Transcript Chronic Total Occlusions

Chronic Total Occlusions
J. Jeffrey Marshall, MD, FSCAI
Past President SCAI, 2012-2013
Director Cardiac Cath Lab
Northeast GA Heart Center
SCAI Fellow’s Course at Qingdao, CHINA
August 23, 2014
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Georgia
Heart Center
Disclosures
None
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Coronary CTO
Rationale for CTO Revascularization
• Improve symptoms/functional QOL status
• Improve ventricular function
• Reduce incidence of late CABG
• Improve event-free survival
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PCI of CTO and Long-term Survival
N=2007 pts; 1980-1999 (10% stents)
100
%
90
CTO Success
80
74%
70
65%
p=0.002
60
CTO Failure
50
2
Suero et al: JACC 2001
4
6
Years
8
10
Impact of CTO Success on Outcome
n = 486 pts; 527 CTO; DES; Success 71%
2003-2006
Valenti R: EHJ 2008;29:2336
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CTO PCI: Survival by Success
Mortality at FU
50
40
30
%
Success
p<0.001
Failure
34.9
26.5
p=0.02
20
p<0.04
12
10
p<0.025
p=0.045
6.5
8.4
5.8
2
12.6
1.1
3.6
0
Suero
N: 2007
FU: 10 yr
Grantham JA: JACC 2009: 2: 479 - 486
Hoye
Aziz
874
4.5 yr
199
2 yr
Olivari
Valenti
369
1 yr
486
4 yr
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CTO PCI
Improved QOL, Angina and Physical Activity
N: 125 pts; CTO Success: 55%
SAQ Angina Frequency
SAQ Physical Limitation
SAQ Quality of Life
Effect of Procedure Success
Grantham AJ, et al. Circ Qual Outcomes 2010;3:284
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Coronary CTO
Who to treat?
• Symptomatic
• Significant Ischemia
• Reasonable likelihood of success
• Low expected complication rate
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2011 ACCF/AHA/SCAI PCI Guidelines
What We Can Do
PCI of CTO
• Class IIa Recommendation
• PCI of a CTO in pts with appropriate clinical
indications and suitable anatomy is reasonable
when performed by operators with appropriate
expertise (Level of Evidence: B)
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Levine GN, et al. JACC doi:10.1016/j.jacc.2011.08.007
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PCI Appropriate Use Criteria 2012
What We Should Do
• Technical panel of 17 MD:
• 4 IC; 4 CVS; 8 non-IC; 1 health plan MD
• Classification:
• 61 clinical scenarios
• Median score of panel (1 to 9)
• Appropriate: median score of 7-9
• Uncertain: median score 4-6
• Inappropriate: median score 1-3
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Appropriate Use Criteria 2012
CTO (no other CAD)
Stress test results, Medications
Asx
CCS 1-2
CCS 3-4
Low risk, No / min meds
I (1)
I (2)
I (3)
Low risk, Max meds
I (1)
U (4)
U (6)
Intermed risk, No / min meds
I (3)
U (4)
U (6)
Intermed risk, Max meds
U (4)
U (5)
A (7)
High risk, No / min meds
U (4)
U (5)
A (7)
High risk, Max meds
U (5)
A (7)
A (8)
CTO PCI in the US
NCDR Registry
Approximately 15-30% of all patients referred for cath have a CTO
20
CTO Attempts
13.6
11.7
12.4
11.8
2005
2006
2007
% 10
0
2004
PCI attempt rate is unchanged over the last 5 years
Grantham JA: JACC 2009: 2: 479 - 486
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CTO PCI in the US
Usage by Operator Volume
50
CTO Attempts
40
p<0.05
p<0.05
p=0.115
30
20.5
% 20
23
15
10
0
Low
Intermediate
High
(<75)
75 – 200
>200
Grantham JA: JACC 2009: 2: 479 - 486
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CTO PCI in the US
NCDR Registry
MACE
Technical Success
100
80
15
71.1
70.3
73.3
10
60
%
40
%
5
20
0
3.2
3.7
3.3
2004
2005-2007
2008
0
2004
2005-2007
Grantham JA: JACC 2009: 2: 479 - 486
2008
CTO PCI in the US
Barriers to Wider Use
• Operator inexperience
• Difficulty in wire crossing
• Perceived increased risk
• Financial disincentives
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CTO: Predictors of Outcome
Procedural Success
•
•
•
•
•
•
•
•
Functional occlusion
Occlusion <12 wks
Length <15 mm
Tapered stump
No branch at occl site
No bridge collaterals
No / mild Calcium
Straight lesion
Procedural Failure
•
•
•
•
•
•
•
•
Total occlusion
Occlusion > 12 wks
Length >15 mm
Abrupt cut-off
Side branch present
Bridge collaterals
Heavy calcification
Tortuosity
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Rathore S: JACC CV Intv 2009; 2: 489-497
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Contemporary CTO Results
Impact of Novel Guidewire Techniques
2002 – 2008; n=904 procedures
%
Success
Fluoro
(min)
Procedure
(hrs)
Single wire
64%
57%
76.8
2.56
Parallel wire
19%
55%
95.5
3.18
Retrograde
7%
42%
108
3.36
CART
10%
94%
114
3.61
Total
100%
86.2%
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Rathore: JACC Intv 2009: 2: 489-497
Chronic Total Occlusion PCI
• Basic (Conventional) Techniques
• Antegrade wires, dual injection
• Advanced Techniques
• Retrograde, CART, new devices
• Requires dedicated operators / centers
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CTO Techniques
Organizational Issues
• Advanced techniques
• Should be done in a careful, organized fashion
• Heparin only for anticoagulation
• Avoid ad hoc procedures – planning is crucial
• Start with a proctor, participate in CTO clubs
• Prepare for the unexpected (perforations, tamponade, etc.)
