2.jpg)
Speaker's name: Simon Walsh
Consulting and Research Funding: Abbott Vascular
Consulting and Research Funding: Boston Scientific
Research Funding: Nitiloop
Consulting: Vascular Solutions
Potential Conflicts of
Interest
![Page 3: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/3.jpg)
Why treat CTOs at all?
• “Patients are protected by collaterals”
• “The lesions can’t get any worse”
• “It’s too difficult, the risks outweigh the benefits”
• “Success rates are too low”
• My personal favourite - “There is no mortality benefit”
![Page 4: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/4.jpg)
The “protection” from collaterals
![Page 5: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/5.jpg)
Mortality benefit in stable angina with PCI?
RITA 2 - 7 yrs. Henderson et al. JACC 2003;42:1161 FAME 2. de Bruyne et al. NEJM 2012;367:991
![Page 6: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/6.jpg)
To treat or not to treat?
A 65 yr old male with limiting angina despite
medical therapy
![Page 7: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/7.jpg)
To treat or not to treat?
A 65 yr old male with limiting angina despite
medical therapy
![Page 8: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/8.jpg)
To treat or not to treat?
A 65 yr old male with limiting angina despite
medical therapy
![Page 9: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/9.jpg)
To treat or not to treat?
A 65 yr old male with limiting angina despite
medical therapy
![Page 10: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/10.jpg)
The symptom burden and treatment benefits
are the same if not more for CTO PCI
• Compared pts with successful SVCAD PCI
• 141 CTO pts and 1616 pts with non-CTO lesions
• Compared standardised measures of symptoms (SAQ/RDS), function
and QoL (EQ5D)
• CTO pts worse at baseline
• Benefit to the same endpoint after a successful procedure
CCI 2014;84:629-634
![Page 11: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/11.jpg)
Current evidence in stable disease?
OPEN ATERY CTO
Mortality Benefit
Reduced Angina
Improved exercise
capacity
Improved QoL
X
✔︎
X
✔︎ ✔︎
✔︎ ✔︎
✔︎
Maybe inferred
from non-
randomised data
![Page 12: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/12.jpg)
Established for CTO PCI
• Clear symptomatic and QoL benefits
• Successful opening reduces mortality versus failed
• CTO as non-culprit in STEMI doubles mortality risk from
acute MI
• Potential to increase LV function in ischaemic
cardiomyopathy with viable myocardium
• Potential to reduce arrhythmia
![Page 13: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/13.jpg)
The treatment paradox: CTO is a
barrier to PCI
388 US centres
>35,000 CTOs/>640,000 angiograms
Indication for cardiac surgery excluded from
analysis (valve disease)
Grantham et al. JACC Int 2009;2:479
>8,000 sequential angiograms
Cleveland Clinic
CTO strong predictor of PCI not being
performed (OR 0.26, 022-0.31; p<0.0001)
Christofferson et al. Am J Cardiol 2005;95:1088
![Page 14: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/14.jpg)
Current Practice: Patients
undergoing angiography with CTO
![Page 15: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/15.jpg)
Patients with CTO offered PCI
10 - 15%
![Page 16: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/16.jpg)
Optimal Revascularization -
Agreed??
• Patients with CAD should have “optimal revascularization” by PCI or
CABG
• Viable and ischaemic myocardium should be revascularized
• <5% of LV mass with residual ischaemia
![Page 17: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/17.jpg)
Where has PCI PLC gone wrong in
the past?
11,249 patients having PCI in NY state 2003-2004
Predictor of MACE - 2 diseased vessels with a CTO
Hannan et al. JACC Int 2009;2:17-25
![Page 18: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/18.jpg)
• Observational data from BCIS
mandatory returns
• 5 calendar years of data (05-09
inclusive)
• 13,443 pts undergoing attempted
CTO PCI
• Overall success rate 71%
• Mortality data linked from unique
patient number from Office for
National Statistics
George et al. JACC 2014;64:235-43
![Page 19: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/19.jpg)
The Syntax Trial: A Lucky
Miss
Mohr et al. Lancet 2013;381:629-38
![Page 20: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/20.jpg)
CTO in Syntax?
