Complex Coronary Cases
Supported by:
• Abbott Vascular
• Boston Scientific Corporation
• Medtronic, Inc.
• Astrazeneca
Disclosures
Samin K. Sharma, MBBS, FACC
Speaker’s Bureau – Boston Scientific Corporation,
Abbott Vascular Inc, AngioScore, The Medicines
Company, Daiichi Sankyo, Inc. and Lilly USA, LLC
Annapoorna S. Kini, MBBS, FACC
Nothing to disclose
Sameer Mehta, MBBS, FACC
Consulting Fees – The Medicines Company
American College of Cardiology Foundation staff involved
with this case have nothing to disclose
August 20th 2013 Case #14: SD, 62 yr M
Presentation:
Patient with new onset cresendo angina and positive stress
echo for infero-lateral ischemia underwent cardiac cath on
June 26, 2013 which revealed 3 V CAD (60% prox LAD, 80%
distal LCx and 100% distal RCA) and normal LV function;
SYNTAX score 22. CABG was recommended but declined
and pt underwent Resolute Integrity (3.5/30mm) DES PCI of
distal LCx. Pt continued to have class II angina on MMT.
Prior History:
Hypertension, NIDDM, +F/H
Medications: All once daily dosage
Atenolol 50mg, Amlodipine 5mg, Aspirin 81mg, Prasugrel 5mg,
Metformin XR 1000mg, Glimeperide 2mg, Omeprazole 20mg
Case# 14: cont…
Cardiac Cath 6/26/2013: Right Dominance
3 V CAD with LVEF 65%
Left Main: No obstruction
LAD: 60% prox LAD and 60% D1 non-bifurcation lesions
LCx: 80% distal LCx, large vessel
RCA: 80% mid and 100% distal RCA occlusion and distal
vessel fills via bridge as well as retrograde collaterals
Pt underwent successful DES PCI of distal LCx using 3.5/30mm
Resolute Integrity DES. Pt did well but had class II angina
despite MMT. Did not tolerate ISMN
Plan Today:
- PCI of distal RCA CTO using retrograde recanalization.
Appropriateness Criteria for Coronary Revascularization
Issues Involving The Case
• Current status of CTO lesion success
• Retrograde recanalization approach
Issues Involving The Case
• Current status of CTO lesion success
• Retrograde recanalization approach
Chronic Total Occlusion (CTO)
From Randomized Trials to Daily Practice
1. CTO is present in 20-22% of cath cases but PCI is
attempted only in 5-13% of these cases
2. From BARI trial (1994) to SYNTAX trial (2007) , the
single most common reason for a patient to be
referred to surgery and not randomized was a CTO
with low success rate of recanalization
3. Even in the recent era of increasing success rate of
CTO recanalization (60-85%), the PCI success rate for
CTO lesions in the SYNTAX trial was only 53%
Current Perspective on Coronary CTO
The Canadian Multicenter CTO Registry
Management of CTO Registry Patients by Treating Center
Fefer et al, J Am Coll Cardiol 2012;59:991
Anatomic Descriptors of Procedural Success
In the current ERA;
Severe calcification
Predictors of CTO Procedural Success
Multivariate analysis from TOAST-GISE
Variables
Hazard Ratio
p
Length ≥15 vs. <8 mm
3.9
0.028
Severe calcification
3.5
0.023
Duration ≥ 180 days
3.1
0.013
Multi-vessel disease
2.3
0.009
Bridge collaterals present
2.2
0.023
Stump morphology
2.2
0.048
Olivari et al., J Am Cardiol Coll 2003;41:1672
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
Temporal Trends in Cumulative Angiographic Success
Rates and Major Procedural Complication Rates
80%
0.5%
Patel et al., JACC Cardiovasc Interv 2013;6:128
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.
