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Debate: Is there a difference between RDR and reverse CART? – No
Dimitri Karmpaliotis, MD,PhD FACCAssociate Professor of Medicine
Columbia University Medical CenterDirector of CTO, Complex and High Risk Angioplasty
NYPH/Columbia
Email: [email protected] CTO CLUB, 11th Experts Live CTOBerlin, Germany, September 13-14, 2019
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Disclosures
• As a faculty member for this program, I disclose the following relationships with industry:
• Honoraria from Abbott Vascular, Abiomed and Boston Scientific
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That’s What Paul Needs to Prove to You
to Convince you that RCART is Better than ADR
• His Arguments Need to be Based on Data
• His Arguments Need to be Based on Common Sense
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That’s What Paul Needs to Prove to You
to Convince you that RCART is Better than ADR
• His Arguments Need to be Based on Data
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That’s What Paul Needs to Prove to You
to Convince you that RCART is Better than ADR
• ADR is not needed to achieve high success rates and that AWE and Retrograde CTO PCI can take care of all cases
• Even before he gets to perform his magic RACRT, he can get at the distal cap all the time
• Consistently requires less number of stents to complete( Which is used as a surrogated of more controlled dissections)
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That’s What Paul Needs to Prove to You
to Convince you that RCART is Better than ADR
• Retrograde PCI is:• Easier, Faster, Requires less Contrast• Safer than Antegrade PCI• Easier to teach, adopt and disseminate
among CTO Operators• Associated with better periprocedural
outcomes• Associated with better long-term
outcomes
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If Paul Fails to Prove to You Convincingly at least most of these points, then he would have failed miserably in making his point that
RCART is Better than ADR
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Having said all this, I am Confident that Paul will Triumph in making his point
that RCART is Better than ADRBecause I set the bar too low for a man
of his CALIBER
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• ADR is not needed to achieve high success rates and that AWE and Retrograde CTO PCI can take care of all cases
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Multiple strategies may be necessary to succeed in
CTO-PCI
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1/2012 to 2/2014n=632Technical success: 92.4%Major complications: 1.9%
•Appleton Cardiology, WI•Dallas VAMC/UTSW, TX•Peaceheath Bellingham, WA •Piedmont Heart Institute, GA•St Luke’s Mid America Heart
Institute, MO•Torrance Medical Center, CA
Christopoulos, Karmpaliotis, Alaswad, Wyman, Lombardi, Grantham, Thompson, Brilakis et alJournal of Invasive Cardiology 2014;26:427-432
42
27
31
Antegrade
Antegrade dissection/re-entry
Retrograde
65
37 44
0
20
40
60
80
100
Techniques Used
%
AntegradeAntegrade DRRetrograde
Successful technique
PROspective Global REgiStry for the Study of CTO interventions
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87.2
93.7
78.1
90.0
70
80
90
100
2006-2011 2012-2013
%
No prior CABG
Prior CABG
Pre “Hybrid” era
Michael, Karmpaliotis, Brilakis, Lombardi, Kandzari et al. Heart 2013;99:1515-8
Δ=9.1%P<0.001
Christopoulos, Menon, Karmpaliotis, Alaswad, Lombardi, Grantham, Brilakis et al. AJC 2014;113-1990-4
CTO PCI: success and prior CABG
N=1,3633 US sitesPrior CABG: 37%Complications: 1.5% vs. 2.1%Retrograde: 27.1% vs. 46.7%
Δ=3.7%P=0.092
“Hybrid” era
N=6306 US sitesPrior CABG: 37%Complications: 2.5% vs. 0.8%Retrograde: 34% vs. 39%
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87.2% 86.5%
78.1%81.9%
70%
80%
90%
100%
2006-2011 2012-2017
No priorCABGPrior CABG
Pre Hybrid era
Δ=9.1%p<0.001
Effect of Prior CABG
Michael, Karmpaliotis, Brilakis, Abdullah, Kirkland, Mishoe, Lembo, Kalynych, Carlson, Banerjee, Lombardi, Kandzari.