• Equipment (wires, covered stents, etc)
• Mental preparation
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CTO Pathology Impacts the Required Techniques
for Recannalization
Micro-channels increase success
Hydrophilic wires and low profile tips
facilitate crossing
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CTO Techniques
Equipment - Wires
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CTO Guidewires
Comparison of Penetration Power
Remember – the closer the wire is to the tip of the balloon the more force that can be
exerted on the vessel (eg. A 3gm wire < 5mm to a balloon tip is ~ equivalent to a 12 gm
wire)
Asahi Fielder Guidewires
CTO Techniques
Antegrade wire techniques/strategies
• Coated, floppy wires 1st to try and find a microchannels
• A graduated, increase in wire stiffness should be used for
the first 50 cases or so, before “jumping” directly to
stiffer wires as a first approach
• Parallel wire techniques
• See-saw techniques
• Use orthogonal views to determine sub-intimal vs luminal
location
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Hydrophilic vs Hydrophobic GW Tips
High lubricity tip
Low lubricity tip
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CTO Guidewire Techniques
• Anchor technique
• Side branch technique
• Retrograde wire technique
• IVUS-guided technique
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Anchor Technique
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Anchor Technique Using OTW Balloon
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Side Branch Technique
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MicroCatheters
Cordis Transit
Finecross (Terumo)
Spectranetics Quick
Cross
Subintimal Tracking
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Creation of Re-entry
Small false lumen
True lumen
Easy to make re-entry
Large false lumen
Difficult to make re-entry
Retrograde Approach
• Approach from collateral channel
• Usually for RCA and LAD via septals
• Easier to penetrate distal cap than from
antegrade approach
• Requires delivery of supporting micro-catheter
or OTW balloon catheter through the channel
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Retrograde Technique
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Retrograde Approach
Retrograde CTO Guidewire Techniques
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CART Technique
Controlled Antegrade and Retrograde Subintimal Tracking
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Brilakis ES et al: JACC Intv 2012; 5:367–79)
Algorithm for CTO Techniques
1
Dual Injection
2
yes
no
6
Antegrade
3
Antegrade
Wiring
Retrograde
Lesion length <20 mm
no
yes
4
1) Ambiguous prox cap
2) Poor distal target
3) Appropriate collaterals
5
Antegrade dissection and
reentry
Controlled
(Stingray)
7
Brilakis ES et al: JACC Intv 2012; 5:367–79
Retrograde true
lumen puncture
Retrograde
dissection and
reentry
Wire based
(LaST)
Switch Strategy
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Karmpaliotis D: JACC CV Intv 2012; 5:1273–9)
Retrograde CTO Results
Published Reports Including >90 Pts
n=1247 pts
Study
Sianos 2008
Rathore 2009
Kimura 2009
Tsuchikane 2010
Morino 2010
Karmpaliotis 2012
Karmpaliotis D: JACC CV Intv 2012; 5:1273–9)
N
175
157
224
93
136
462
Technical
Success
84%
85%
92%
99%
79%
81%
Major
Compl
4.6%
4.5%
1.8%
0
-2.6%
Fluoro
min
59
-73
60
-61
Contrast
ml
421
-457
256
-345
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Coronary CTO
I Can’t Make This Worse, Right?
• Perforation with tamponade
• Aortic dissection
• Compromise of collateral flow of the target or
non target vessel
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Coronary CTO: When to Quit
Considerations
•
•
•
•
•
Watch the time clock
Watch the radiation meter
Watch the contrast bucket
Watch the cost (cash) register
Keep track of remaining options
• Plan B, C, D, E ……
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Coronary CTO
When to Quit?
• Technical success
• Major complication
• Operational limits reached
• Patient tolerance
• Fluoro time
• Contrast volume
• Procedural time
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Issues with CTO
•
•
•
•
Long Procedure times
Large contrast volume
Significant radiation dosing
Cost:
•
•
•
•
•
Multiple guides
Multiple wires
Multiple balloons
Delivery catheters
Multiple stents
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CTO PCI
Summary
•
•
•
•
Have clear cut indications for PCI
Proper case selection for operator skills
Have pre-defined limits for stopping
Avoid preventable complications
• excess contrast, radiation
• Failed PCI is not a bad outcome
• Stage 2 may yield better result
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