CCCSymposium 2014
Debate #4: CTO Revascularization
Most CTO Should be Opened: Samin K Sharma, MD
Only Limited CTO Should be Opened: Carlo Di Mario, MD
Samin K Sharma, MD, FACC, FSCAI
Director Clinical & Interventional Cardiology
Zena and Michael a Weiner Professor of Medicine
Mount Sinai Hospital, NY
I will make my point for;
Most CTOs Should be Opened
Chronic Total Occlusion (CTO)
Presence of CTO in CAD Imparts
Adverse Prognosis
Impact of Completeness of PCI Revascularization
on Long-Term Outcomes in the Stent Era
HRs for Mortality for Various Subgroups of Incomplete
Revascularization
N
Unadjusted HR
Compared with CR
[95%CI]
Adjusted HR
Compared with CR
[95%CI]
Complete Revascularization
6817
1.00
1.00
1 IR vessel with no CTO
8518
1.20 [1.04-1.38]
1.00 [0.87-1.15]
 2 IR vessel with no CTO
2057
1.88 [1.57-2.27]
1.25 [1.03-1.50]
1 IR vessel CTO
3232
1.81 [1.53-2.13]
1.35 [1.14-1.59]
 2 IR vessels at least 1 CTO
1321
2.77 [2.29-3.35]
1.36 [1.12-1.66]
Hannah, Holmes, King, Sharma et al. Circulation 2006;113:2406
Incomplete Revascularization in the
Era of DES: NY State Database Report
Conclusion: Pts with ≥2 IR vessels with a CTO, have the worst
long-term prognosis and greater need for CABG or re-PCI
Hannan, Sharma et al. JACC Cardio Interv 2009;2:17
Effect of a Concurrent CTO on Long-Term Mortality
and LVEF in Pts After Primary PCI in AMI
3277 STEMI pts 1997-05: SVD 65%, MVD 22%, MVD + CTO 13%
Landmark Survival Analysis
Endpoint: Survival at 5 yrs, LVEF at 12 mo (median F/U 3.1 yrs)
Claessen et al. JACC Cardio Interv 2009;2:1128.
Temporal Trends in Cumulative Angiographic Success
Rates and Major Procedural Complication Rates
80%
0.5%
Patel et al., JACC Cardiovasc Interv 2013;6:128
Incidence of Procedural Complications in
Successful vs. Unsuccessful CTO PCI
Complications
Successful
Unsuccessful
p value
MACE (%)
3.7
4.3
0.68
Death (%)
0.4
1.5
<0.0001
Emergent CABG (%)
0.03
0.17
0.74
Stroke (%)
0.07
0.4
0.04
MI (%)
2.8
3.0
0.87
Q-wave MI (%)
0.3
0.5
0.26
Coronary perforation (%)
3.7
10.7
<0.0001
Tamponade (%)
0.0
1.7
<0.0001
Vascular complication (%)
1.7
0.9
0.20
Contrast nephropathy (%)
5.0
4.6
0.86
Patel et al., JACC Cardiovasc Interv 2013;6:128
CTO: Anatomic Descriptors of Procedural Success
In the current ERA;
Severe calcification
Chronic Total Occlusion (CTO)
Why Bother to do PCI?
Presence of CTO in CAD Imparts Adverse Prognosis
Because successful CTO recanalization may result in
Angina/Ischemia relief
Freedom from subsequent CABG
Improved LV function
Improvement in event-free survival
Chronic Total Occlusion (CTO)
CTO Recanalization and Angina Relief
Series
Name/Year
Successful PCI
(N)
FU
(months)
Asymptomatic
(%)
Olivari, 2003
248
12
89
Berger, 1996
139
6
87
Ivanhoe, 1992
264
36
69
Ruocco, 1992
160
24
69
Bell, 1992
234
32
76
>1000
>24 mo
>80%
TOTAL
TOAST-GISE
1 Year Clinical Status of Complication Free Patients
CTO Success
(n = 248)
CTO Failure
(n = 60)
No angina
220 (88.7%)
45 (75.0%)
0.008
ETT performed
210 (84.7%)
42 (70.0%)
0.010
Maximal ETT
155 (62.5%)
20 (33.3%)
<0.0001
Negative ETT
181 (73.0%)
28 (46.7%)
0.0001
P Value
Olivari Z et al, J Am Coll Cardiol 2003;41:1672
Meta-Analysis of CTO Outcomes
13 Observational Studies, 7288 patients
weighted averaged follow-up 6 years
OR for Success
vs. Failure
95% Cl
p Value
Mortality
0.56
0.43-0.72
<0.001
MI
0.74
0.44-1.25
0.26
Subsequent CABG
0.22
0.17-0.27
<0.001
Residual Angina
0.45
0.30-0.67
0.001
Joyal et al., Am Heart J 2010;160:179.
Evaluation of LV Function 3-Yrs after
Percutaneous Recanalization of CTO
Changes in LV Volume Indexes and EF between Baseline and 3-Yr FU
Measured Using Magnetic Resonance Imaging (N=21)
86
35
78
60
63
30
Mean ejection fraction improved slightly, but end-systolic and enddiastolic volume indexes decreased significantly.