Heart 2013;99:1515-8
1,363 lesions; 3 US sitesPrior CABG: 37%
Complications: 1.5% vs. 2.1%Retrograde: 27.1% vs. 46.7%
Δ=4.6%p=0.001
Hybrid era
Current available data in PROGRESS-CTO Registry 02/05/2018
2967 lesions; 20 international sitesPrior CABG: 32%
Complications: 2.9% vs. 3.5%Retrograde: 31% vs. 54%
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Author YearN (CTO lesions)
Prior CABG Diabetes Retrograde
Technical Success
Major complicati
ons DeathTampon
ade
Fluoroscopy time
(minutes)
Contrast use,
(ml)
Rathore 2009 904 12.6 40.0 17 87.5 1.9 0.6 0.6 NR NR
Morino 2010 528 9.6 43.3 26 86.6 NR 0.4 0.4 45
(1-301)*
293
(53-1,097)*
Galassi 2011 1983 14.6 28.8 14 82.9 1.8 0.3 0.5 42.3±47.4 313 ±184
U.S
Registry*
2013 1361 37.0 40.0 3485.5
1.80.22 0.6 42±29 294 ±158
* Median (range)
Summary of Large Contemporary Registry Publications of Percutaneous Coronary Interventions of Chronic Total Occlusions
* Tesfaldet, Karmpaliotis, Brilakis, Lembo, Lombardi, Kandzari. Am J Cardiol 2013
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Author Year n
Prior CABG
(%)
Septal collaterals used (%)
Reverse CART (%)
Technical Success
(%)
Major complications
(%)Fluoroscopy
time, minContrast use, mL
Sianos 2008 175 10.9 79.4 NR 83.4 4.6 59 ± 29 421 ± 167
Rathore 2009 157 17.8 67.5 NR 84.7 4.5 NR NR
Kimura 2009 224 17.6 79 14 92.4 1.8 73 ± 42 457 ± 199
Tsuchikane 2010 93 10.8 82.8 60.9 98.9 0 60 ± 26 256 ± 169
Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR*
Karmpaliotis* 2012 462 50.0 71 41 81.4 2.661 ± 40 345 ± 177
Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.
Retrograde Coronary Chronic Total Occlusion Revascularization:Procedural and In-Hospital Procedural Outcomes from a Multicenter
Registry in the United States
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Technical approach
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PROspective Global REgiStry for the Study of CTOinterventions
www.progresscto.org
Successful crossing strategy stratified by J-CTO score
88.3%71.6%
50.6%31.9%
17.3% 16.9%
5.8%
14.7%
20.5%
24.1%
21.6% 20.2%
3.1%9.0%
19.7%35.3%
41.5% 43.6%
0%
20%
40%
60%
80%
100%
J-CTO Score 0 J-CTO Score 1 J-CTO Score 2 J-CTO Score 3 J-CTO Score 4 J-CTO Score 5
RetrogradeADRAWE
p<0.0001
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• Even before he gets to perform his magic RACRT, he can get at the distal cap all the time
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Limitations of Retrograde Approaches
McEntegart et al. EuroIntervention. 2016;11:e1596-1603
Data from 481 patients with 519 CTOs
• Visible “interventional” collaterals only seen in
64% of lesions
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Limitations of Retrograde Approaches
Tsuchikane et al. CCI. 2013;82:e654-61
Data from 801 patients in J-PROCTOR registry
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Reasons For Failure With Attempted Retrograde CTO PCI
J Proctor CCI 2013.
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Limitations of Retrograde Approaches
• Similar updated experience from Japan
• Examined 5984 CTO PCIs from 45 centres (2009-12)
• Retrograde attempt in 1656 cases
• Failed to cross with wire/micro-catheter in 23%
Suzuki et al. CCI. 2016;In Press doi: 10.1002/ccd.26785
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• Consistently requires less number of stents to complete( Which is used as a surrogated of more controlled dissections)
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• Retrograde PCI is:• Easier, Faster, Requires less Contrast• Easier to teach, adopt and disseminate
among CTO Operators
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Author Year n
Prior CABG
(%)
Septal collaterals used (%)
Reverse CART (%)
Technical Success
(%)
Major complications
(%)Fluoroscopy
time, minContrast use, mL
Sianos 2008 175 10.9 79.4 NR 83.4 4.6 59 ± 29 421 ± 167
Rathore 2009 157 17.8 67.5 NR 84.7 4.5 NR NR
Kimura 2009 224 17.6 79 14 92.4 1.8 73 ± 42 457 ± 199
Tsuchikane 2010 93 10.8 82.8 60.9 98.9 0 60 ± 26 256 ± 169
Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR*
Karmpaliotis* 2012 462 50.0 71 41 81.4 2.661 ± 40 345 ± 177
Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.
