Disclosures Research Support: Siemens Medical Systems, Svelte, PCI - - PDF document

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PCI of Chronic Total Occlusion: Is It Helpful?

Kendrick Shunk, MD PhD Director, Interventional Cardiology SFVA Professor of Clinical Medicine, UCSF

Disclosures

Research Support: Siemens Medical Systems, Svelte, Cardiovascular Systems Inc. Consulting: Terumo, TransAortic Medical, Medeon Bio

CTO PCI

■ Perception of higher level of ◆ Difficulty

✦ Time ✦ Radiation ✦ Contrast

◆ Risk (MACE and procedural success) ◆ Benefit!

✦ ORBITA Controversy: NYT Nov2, 2017

‘Unbelievable’: Heart Stents Fail to Ease Chest Pain

■

Moving Target!

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Pt presentation

■ 67 yo male Veteran, DM,

HTN, HL

◆ Prior CABG 2004

✦ LIMA->LAD ✦ SVG->OM ✦ SVG->RCA

◆ Cath 2013 for angina

Pt presentation

■ 67 yo male Veteran, DM,

HTN, HL

◆ Prior CABG 2004

✦ LIMA->LAD (patent) ✦ SVG->OM (occluded) ✦ SVG->RCA (occluded)

◆ Cath 2013 for angina

Pt presentation

■ 67 yo male Veteran, DM,

HTN, HL

◆ Prior CABG 2004

✦ LIMA->LAD (patent) ✦ SVG->OM (occluded) ✦ SVG->RCA (occluded)

◆ Cath 2013 for angina

✦ PCI native OM ✦ OMT for CTO of native RCA

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Pt presentation

■ 67 yo male Veteran, DM,

HTN, HL

◆ Prior CABG 2004

✦ LIMA->LAD ✦ SVG->OM ✦ SVG->RCA

◆ PCI of native Cx/OM 2013 with DES

Pt presentation

■ 67 yo male Veteran, DM,

HTN, HL

◆ Prior CABG 2004

✦ LIMA->LAD ✦ SVG->OM ✦ SVG->RCA

◆ PCI of native Cx/OM 2013 with DES ◆ Persistent Sx despite OMT

Pt presentation

■ 67 yo male Veteran, DM,

HTN, HL

◆ Prior CABG 2004

✦ LIMA->LAD ✦ SVG->OM ✦ SVG->RCA

◆ PCI of native Cx/OM 2013 with DES ◆ Persistent Sx despite OMT ◆ Referred for PCI of RCA CTO

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“H “Heads y you g get C CTO P PCI, Ta Tails yo you take ke a baby y aspirin” n”

◆Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015.

Main Findings: NCDR

■

Of 594,510 PCI performed between 2009 and 2013

◆ 3.8% were CTO PCI ◆ Success:

✦ Non-CTO:

96%

✦ CTO:

59%

◆ MACE

✦ Non-CTO:

0.8%

✦ CTO:

1.6%

◆Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015.

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◆Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. ◆Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015.

◆Success and MACE rates over time

◆Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. ◆Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015.

Success and MACE as a function of CTO Volume

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◆Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015.

Pt presentation

■ 67 yo male Veteran, DM,

HTN, HL

◆ Prior CABG 2004

✦ LIMA->LAD ✦ SVG->OM ✦ SVG->RCA

◆ PCI of native Cx/OM 2013 with DES ◆ Persistent Sx despite OMT ◆ Referred for PCI of RCA CTO

◆CTO Procedure

• Bilateral Femoral access
• RCA: 8F 90cm AL1 + GL
• LM: 6F EBU3.5
• NATO algorithm /Hybrid approach
• Initial AWE

135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL)

• Poor re-entry zone for ADR
• CC0 septal collaterals

150 Corsair/Sion via SP1 to PDA

• Guideliner reverse CART

successful Externalized wire, balloon, 3 stents

• TIMI III antegrade flow
• IVUS

Dual Injections RAO

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◆CTO Procedure

• Bilateral Femoral access
• RCA: 8F 90cm AL1 + GL
• LM: 6F EBU3.5
• NATO algorithm /Hybrid approach

Algorithm nodes

• Initial AWE

135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL)

• Poor re-entry zone for ADR
• CC0 septal collaterals

150 Corsair/Sion via SP1 to PDA

• Guideliner reverse CART

successful Externalized wire, balloon, 3 stents

• TIMI III antegrade flow
• IVUS
• To Recovery 12:40pm

AWE

◆CTO Procedure

• Bilateral Femoral access
• RCA: 8F 90cm AL1 + GL
• LM: 6F EBU3.5
• NATO algorithm /Hybrid approach

Algorithm nodes

• Initial AWE

135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL)

• Poor re-entry zone for ADR
• CC0 septal collaterals

150 Corsair/Sion via SP1 to PDA

• Guideliner reverse CART

successful Externalized wire, balloon, 3 stents

• TIMI III antegrade flow
• IVUS
• To Recovery 12:40pm

Septal Surfing to PDA

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Redirecting wire Adjacent wires ReverseCART LCA Corsair into RCA GC

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◆CTO Procedure

• Bilateral Femoral access
• RCA: 8F 90cm AL1 + GL
• LM: 6F EBU3.5
• NATO algorithm /Hybrid approach

Algorithm nodes

• Initial AWE

135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL)

• Poor re-entry zone for ADR
• CC0 septal collaterals

150 Corsair/Sion via SP1 to PDA

• Guideliner reverse CART

successful Externalized wire, balloon, 3 stents

• TIMI III antegrade flow
• IVUS
• To Recovery 12:40pm

Positioning stent #1 Final LAO/Cranial Final RAO

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◆CTO Procedure

• Bilateral Femoral access
• RCA: 8F 90cm AL1 + GL
• LM: 6F EBU3.5
• NATO algorithm /Hybrid approach

Algorithm nodes

• Initial AWE

135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL)

• Poor re-entry zone for ADR
• CC0 septal collaterals

150 Corsair/Sion via SP1 to PDA

• Guideliner reverse CART

successful Externalized wire, balloon, 3 stents

• TIMI III antegrade flow
• IVUS
• To Recovery 12:40pm

Eur Heart J. 2015;37(35):2692-2700

■ CTO are commonly seen on coronary

angiography.

■ European and American guidelines:

Class IIa (Level B) for CTO PCI.

■ QOL is an important measure of

utility: significant improvement in physical limitation, anginal episodes, and treatment satisfaction in successful versus failed CTO PCI patients.

CTO Appropriateness Summary I

■ Revascularization modality and

risk/benefit must be individualized. (elderly, comorbidities, post CABG, impaired EF, operator’s experience.)

■ CTO PCI should be performed by

expert operators in labs equipped for management of potential complications.

■ Current Guidelines do not address

discordance of recommendations for CTO vs non-CTO PCI with respect to

• perator expertise or outcomes.

CTO Appropriateness Summary II

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Thank you.

Questions?