chronic total occlusions: the road less traveled
TRANSCRIPT
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The Road Less Travelled: Update on Percutaneous Coronary Interventions (PCI)
for Chronic Total Occlusions (CTO)
M Nicholas Burke, MDMinneapolis Heart Institute and Foundation
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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
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Chronic Total OcclusionsEffect on therapy
Christofferson AJC 2005
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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
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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
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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
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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
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Collaterals Are Rarely Sufficient To Substantially Reduce Ischemia In CTO
Modified from Werner GS et al, European Heart Journal 2006, courtesy Werner GS
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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
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CTO of Non IRA and STEMI-CTO of Non IRA and STEMI-Double JeopardyDouble Jeopardy
J. Am. Coll. Cardiol. Intv. 2009;2;1128-1134
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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
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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)
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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
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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
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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 ?
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CTOs: What are we trying to do?
1. Make People Feel Better (improve symptoms)
2. Make People Live Longer (avoid future events)
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CTOs: What are we trying to do?
Medical therapy
Let’s look at the evidence
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Myocardial IschemiaTherapy: NitratesMyocardial IschemiaTherapy: NitratesTo Improve SymptomsTo Improve Symptoms
Am J Cardiol 72 1993
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Long-Term Nitrate Use in CAD
AHJ 138(3) 1999
Myocardial IschemiaTherapy: NitratesTo Reduce Future Events (?)To Reduce Future Events (?)
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Myocardial IschemiaTherapy: CCBTo Reduce Future Events (?)To Reduce Future Events (?)
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Myocardial IschemiaTherapy: CCBTo Reduce Future Events (?)
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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
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Myocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
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Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
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Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
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Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
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Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
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Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
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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
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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
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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
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CTO PCI: Why don’t we do it?(the REAL reason)
BECAUSEIT’S
HARD TO DO(and Interventionalists hate to fail)
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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
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Chronic Total Occlusion RevascularizationNew Tools and Technology
Things that have not worked:• Drills• Jackhammers• Lasers• RFA• IR• Blunt micro-dissection• Lytics
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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
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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
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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
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BridgePoint System
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Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: Retrograde
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Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART
Surmely JF: J Invasive Cardiol. 2006 Jul 18(7):33408
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Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART
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Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART
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Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART
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Case Presentation: SD
• 42 yo pt WF with FH and Tobacco Abuse
• Admitted 12/12 with NSTEMI
• Angiogram:
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SD continued
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SD continued
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SD continued
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SD continued
• Discharged to Home on Medical Therapy
• Try to Quit Smoking
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SD continued
• Readmitted 3/13 with USA
• ECG with CP: Inferior ST depression
• Angiogram: NO CHANGE
• TIME to FIX THIS THING
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SD continued
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SD continued
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SD continued
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SD continued
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SD continued
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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:
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Case Presentation: TL
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TL continued
• Cardiac Rehab
– Exercise induced VT
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TL continued: PCI
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TL continued: PCI
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TL contiued: PCI
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TL continued
• Exercise stress test 2 weeks after PCI:
– 13’30” no VT
• Echo approximately 2 months after PCI:
– EF ~55%