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

▶
debate is there a difference between
SMART_READER_LITE
LIVE PREVIEW

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

Oct 07, 2023 248 likes •808 views

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:

slide-1
SLIDE 1

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, 11th Experts Live CTO Berlin, Germany, September 13-14, 2019

slide-2
SLIDE 2

Disclosures

  • As a faculty member for this program,

I disclose the following relationships with industry:

  • Honoraria from Abbott Vascular,

Abiomed and Boston Scientific

slide-3
SLIDE 3
slide-4
SLIDE 4

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

slide-5
SLIDE 5

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

slide-6
SLIDE 6

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)

slide-7
SLIDE 7

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
  • utcomes
  • Associated with better long-term
  • utcomes
slide-8
SLIDE 8

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

slide-9
SLIDE 9

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

  • f his CALIBER
slide-10
SLIDE 10
  • ADR is not needed to achieve high

success rates and that AWE and Retrograde CTO PCI can take care of all cases

slide-11
SLIDE 11

Multiple strategies may be necessary to succeed in CTO-PCI

slide-12
SLIDE 12

1/2012 to 2/2014 n=632 Technical success: 92.4% Major complications: 1.9%

  • Appleton Cardiology, WI
  • Dallas VAMC/UTSW, TX
  • Peaceheath Bellingham, WA
  • Piedmont Heart Institute, GA
  • St Luke’s Mid America Heart

Institute, MO

  • Torrance Medical Center, CA

Christopoulos, Karmpaliotis, Alaswad, Wyman, Lombardi, Grantham, Thompson, Brilakis et al Journal of Invasive Cardiology 2014;26:427-432

42 27 31

Antegrade Antegrade dissection/re-entry Retrograde

65 37 44

20 40 60 80 100 Techniques Used

%

Antegrade Antegrade DR Retrograde

Successful technique

PROspective Global REgiStry for the Study of CTO interventions

slide-13
SLIDE 13

87.2 93.7 78.1 90.0

70 80 90 100 2006-2011 2012-2013

%

No prior CABG Prior CABG

Pre “Hybrid” era

Michael, Karmpaliotis, Brilakis, Lombardi, Kandzari et al. Heart 2013;99:1515-8

Δ=9.1% P<0.001

Christopoulos, Menon, Karmpaliotis, Alaswad, Lombardi, Grantham, Brilakis et al. AJC 2014;113-1990-4

CTO PCI: success and prior CABG N=1,363 3 US sites Prior CABG: 37% Complications: 1.5% vs. 2.1% Retrograde: 27.1% vs. 46.7% Δ=3.7% P=0.092

“Hybrid” era

N=630 6 US sites Prior CABG: 37% Complications: 2.5% vs. 0.8% Retrograde: 34% vs. 39%

slide-14
SLIDE 14

87.2% 86.5%

78.1% 81.9%

70% 80% 90% 100%

2006-2011 2012-2017

No prior CABG Prior CABG

Pre Hybrid era

Δ=9.1% p<0.001

Effect of Prior CABG

Michael, Karmpaliotis, Brilakis, Abdullah, Kirkland, Mishoe, Lembo, Kalynych, Carlson, Banerjee, Lombardi, Kandzari. Heart 2013;99:1515-8

1,363 lesions; 3 US sites Prior CABG: 37% Complications: 1.5% vs. 2.1% Retrograde: 27.1% vs. 46.7%

Δ=4.6% p=0.001

Hybrid era

Current available data in PROGRESS-CTO Registry 02/05/2018

2967 lesions; 20 international sites Prior CABG: 32% Complications: 2.9% vs. 3.5% Retrograde: 31% vs. 54%

slide-15
SLIDE 15

Author Year N (CTO lesions) Prior CABG Diabetes Retrograde Technical Success Major complicati

  • ns

Death Tampon ade Fluoroscopy time (minutes) Contrast use, (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 (1-301)* 293 (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 U.S Registry* 2013 1361 37.0 40.0 34 85.5 1.8 0.22 0.6 42±29 294 ±158

* Median (range)

Summary of Large Contemporary Registry Publications of Percutaneous Coronary Interventions of Chronic Total Occlusions

* Tesfaldet, Karmpaliotis, Brilakis, Lembo, Lombardi, Kandzari. Am J Cardiol 2013

slide-16
SLIDE 16

Author Year n Prior CABG (%) Septal collaterals used (%) Reverse CART (%) Technical Success (%) Major complications (%) Fluoroscopy time, min Contrast 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 60 ± 26 256 ± 169 Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR* Karmpaliotis* 2012 462 50.0 71 41 81.4 2.6 61 ± 40 345 ± 177

Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.

Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Procedural Outcomes from a Multicenter Registry in the United States

slide-17
SLIDE 17

Technical approach

slide-18
SLIDE 18

PROspective Global REgiStry for the Study of CTO interventions

www.progresscto.org

Successful crossing strategy stratified by J-CTO score

88.3% 71.6% 50.6% 31.9% 17.3% 16.9% 5.8% 14.7% 20.5% 24.1% 21.6% 20.2% 3.1% 9.0% 19.7% 35.3% 41.5% 43.6%

0% 20% 40% 60% 80% 100%

J-CTO Score 0 J-CTO Score 1 J-CTO Score 2 J-CTO Score 3 J-CTO Score 4 J-CTO Score 5

Retrograde ADR AWE

p<0.0001

slide-19
SLIDE 19
slide-20
SLIDE 20
  • Even before he gets to perform his

magic RACRT, he can get at the distal cap all the time

slide-21
SLIDE 21

Limitations of Retrograde Approaches

McEntegart et al. EuroIntervention. 2016;11:e1596-1603

Data from 481 patients with 519 CTOs

  • Visible “interventional” collaterals only seen in

64% of lesions

slide-22
SLIDE 22

Limitations of Retrograde Approaches

Tsuchikane et al. CCI. 2013;82:e654-61

Data from 801 patients in J-PROCTOR registry

slide-23
SLIDE 23

Reasons For Failure With Attempted Retrograde CTO PCI

J Proctor CCI 2013.

slide-24
SLIDE 24

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

slide-25
SLIDE 25
  • Consistently requires less number of

stents to complete( Which is used as a surrogated of more controlled dissections)

slide-26
SLIDE 26
slide-27
SLIDE 27
  • Retrograde PCI is:
  • Easier, Faster, Requires less Contrast
  • Easier to teach, adopt and disseminate

among CTO Operators

slide-28
SLIDE 28

Author Year n Prior CABG (%) Septal collaterals used (%) Reverse CART (%) Technical Success (%) Major complications (%) Fluoroscopy time, min Contrast 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 60 ± 26 256 ± 169 Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR* Karmpaliotis* 2012 462 50.0 71 41 81.4 2.6 61 ± 40 345 ± 177

Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.

Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Procedural Outcomes from a Multicenter Registry in the United States

slide-29
SLIDE 29
  • Retrograde PCI is:
  • Safer than Antegrade PCI
  • Associated with better periprocedural
  • utcomes
  • Associated with better long-term
  • utcomes
slide-30
SLIDE 30

Insights from the Progress CTO Registry

slide-31
SLIDE 31
slide-32
SLIDE 32

Retrograde vs. antegrade-only: outcomes

2012-2015 11 centers, 1,301 lesions Retrograde utilization: 41%

84.8 81.9 93.7 93.3

50 100 Technical Success Procedural Success

Success rate (%) Retrograde Antegrade-only

Δ= 8.9% p<0.001 Δ=11.4% p<0.001 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)

slide-33
SLIDE 33

4.3 2.1 0.4 1.3 0.6 0.8 1.1 0.3 0.3 0.3 0.1 0.1

1 2 3 4 5

MACE MI Stroke Pericardiocentesis Re-PCI Death

Complication rate (%)

Retrograde Antegrade-only

Retrograde vs. antegrade-only: in-hospital MACE

p<0.001 p=0.003 p=0.999 p=0.039 p=0.314 p=0.167

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)

slide-34
SLIDE 34
  • Co PIs

James Sapontis, Bill Lombardi

  • Manager Karen Nugent
  • Statistician

Kensey Gosch

  • Core Lab Federico Gallegos
  • Publications Spertus, Cohen, Marso, Yeh,

McCabe, Grantham, Karmpaliotis

slide-35
SLIDE 35
slide-36
SLIDE 36
slide-37
SLIDE 37
slide-38
SLIDE 38
slide-39
SLIDE 39
slide-40
SLIDE 40
slide-41
SLIDE 41

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

Common Sense

slide-42
SLIDE 42

CASE EXAMPLE

CTO-RCA

slide-43
SLIDE 43

CTO-RCA Dual Injections

7Fr Slender Sheaths Right Radial Artery 7Fr EBU 3.5 90cm Left Radial Artery 7Fr AL0.75 SH 90cm

slide-44
SLIDE 44

CTO-RCA Dual Injections

7Fr Slender Sheaths Right Radial Artery 7Fr EBU 3.5 90cm Left Radial Artery 7Fr AL0.75 SH 90cm

slide-45
SLIDE 45

Retrograde via LAD septal

TurnPike 150cm Sion wire

slide-46
SLIDE 46

Setting up for Reverse CART

Antegrade TurnPike 135cm Retrograde TurnPike 150cm Antegrade Pilot 200 Retrograde Pilot 200 Very Hard to get into vessel structure because of tortuous and ectatic vessel added to proximal bridging collaterals and ambiguous proximal cap

slide-47
SLIDE 47

“Move the Cap” Technique

Antegrade 4.0 x 12 Balloon inflated in pRCA On looped BMW wire Antegrade TurnPike 135cm With Knuckled Fielder XT Wire NEXT to the Balloon “Move the Cap” by entering the sub-intimal place (with your knuckle) more proximally that the proximal CTO cap

slide-48
SLIDE 48

ADR-StingRay

StingRay LP StingRay Wire Fenestrations

slide-49
SLIDE 49

ADR-StingRay

StingRay LP Pilot 200 rapidly advanced with wiring of the distal true lumen Into a smaller branch Retrograde Distal Tip Injections with Medallion Syringe for visualization

slide-50
SLIDE 50

After 6Fr Guideliner supported PCI

DES 3.5 x 38 mm DES 4.0 x 38 mm DES 4.0 x 18 mm DES 4.0 x 28 mm

slide-51
SLIDE 51

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

  • f his CALIBER

So, Good Luck Paul……

slide-52
SLIDE 52
slide-53
SLIDE 53

THANK YOU

slide-54
SLIDE 54

THANK YOU