Improving Outcomes in CTO– New Approaches

William Lombardi MD.

Director Complex Coronary Therapies

CTO Basics

• Myocytes don’t know why they are ischemic

• Myocytes don’t care how the oxygen gets tothem

Indications for revascularization are determinedIndications for revascularization are determinedprior to angiography

Treatment According toAppropriateness

Unadjusted rates and adjusted Hazards of death orrecurrent ACS at 3 Years, According to

Appropriateness Categories and CoronaryRevascularization

AppropriatenessCategory

NNo

RevascularizationRevascularization

HR (95% CI)

0.99 (0.48-Inappropriate* 311 16 (9.4%) 20 (14.2%)

0.99 (0.48-2.02)

Uncertain* 32623 (15.3%)

14 (8.0%)0.57 (0.28-

1.16)

Appropriate† 991 50 (16.1%) 80 (11.8%)0.61 (0.42-

0.88)

SYNTAXCTO subset procedural characteristics: per lesion analysis

Per Lesion

Serruys P, CRT 2009 [modified]; courtesy Prof Serruys and the SYNTAX investigators

SYNTAXCTO Subset Procedural characteristics Per lesion analysis

ITT, Per LesionSerruys P, CRT 2009 [modified]; courtesy Prof Serruys and the SYNTAX investigators

55.557.1

59.2 59.861.9

40

50

60

70 % of total PCI Procedural success MACE

Trends over time

3.2 3.5 3.8 4.2 4.8

0

10

20

30

40

2009 2010 2011 2012 2013

%

Brilakis et al, JACC Cardiovasc Intv 2014 – in press

4%

6%

8%

10%Failed CTO

Successful CTO

BCIS Data

0%

2%

4%

10199 9080 6621 4340 2252Success

4240 3690 2646 1707 806Failure

0 .5 1 1.5 2 2.5 3 3.5 4

Follow-up time (years)

What is limiting the adoption of CTO PCI?

Complexity:• Poor success rates

• Procedure time

• Complication rates

• Cost

Confusion:• Inconsistency

of teaching

• Clinical justification

Confidence:

• Understanding own ability

• Lack of planning

• Post-case analysis

The Hybrid Algorithm for CTO PCIprovisional approaches

Dual Catheter Angiography

1. Clear proximal cap2. Good Distal Target

3. Length < 20mm

Antegrade Retrograde

yes no

yes yes no3. Length < 20mm

Wireescalation

Dissection Reentry(crossboss-stingray)

Wireescalation

Dissection Reentry(reverse CART)

yes yes nono

Dissection Reentry(reverse CART)

Dissection Reentry(crossboss-stingray))

fail

fail

fail

fail

CTO Basics: Set up for success

• Large extra support guide

• Two Guides

• Have all the tools and know how to use them

• Separation is in the Preperation

– Don’t plan for success know your options

Wire Escalation

Pilot 200

Clear Path andTarget

CONFIANZA PRO12g

Gaia 2nd

AN

TE

GR

AD

EWire Escalation

Pilot 200

Clear Path andTarget

CONFIANZA PRO12g

Gaia 3rd

RE

TR

OG

RA

DE

Antegrade

Dissection ReEntry

DissectionMethod

CROSSBOSS

ReentryMethod

STINGRAY

AN

TE

GR

AD

E

Retrograde

Dissection ReEntry

DissectionMethod

KNUCKLEWIRE

ReEntryMethod

REVERSECART

RE

TR

OG

RA

DE

Refractory

Greater chance of success = Hybrid Skills

Why poor uptake?

• Skillsets are taught

• Skills are acquired• Skills are acquired

Skillsets should be:

• Teachable• Reproducible• Successful• Successful

• Understandable

We now know enough to deliverhigh-value educational courses

CTO Mastery

Improving Outcomes in CTO – New Approaches…

Case Examples

• Fellow does ADR.

Fellows Case 2

• Retrograde dissection and re-entry

How to learn

• Fixed mindset with failure.

– It was too hard

– I can’t do that

– Blame the surgeon– Blame the surgeon

Growth Mindset

What did I learn

With more practice I will get better

I need more experience

How to learn

• Fixed Mindset with success

– See I got it I am really good

– I am amazing I clearly can do this

– I am a good person– I am a good person

• Growth Mindset with success

– What did I learn from this case

– How could I have been more efficient

– I am getting better but still need more practice

Conclusions

• You can learn the skillsets

• Takes lots of volume

• No rules just solutions

• Work with the others and always get better.

• Have a Growth Mindset

• Remember its about the patient