Very poor technical outcomes with PCI
Farooq et al. JACC 2013;61:282-94
![Page 21: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/21.jpg)
![Page 22: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/22.jpg)
Cause of a Poor Outcome in Syntax?
Incomplete Revascularization
• Residual Syntax score >8 associated with 35.3% mortality at 5 years
follow-up
Farooq et al. Circulation 2013;128:141-151
![Page 23: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/23.jpg)
CTO: The biggest per lesion
contributor to the Syntax score
Likely the largest contributor to the
residual Syntax score too
![Page 24: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/24.jpg)
Contemporary CTO Practice &
Results
What is possible?
![Page 25: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/25.jpg)
The necessary skill sets to facilitate the hybrid approach?
![Page 26: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/26.jpg)
Antegrade
Wire Escalation
![Page 27: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/27.jpg)
Antegrade
Dissection
Re-entry
![Page 28: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/28.jpg)
Retrograde wire
escalation
![Page 29: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/29.jpg)
Retrograde
Dissection
Re-entry
![Page 30: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/30.jpg)
Hybrid CTO PCI
• Success requires
flexbility in approach
• No dogma
• Open the artery safely,
but open the artery
• Apply every option you
have to help the patient
• Aim for efficiency (i.e.
safety)
![Page 31: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/31.jpg)
The Hybrid Algorithm for CTO PCI
initial 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
![Page 32: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/32.jpg)
The Hybrid Algorithm for CTO PCI
provisional approaches
Dual Catheter Angiography
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
1. Clear proximal cap
2. Good distal target
When you stall:
CHANGE STRATEGY
![Page 33: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/33.jpg)
CTO PCI: Integration of good
technology with the right skill mix
![Page 34: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/34.jpg)
Good principles and fundamental to hybrid: Exit
failure modes early - don’t waste time failing
X
X
X
180 minutes??
4 Gray??300 mls contrast??
![Page 35: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/35.jpg)
This can be taught and transferred
Sharma et al. Open Heart 2015;2:e000228. doi:10.1136/openhrt-2014- 000228
![Page 36: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/36.jpg)
0
10
20
30
40
50
60
70
Easy (0)
Intermediate (1)
Difficult (2)
V Difficult (≥3)
Japanese 2012 data
1553 procedures
44 hospitals
Presented: NY CTO 2014
Belfast CTO data
2012 / 13
305 procedures
Per lesion success 91%
![Page 37: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/37.jpg)
0
17,5
35
52,5
70
Easy (0) Intermediate (1) Difficult (2) V Difficult (≥3)
Belfast JCTO
Different complexity, different
pathology?
Post CABG 30% vs 9%
![Page 38: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/38.jpg)
Optimal Revascularization -
Agreed??
• Patients with CAD should have “optimal revascularization” by PCI or
CABG
• Viable and ischaemic myocardium should be revascularized
• <5% of LV mass with residual ischaemia
![Page 39: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/39.jpg)
Multi-vessel CAD and complete
revascularization: We can and must do
better in 2015
![Page 40: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/40.jpg)
Contemporary complete
revascularization: The
portfolio matters
![Page 41: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/41.jpg)
3v
CAD?
![Page 42: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/42.jpg)
iFR negative
FFR = 0.86
![Page 43: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/43.jpg)
iFR negative
FFR = 0.94
![Page 44: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/44.jpg)
Now single vessel CTO
CrossBoss Stingray
![Page 45: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/45.jpg)
![Page 46: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/46.jpg)
![Page 47: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/47.jpg)
Syntax 2 is not just
simple 3vCAD
![Page 48: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/48.jpg)
![Page 49: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/49.jpg)
With no Guidezilla, no PCI!
![Page 50: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/50.jpg)
New technology gets
us from….