Retrograde Coronary Chronic Total Occlusion Revascularization:Procedural and In-Hospital Procedural Outcomes from a Multicenter
Registry in the United States
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• Retrograde PCI is:• Safer than Antegrade PCI• Associated with better periprocedural
outcomes• Associated with better long-term
outcomes
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Insights from the Progress CTO Registry
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Retrograde vs. antegrade-only: outcomes
2012-201511 centers, 1,301 lesionsRetrograde utilization: 41%
84.8 81.993.7 93.3
0
50
100
Technical Success Procedural Success
Succ
ess
rate
(%)
RetrogradeAntegrade-only
Δ= 8.9%p<0.001
Δ=11.4%p<0.001
Karmpaliotis D, Karatasakis A, Alaswad K, Jaffer FA, Yeh RW, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Patel M, BahadoraniJ, Moses JW, Kirtane AJ, Parikh M, Ali Z, Kalra S, Nguyen-Trong PJ, Danek BA, Karacsonyi J, Rangan BV, Roesle M, Thompson CA, Banerjee S, Brilakis ES.
Circ Cardiovasc Interv 2016 Jun;9(6)
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4.3
2.1
0.4
1.3
0.60.8
1.1
0.3 0.3 0.30.1 0.1
0
1
2
3
4
5
MACE MI Stroke Pericardiocentesis Re-PCI Death
Com
plica
tion
rate
(%) Retrograde
Antegrade-only
Retrograde vs. antegrade-only: in-hospital MACEp<0.001
p=0.003
p=0.999
p=0.039
p=0.314
p=0.167
Karmpaliotis D, Karatasakis A, Alaswad K, Jaffer FA, Yeh RW, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Patel M, BahadoraniJ, Moses JW, Kirtane AJ, Parikh M, Ali Z, Kalra S, Nguyen-Trong PJ, Danek BA, Karacsonyi J, Rangan BV, Roesle M, Thompson CA, Banerjee S, Brilakis ES.
Circ Cardiovasc Interv 2016 Jun;9(6)
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• Co PIs James Sapontis, Bill Lombardi• Manager Karen Nugent• Statistician Kensey Gosch• Core Lab Federico Gallegos• Publications Spertus, Cohen, Marso, Yeh,
McCabe, Grantham, Karmpaliotis
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That’s What Paul Needs to Prove to You
to Convince you that RCART is Better than ADR
• His Arguments Need to be Based on Common Sense
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CASE EXAMPLECTO-RCA
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CTO-RCA Dual Injections
7Fr Slender Sheaths
Right Radial Artery7Fr EBU 3.5 90cm
Left Radial Artery7Fr AL0.75 SH 90cm
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CTO-RCA Dual Injections
7Fr Slender Sheaths
Right Radial Artery7Fr EBU 3.5 90cm
Left Radial Artery7Fr AL0.75 SH 90cm
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Retrograde via LAD septal
TurnPike 150cm
Sion wire
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Setting up for Reverse CART
Antegrade TurnPike 135cm
Retrograde TurnPike 150cm
Antegrade Pilot 200Retrograde Pilot 200
Very Hard to get into vessel structure because of tortuous
and ectatic vessel added to proximal bridging collaterals and
ambiguous proximal cap
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“Move the Cap” Technique
Antegrade4.0 x 12 Balloon inflated
in pRCA On looped BMW wire
Antegrade TurnPike 135cmWith
Knuckled Fielder XT WireNEXT to the Balloon
“Move the Cap” by entering the
sub-intimal place (with your knuckle) more proximally that the
proximal CTO cap
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ADR-StingRay
StingRay LP
StingRay Wire Fenestrations
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ADR-StingRay
StingRay LP
Pilot 200 rapidly advanced with wiring of the distal true lumen
Into a smaller branch
Retrograde Distal Tip Injections with Medallion Syringe for
visualization
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After 6Fr Guideliner supported PCI
DES 3.5 x 38 mmDES 4.0 x 38 mm DES 4.0 x 18 mmDES 4.0 x 28 mm
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Having said all this, I am Confident that Paul will Triumph in making his point
that RCART is Better than ADRBecause I set the bar too low for a man
of his CALIBER
So, Good Luck Paul……
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THANK YOU
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THANK YOU