Kirschbaum S et al, Am J Cardiol 2008;101:179
Segmental wall thickening (%)
MRI Predicts LV EF & Wall Motion Improvement
with CTO Revascularization (N=21) with prior MI
90
SWT at Baseline (n=21)
SWT 5 mths post Stent Implantation
SWT 3 yrs post stent Implantation
P<0.001
P=ns
P=ns
P<0.05
80
70
P<0.05
60
50
P<0.05
P<0.001
P<0.05
40
P<0.05
P=ns
30
20
P=ns
10
P=ns
0
-10
-20
<25%
25-75%
>75%
Remote
Transmural extent of infarction
Kirschbaum et al, Am J Cardiol 2008;101:179
Effect of Successful vs. Failed CTO PCI in All-Cause
Mortality During Long-Term Follow-up
Author, Year
Yr Follow-up
PCI Success (n)
PCI Failure (n)
OR/HR, 95% CI
Finci, et al., 1990
2
100
100
OR: 1.70, 0.40 - 7.32
Warren et al., 1990
2.6
26
18
N/A
Ivanhoe et al., 1992
4
317
163
OR: 0.21, 0.05 - 0.83
Angioi et al., 1995
3.6
93
108
OR: 0.37, 0.10 - 1.40
Noguchi et al., 2000
4.3
134
92
OR: 0.28, 0.11 – 0.72
Suero et al., 2001
10
1,491
514
OR: 0.67, 0.54 – 0.83
Olivari et al., 2003
1
289
87
OR: 0.19, 0.03 – 1.14
Hoye et al., 2005
4.5
567
304
OR: 0.52, 0.32 – 0.84
Drozd et al., 2006
2.5
298
161
OR: 0.74, 0.23 – 2.37
Aziz, et al.,2007
1.7
377
166
OR: 0.31, 0.13 – 0.76
Prasad et al., 2007
10
914
348
OR: 0.82, 0.62 – 1.08
Valenti et al., 2008
1
344
142
OR: 038, 0.19 – 0.77
de Labriolle et al., 2008
2
127
45
OR: 1.25, 0.25 – 6.27
Mehran et al., 2011
2.9
1,226
565
HR: 0.63, 0.40 – 1.0
Jones et al., 2012
3.8
582
254
HR: 0.28, 0.15 – 0.52
5,056
2,236
OR: 0.56, 0.43 – 0.72
Joyal et al., 2010
Moses et al., JACC Cardio Interv 2012;5:389
Successful Recanalization of CTO Associated
with Improved Long-Term Survival
Jones et al., JACC Cardio Interv 2012;5:380
Advanced Techniques
for Chronic Total Occlusion
Japanese Specialized Technique
•
•
•
•
•
Anchor balloon technique
Mother-Child catheter technique
Parallel wire
IVUS guidance
Retrograde approach
Retrograde Wire Technique for Chronic Total
Occlusion Recanalization
Four Patterns of Success in Retrograde CTO Recanalization
Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.
Increased Use of Retrograde Approach and
Technical Success Rate Over Time
2006
2007
2008
2009
2010
2011
≈35%
%
Michael et al., Am J Cardiol 2013;112:488
ACCF/SCAI/STS/AATS/AHA/ASNC 2012
Appropriateness Criteria for Coronary Revascularization
Chronic Total Occlusions: Indications for PCI
Appropriateness Score (1-9)
INDICATION
CCS Angina Class
Asymptomatic
I or II
III or IV
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses
• Low-risk findings on noninvasive testing
• Receiving no or minimal anti-ischemic medical therapy
I
I
I
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses
• Low-risk findings on noninvasive testing
• Receiving a course of maximal anti-ischemic medical therapy
I
U
U
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses
• Intermediate-risk findings on noninvasive testing
• Receiving no or minimal anti-ischemic medical therapy
I
U
U
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses
• Intermediate-risk criteria on noninvasive testing
• Receiving a course of maximal anti-ischemic medical therapy
U
U
A
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses
• High-risk findings on noninvasive testing
• Receiving no or minimal anti-ischemic medical therapy
U
U
A
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses
• High-risk criteria on noninvasive testing
• Receiving a course of maximal anti-ischemic medical therapy
U
A
A
Patel et al. JACC 2012;53:530-553
Chronic Total Occlusions
I IIaIIb III
PCI of a CTO in patients with
appropriate clinical indications and
suitable anatomy is reasonable when
performed by operators with
appropriate expertise
Fundamental Wire Technique and Current
Strategy for Chronic Total Occlusion PCI
Procedural Steps of Current CTO-PCI
CTO - PCI
Cotralateral
Dual Injection
Antegrade
approach x2
Retrograde
approach (ostial)
Single Wire
Technique
Parallel Wire
Technique
Retrograde Wire Cross
Kissing Wire Cross
IVUS guide re-entry
Success
Failure
CART
Reverse CART
Procedural Success of CTO PCI at MSH
100
Asahi wires
Retrograde
technique
78
Planned 2nd (18%) or
3rd (8%) attempt
86
93
80
68
%
EXPERT
CTO
US Trial:
90+ success
60
40
20
397
806
665
782
0
2003-2005
2006-2008
2009-10
2011-12
Conclusions:
Rationale for CTO Recanalization in ALL
 Presence of a CTO imparts adverse prognosis.
 Non randomized data support improved overall CV
outcomes (including mortality) with successful CTO
procedures. A randomized trial will be needed to establish
the PCI efficacy in CTO pts.
 Therefore developing technical skills (dedicated
centers and dedicated Interventionalists) is essential to
tackle this “last frontier of Interventional Cardiology”
to improve overall outcomes of our complex CAD pts.
 KEY to better CTO outcomes is successful
recanalization