Debate: Is there a difference between RDR and reverse CART? No - PowerPoint PPT Presentation

Debate: Is there a difference between RDR and reverse CART? – No Dimitri Karmpaliotis, MD,PhD FACC Associate Professor of Medicine Columbia University Medical Center Director of CTO, Complex and High Risk Angioplasty NYPH/Columbia Email: dk2787@columbia.edu EURO CTO CLUB, 11 th Experts Live CTO Berlin, Germany, September 13-14, 2019

Disclosures • As a faculty member for this program, I disclose the following relationships with industry: • Honoraria from Abbott Vascular, Abiomed and Boston Scientific

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

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

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)

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

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

Having said all this, I am Confident that Paul will Triumph in making his point that RCART is Better than ADR Because I set the bar too low for a man of his CALIBER

• ADR is not needed to achieve high success rates and that AWE and Retrograde CTO PCI can take care of all cases

Multiple strategies may be necessary to succeed in CTO-PCI

PROspective Global REgiStry for the Study of CTO interventions • Appleton Cardiology, WI 1/2012 to 2/2014 • Dallas VAMC/UTSW, TX n=632 • Peaceheath Bellingham, WA Technical success: 92.4% • Piedmont Heart Institute, GA Major complications: 1.9% • St Luke’s Mid America Heart Institute, MO • Torrance Medical Center, CA Successful technique 100 Antegrade Antegrade Antegrade dissection/re-entry Antegrade DR 80 Retrograde Retrograde 65 60 31 42 44 % 37 40 20 27 0 Techniques Used Christopoulos, Karmpaliotis, Alaswad, Wyman, Lombardi, Grantham, Thompson, Brilakis et al Journal of Invasive Cardiology 2014;26:427-432

CTO PCI: success and prior CABG Pre “Hybrid” era “Hybrid” era No prior CABG Δ =9.1% Prior CABG P<0.001 100 Δ =3.7% P=0.092 93.7 90 90.0 87.2 % 80 78.1 70 2006-2011 2012-2013 N=630 N=1,363 6 US sites 3 US sites Prior CABG: 37% Prior CABG: 37% Complications: 2.5% vs. 0.8% Complications: 1.5% vs. 2.1% Retrograde: 34% vs. 39% Retrograde: 27.1% vs. 46.7% Michael, Karmpaliotis, Brilakis, Lombardi, Christopoulos, Menon, Karmpaliotis, Alaswad, Kandzari et al. Heart 2013;99:1515-8 Lombardi, Grantham, Brilakis et al. AJC 2014;113-1990-4

Effect of Prior CABG Pre Hybrid era Hybrid era 100% Δ =9.1% Δ =4.6% 90% p<0.001 p=0.001 No prior CABG 87.2% 86.5% Prior CABG 80% 81.9% 78.1% 70% 2006-2011 2012-2017 1,363 lesions; 3 US sites 2967 lesions; 20 international sites Prior CABG: 37% Prior CABG: 32% Complications: 1.5% vs. 2.1% Complications: 2.9% vs. 3.5% Retrograde: 27.1% vs. 46.7% Retrograde: 31% vs. 54% Michael, Karmpaliotis, Brilakis, Abdullah, Kirkland, Mishoe, Current available data in PROGRESS-CTO Registry Lembo, Kalynych, Carlson, Banerjee, Lombardi, Kandzari. 02/05/2018 Heart 2013;99:1515-8

Summary of Large Contemporary Registry Publications of Percutaneous Coronary Interventions of Chronic Total Occlusions Major Fluoroscopy Contrast use, N (CTO Prior Technical complicati Tampon time Author Year lesions) CABG Diabetes Retrograde Success ons Death ade (minutes) (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 45 293 (1-301)* (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 85.5 0.22 0.6 42 ± 29 294 ± 158 U.S 2013 1361 37.0 40.0 34 1.8 Registry* * Median (range) * Tesfaldet, Karmpaliotis, Brilakis, Lembo, Lombardi, Kandzari. Am J Cardiol 2013

Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Procedural Outcomes from a Multicenter Registry in the United States Prior Septal Reverse Technical Major CABG collaterals CART Success complications Fluoroscopy Contrast Author Year n (%) used (%) (%) (%) (%) time, min 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* 61 ± 40 345 ± 177 Karmpaliotis* 2012 462 50.0 71 41 81.4 2.6 Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.

Technical approach

PROspective Global REgiStry for the Study of CTO interventions www.progresscto.org Successful crossing strategy stratified by J-CTO score Retrograde p<0.0001 ADR AWE 3.1% 100% 5.8% 9.0% 19.7% 80% 14.7% 35.3% 20.5% 60% 41.5% 43.6% 88.3% 24.1% 40% 71.6% 21.6% 20.2% 50.6% 20% 31.9% 17.3% 16.9% 0% J-CTO Score 0 J-CTO Score 1 J-CTO Score 2 J-CTO Score 3 J-CTO Score 4 J-CTO Score 5

• Even before he gets to perform his magic RACRT, he can get at the distal cap all the time

Limitations of Retrograde Approaches • Visible “interventional” collaterals only seen in 64% of lesions Data from 481 patients with 519 CTOs McEntegart et al. EuroIntervention. 2016;11:e1596-1603

Limitations of Retrograde Approaches Data from 801 patients in J-PROCTOR registry Tsuchikane et al. CCI. 2013;82:e654-61

Reasons For Failure With Attempted Retrograde CTO PCI J Proctor CCI 2013.

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

• Consistently requires less number of stents to complete( Which is used as a surrogated of more controlled dissections)

• Retrograde PCI is: • Easier, Faster, Requires less Contrast • Easier to teach, adopt and disseminate among CTO Operators

Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Procedural Outcomes from a Multicenter Registry in the United States Prior Septal Reverse Technical Major CABG collaterals CART Success complications Fluoroscopy Contrast Author Year n (%) used (%) (%) (%) (%) time, min 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* 61 ± 40 345 ± 177 Karmpaliotis* 2012 462 50.0 71 41 81.4 2.6 Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.

• Retrograde PCI is: • Safer than Antegrade PCI • Associated with better periprocedural outcomes • Associated with better long-term outcomes

Insights from the Progress CTO Registry

Retrograde vs. antegrade-only: outcomes 2012-2015 11 centers, 1,301 lesions Δ = 8.9% Δ =11.4% Retrograde Retrograde utilization: 41% p<0.001 p<0.001 Antegrade-only 93.7 93.3 100 84.8 81.9 Success rate (%) 50 0 Technical Success Procedural Success Karmpaliotis D, Karatasakis A, Alaswad K, Jaffer FA, Yeh RW, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Patel M, Bahadorani J, 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)

Retrograde vs. antegrade-only: in-hospital MACE 5 p<0.001 4.3 Retrograde 4 Complication rate (%) Antegrade-only 3 p=0.003 2.1 p=0.039 2 p=0.167 1.3 p=0.314 p=0.999 1.1 1 0.8 0.6 0.4 0.3 0.3 0.3 0.1 0.1 0 MACE MI Stroke Pericardiocentesis Re-PCI Death Karmpaliotis D, Karatasakis A, Alaswad K, Jaffer FA, Yeh RW, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Patel M, Bahadorani J, 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)

• Co PIs James Sapontis, Bill Lombardi • Manager Karen Nugent • Statistician Kensey Gosch • Core Lab Federico Gallegos • Publications Spertus, Cohen, Marso, Yeh, McCabe, Grantham, Karmpaliotis