All-Cause Mortality for Successful and Failed
Groups of CTO Duration >3 Months
Khan et al., Cath & Cardiovasc Intervn 2013;82:95
Residual SYNTAX Score: 1-Year Outcomes
According to the rSS
rSS = 0
rSS = 3-8
rSS = 0-2
rSS = >8
P = 0.006
22.4
25
20
20
P =0.32
18
16.3
P = 0.007
(%)
15
12.6 13.1
10.9 11.1
12
10.4
9.7
P = 0.001
10
P = 0.23
7.1
4.8
5
2.8
1.4
0
MACE
2.1
Death
1 1.6 1.6
MI
2.5
Stent
uTVR
Thrombosis
Généreux et al., JACC2012;59:2165
PCI: Four-Year Clinical Outcomes in Patients
by Complete vs. Incomplete Revascularization
Patients (%)
Complete Revascularization (n=578)
Incomplete Revascularization (n=510)
p=<0.001
p=0.011
p=0.052
p=0.059
p=0.046
p=0.23
Farooq et . al., J Am Coll Cardiol 2013;61:282
Total Charges, Payments and Direct Costs per Patient
Undergoing CTO and Non-CTO PCI
CTO (n=154)
p=<0.001
Cost (D o l l a r s )
Non-CTO (n=1,847)
p=<0.001
p=0.58
Karmpaliotis et al., Cath & Cardiovasc Interv 2013;82:1
Issues Involving The Case
• Current status of CTO lesion success
• Retrograde recanalization approach
Retrograde Wire Technique of CTO
Recanalization
Retrograde Techniques for CTO
Recanalization
• Typically reserved for LAD or RCA CTOs via
septal collaterals; avoid using epicardial collaterals
• Four techniques:
– Direct retrograde crossing
– Kissing wire crossing
– Controlled Antegrade and Retrograde Subintimal
Tracking (CART); balloon dilatation or knuckle wire
– Reverse CART
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
30%
%
Michael et al., Am J Cardiol 2013;112:488
Summary of Published Retrograde CTO PCI Series
Year
N
Prior
CABG
%
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
79.0
14.0
92.4
1.8
73 ± 42
457 ± 199
Tsuchikane
2010
93
10.8
82.8
60.9
98.9
0.0
60 ± 26
256 ± 169
Morino
2010
136
9.6
63.9
NR
79.2
NR
NR
NR
US Registry
2012
462
50.0
71.0
41.0
81.4
2.6
61 ±
345 ± 177
Study
Septal
Collateral
Used %
Reverse
CART, %
Technical
Success
%
Major
Complic %
Flouroscopy
Time, min,
mean ± SD
Contrast
Use, ml
mean ± SD
Karmpaliotis et al., JACC Cardio Interv 2012;5:1273
Retrograde PCI: 5 Steps
Retrograde PCI for recanalization of CTOs has gained acceptance
as a necessary technique to improve success
The procedure involves five key steps:
1. Wiring of the collateral from the donor artery into the distal bed of the
recipient artery, usually with the use of hydrophilic jacketed guidewires
2. Delivery of over-the-wire microcatheters especially Corsair channel dilator to
allow an exchange for a CTO-specific guidewire
3. Crossing the total occlusion with the CTO guidewire and dilating the CTO with
the retrograde small balloon (1.25-1.5/8-10mmsize)
4. Placing an antegrade guidewire into the distal bed through the recanalized
CTO. Rarely exteriorization of the long retrograde guidewire (Viper wire 360cm)
is needed to advance antegrade monorail or over-the-wire small balloon
5. Stenting the lesion over the antegrade guidewire
Retrograde Wire Technique for CTO Recanalization
When to do Retrograde technique?
- Minimum 200 CTO cases via antegrade technique
- Dedicated setup, equipments and ability to handle compl.
- Usually after failed antegrade (once or twice) approach
- Ostial stump occlusion (RCA, LAD, LCx)
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
Take Home Message:
Status of CTO lesion PCI and Retrograde
recanalization approach
 Improvement in the procedural techniques and
devices has resulted in increasing success of CTO
PCI. A successful CTO PCI is associated with better
long-term outcome, decreased cost & lower mortality.
 Technique of retrograde recanalization is gaining
increasing momentum and adds to the already
increasing technical success rates. Every advanced
CTO PCI center should dedicated experienced
operators for the retrograde approach.
Question # 1
Which one of the angiographic lesion morphology is associated with
the highest rates of unsuccessful CTO recanalization :
A. Blunt stump
B. Side branch at the site of occlusion
C. Short occlusion length
D. Severe calcification
E. Bridge collaterals
Question # 2
A successful CTO recanalization is associated with following except :
A. Lower MACE
B. Lower mortality
C. Lower stent thrombosis
D. Lower incidence of long-term CABG
E. Lower angina
Question # 3
Following are the techniques for retrograde recanalization except :
A. Kissing wire approach
B. Retrograde wire cross
C. Controlled antegrade and retrograde tracking (CART)
D. Reverse CART
E. Parallel wire technique
Question # 1
Which one of the angiographic lesion morphology is associated with
the highest rates of unsuccessful CTO recanalization :
A. Blunt stump
B. Side branch at the site of occlusion
C. Short occlusion length
D. Severe calcification
E. Bridge collaterals
The correct answer is D as of these unfavorable factors
severe calcification still is associated with highest failure
Olivari et al., J Am Cardiol Coll 2003;41:1672.
Question # 2
A successful CTO recanalization is associated with following except :
A. Lower MACE
B. Lower mortality
C. Lower stent thrombosis
D. Lower incidence of long-term CABG
E. Lower angina
The correct answer is C as stent thrombosis may even be
higher in successful vs. unsuccessful CTO recanalization
Joyal et al., Am Heart J 2010;160:179.
Question # 3
Following are the techniques for retrograde recanalization except :
A. Kissing wire approach
B. Retrograde wire cross
C. Controlled antegrade and retrograde tracking (CART)
D. Reverse CART
E. Parallel wire technique
The correct answer is E as all others are the techniques of
retrograde CTO recanalization while the parallel wire
technique is for antegrade recanalization
Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.