![Page 51: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/51.jpg)
![Page 52: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/52.jpg)
![Page 53: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/53.jpg)
Calcium
![Page 54: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/54.jpg)
![Page 55: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/55.jpg)
![Page 56: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/56.jpg)
rCART for RCA CTO
![Page 57: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/57.jpg)
![Page 58: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/58.jpg)
You need all the tools to
get the right result for the
patient
![Page 59: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/59.jpg)
![Page 60: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/60.jpg)
![Page 61: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/61.jpg)
CTO crossing
![Page 62: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/62.jpg)
Threader
![Page 63: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/63.jpg)
HSRA
![Page 64: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/64.jpg)
Guidezilla
![Page 65: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/65.jpg)
38mm Synergy stents
![Page 66: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/66.jpg)
Deliverable NC balloons
![Page 67: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/67.jpg)
Putting the portfolio together
![Page 68: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/68.jpg)
![Page 69: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/69.jpg)
Durability of Outcome for
CTO PCI, DES Choice
and Vessel Healing
![Page 70: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/70.jpg)
70
Morino et al. JACC CI 2011;4:213-21
Complexity
Success
![Page 71: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/71.jpg)
UK data: Complexity not reliably amenable to wire
based strategies
![Page 72: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/72.jpg)
![Page 73: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/73.jpg)
![Page 74: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/74.jpg)
![Page 75: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/75.jpg)
Is there a downside to dissection
and re-entry?
• All CTOs are not wire cases
• Anatomy should inform strategy, not dictate to attempt
or not
• As complexity rises, advanced techniques are needed
for success
• Healing is crucial for durability and long-term results
• Individual patients demonstrate vast differences in
bleeding risk and DAPT tolerability
![Page 76: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/76.jpg)
rCART case 4 months after CTO PCI
![Page 77: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/77.jpg)
![Page 78: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/78.jpg)
![Page 79: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/79.jpg)
After 5mm NC and then tentative 6mm balloon inflation
![Page 80: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/80.jpg)
Appearance 20 months after index
PCI
![Page 81: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/81.jpg)
IC-143313-AB AUG2013 Slide
Polymer and drug applied as ultra-thin abluminal coating
Synchronized drug release and polymer absorption
Polymer gone shortly after completion of drug elution at 3 months
SYNERGY™ Everolimus-Eluting Stent with
Synchrony™ Bioabsorbable Coating
SYNERGYStent Strut Cross Sections
Arterial Wall
Data on file at BSC. The SYNERGY stent is an investigational device in the US and not for sale.
PLGA bioabsorbable
polymer only on
abluminal surface
PVDF durable polymer
360º around stent strut
PROMUS Element
PLGA
Polymer
Everolimus
Drug
Abluminal
Coating
Coating
Microstructure
SYNERGY
Stent
![Page 82: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/82.jpg)
IC-143313-AB AUG2013 Slide
Boston Scientific data on file; World J Cardiol 2011 March 26; 3(3): 84-92;
Garg, S, J Am Coll Cardiol. 2010;56(10s1):S43-S78. doi:10.1016. Presented by Stephen Windecker, MD, TCT2012.
The Synergy Stent is an investigational device in the US and not for sale.
Polymer: PLGA
Absorption Time: 3-4m
% R
ecovery
Time (months)
The SYNERGY Stent polymer absorbs shortly after drug elution is complete at 3 months
Drug Release and Polymer Absorption Profiles
SYNERGY™
Everolimus
PLGA
Nobori™ and
Biomatrix Flex™
% R
ecovery
Polymer: PLA
Absorption Time: >9m
BA9
PLA
Orsiro™
% R
ecovery
Time (months)
Polymer: PLLA
Absorption Time: >12m
Time (months)
Sirolimus
PLLA
(molecular
weight
change)
% R
ecovery
Time (months)
Absorb™
BVS
Scaffold: PLLA
Polymer: PDLLA
Absorption Time: 3y
Everolimus
PDLLA
![Page 83: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/83.jpg)
Complex RCA occlusion with SVG
failure
Belfast 2 case 4 clip 2
![Page 84: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/84.jpg)
Acute result after RDR - note distal
dissection planes
Belfast 2 case 4 clip 19
![Page 85: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/85.jpg)
6/12 follow-up
Picton follow up 63_3
![Page 86: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/86.jpg)
BSc CTO: Investigator Sponsored Research
CTO Indication (US) & Safety (Sub-Intimal Stenting) with Synergy Stent
Prospective, Multi-Center, Single Arm
N=200 Patients
PI: Dr Simon Walsh, United Kingdom
RECHARGE
REGISTRY
CONSISTENT
Enrolling
Enrolling
Safety & Effectiveness of Hybrid Algoithm & CrossBoss and Stingray Technologies
Prospective, Multi-Centre, Non-Randomised Clinical Registry
N=1000 coronary CTO procedures, acute results
PI: Professor Jo Dens, Belgium
OPEN CTO
Long-term outcome from contemporary CTO PCI (US)
Prospective, Multi-Centre, Non-Randomised Clinical Registry
N=1000 coronary CTO procedures
PI: Dr Aaron Grantham, Mid American Heart Institute
Enrolling
![Page 87: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/87.jpg)
Synergy in Belfast
![Page 88: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/88.jpg)
Non-study cases - clinical indication
for bioabsorbable polymer stent
• Audit of clinical outcomes - 1st 100 cases
• At present, management imposed limits on use
due to cost
• Use is biased towards complex disease and
patients at high-risk of bleeding
• Majority stopping DAPT at 3 months
![Page 89: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/89.jpg)
Patients• N=100
• Mean Age 72 ± 10
• 37% >75 years old, 8% >85 years old
• 25% Diabetic
• 35% ACS
• 12 surgical turn-down at MDM, 16 revascularization after
prior CABG
• Mean Euroscore 11.37
![Page 90: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/90.jpg)
Short DAPT Indication
16%
28%
10%
26%
20%
Frail/Elderly
Anticoagulation
Non-cardiac Op
Bleeding Risk
Other
![Page 91: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/91.jpg)
Complex Disease
13
36
9
37
10
92
0
25
50
75
100
Mean Syntax Score 22.7 ± 12.1
![Page 92: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/92.jpg)
PCI & Outcomes
• Mean Syntax score 22.7 (range 6-53)
• 58=tertile 1, 20=tertile 2, 22=tertile 3
• Mean 1.4 lesions per patient
• Mean 2.7 stents per patient
• Mean stent length 75.3 ± 41.5
![Page 93: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/93.jpg)
PCI & Outcomes
• 76% off DAPT at 3 months
• 0 stent thrombosis
• 4 TLR by 6 months/144 lesions (2.8%)
• 1 non-TLR
• 10 non-cardiac ops/procedures 3-6 months
• 5 non-cardiac deaths by 6 months (2 Ca, 1 AAA, 1
sepsis, 1 vascular post TAVI)
![Page 94: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/94.jpg)
Clinical Trials & Synergy
• Syntax 2 - 57 cases, 1 TVR, 0 ST
• Ideal LM - 12 cases, 0 TVR, 0 ST
• Consistent CTO, 22 cases, 0 TVR, 0 ST
• Celtic Bifurcation, 13 cases, 0 TVR, 0 ST
• ~200 cases, complex disease - no stent
thrombosis
![Page 95: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/95.jpg)
Conclusions
• Default: Complete revascularization should be
considered mandatory
• Optimal revascularization means opening CTOs where
myocardium is viable and ischaemic
• Almost every lesion can be treated
• Provided you have the rights skills and tools
• Complete revascularization with Synergy leads to
excellent short & medium term outcomes
![Page 96: Optimal Revascularization in Multivessel Disease and ... · Optimal Revascularization in Multivessel Disease and Coronary CTO ... 3v CAD? iFR negative FFR = 0.86.](https://reader031.fdocuments.us/reader031/viewer/2022021901/5b819a307f8b9ae97b8c9ddb/html5/thumbnails/96.jpg)
Register on
www.ctoibooks.com
Available now on
iTunes