CTO PCI made simple Samih Lawand MD Saudi Arabia Senior Interventional Cardiologist Head of Cardiology Dallah Hospital 31\5\2016 Cadrioalex 2016
Diclosures • None
Issues with CTO • Long Procedure times • Large contrast volume • Significant radiation dosing • Cost: – Multiple guides – Multiple wires – Multiple balloons – Delivery catheters – Multiple stents
CTOs are currently undertreated Canadian Multicenter Chronic Total Occlusions Registry: • 14,439 patients underwent coronary angiography • 2,630 CTOs (prevalance = 18.2%) - Excluded prior CABG • 54% had a CTO - Excluded STEMI • 10% had a CTO • Attempt rate 10% • Success rate 70% • 87% reported >CCS class I angina Fefer et al J Am Coll Cardiol 2012;59:991 – 7
This represents all patients from the Canadian registry that had CTOs (n=2630) Source: Dr James Spratt
Only 10% of the CTOs were attempted … Source: Dr James Spratt
With a success rate of 70% Source: Dr James Spratt
Contemporary CTO Results Impact of Novel Guidewire Techniques 2002 – 2008; n=904 procedures % Success Fluoro Procedure (min) (hrs) Single wire 64% 57% 76.8 2.56 Parallel wire 19% 55% 95.5 3.18 Retrograde 7% 42% 108 3.36 CART 10% 94% 114 3.61 Total 100% 86.2% Rathore: JACC Intv 2009: 2: 489-497
Chronic Total Occlusion PCI • Basic (Conventional) Techniques – Antegrade wires, dual injection • Advanced Techniques – Retrograde, CART, new devices – Requires dedicated operators / centers
CTO Techniques Organizational Issues • Advanced techniques • Should be done in a careful, organized fashion • Heparin only for anticoagulation • Avoid ad hoc procedures – planning is crucial • Start with a proctor, participate in CTO clubs • Prepare for the unexpected (perforations, tamponade, etc.) – Equipment (wires, covered stents, etc) – Mental preparation
CTO Pathology Impacts the Required Techniques for Recannalization Micro-channels increase success Hydrophilic wires and low profile tips facilitate crossing
CTO Techniques Equipment - Wires
CTO Guidewires Comparison of Penetration Power Remember – the closer the wire is to the tip of the balloon the more force that can be exerted on the vessel (eg. A 3gm wire < 5mm to a balloon tip is ~ equivalent to a 12 gm wire)
Asahi Fielder Guidewires
CTO Techniques Antegrade wire techniques/strategies • Coated, floppy wires 1 st to try and find a microchannels • A graduated, increase in wire stiffness should be used for the first 50 cases or so, before “ jumping ” directly to stiffer wires as a first approach • Parallel wire techniques • See-saw techniques • Use orthogonal views to determine sub-intimal vs luminal location
Hydrophilic vs Hydrophobic GW Tips High lubricity tip Low lubricity tip
CTO Guidewire Techniques • Anchor technique • Side branch technique • Retrograde wire technique • IVUS-guided technique
Anchor Technique
Anchor Technique Using OTW Balloon
Side Branch Technique
MicroCatheters Cordis Transit Finecross (Terumo) Spectranetics Quick Cross
Subintimal Tracking
Creation of Re-entry Small false lumen True lumen Easy to make re-entry Large false lumen Difficult to make re-entry
Retrograde Approach • Approach from collateral channel • Usually for RCA and LAD via septals • Easier to penetrate distal cap than from antegrade approach • Requires delivery of supporting micro-catheter or OTW balloon catheter through the channel
Retrograde Technique
Retrograde Approach
Retrograde CTO Guidewire Techniques
CART Technique Controlled Antegrade and Retrograde Subintimal Tracking
Brilakis ES et al: JACC Intv 2012; 5:367 – 79)
Algorithm for CTO Techniques Dual Injection 1 1) Ambiguous prox cap 2) Poor distal target 2 3) Appropriate collaterals yes no Retrograde Antegrade 6 3 Lesion length <20 mm no yes Retrograde Retrograde 4 Antegrade Antegrade dissection and 5 true lumen dissection and Wiring reentry puncture reentry Controlled Wire based (Stingray) (LaST) Switch Strategy 7 Brilakis ES et al: JACC Intv 2012; 5:367 – 79
Karmpaliotis D: JACC CV Intv 2012; 5:1273 – 9)
Retrograde CTO Results Published Reports Including >90 Pts n=1247 pts Technical Major Fluoro Contrast Study N Success Compl min ml Sianos 2008 175 84% 4.6% 59 421 Rathore 2009 157 85% 4.5% -- -- Kimura 2009 224 92% 1.8% 73 457 Tsuchikane 2010 93 99% 0 60 256 Morino 2010 136 79% -- -- -- Karmpaliotis 2012 462 81% 2.6% 61 345 Karmpaliotis D: JACC CV Intv 2012; 5:1273 – 9)
The Hybrid Approach • SubIntimal tracking Re-crossing Japanese style • Using the CrossBoss ™ and Stingray ™ catheters within the Hybrid Approach
What is the Hybrid Approach? “ The Hybrid approach is a standardised methodology, where the anatomy drives the strategy to maximize the chance for success in CTO-PCI. The Bridge Point CTO Crossing System is a proven and integral part of the Hybrid approach. ”
The Hybrid Algorthim for CTO PCI Dual Catheter Angiography yes no 1. Clear Proximal Cap? 2. Good Distal Target ? Antegrade Retrograde 3. Length < 20mm? yes no yes no Dissection Reentry Wire Dissection Reentry Wire (CrossBoss ™ / Stingray ™ ) (Reverse CART) Escalation Escalation Brilakis ES, et.al., JACC Cardiovasc Interv 2012 Apr, 5(4): 357-79
What Evidence Supports the Hybrid Approach? • Comparing 4 major registries of CTO cases: 1. J CTO - Japan 2. Royal Brompton - UK 3. The Hybrid Registry - US 4. Euro CTO registry - Europe • When the registries were compared, differences became apparent: Source: Dave Daniels, MD; CTO/LM Summit 2013
When Difficulty Increased The Hybrid Approach Consistently Crossed CTOs Source: Dave Daniels, MD; CTO/LM Summit 2013
The Hybrid Approach was Shown to Cross Lesions Faster Source: Dave Daniels, MD; CTO/LM Summit 2013
The Hybrid Approach was shown to have a high success rate, lower procedure time and use less contrast Hybrid J-CTO Euro CTO p Registry Registry Registry (N=144 pts, (N=498 pts, (N=1914 pts, 145 lesions) 528 lesions) 1983 lesions) * 0.039 Procedural 94.4% 88.6% 85.6% Ŧ 0.003 Success (%) 85 ± 54 105 ± 58 Ŧ <0.0001 Procedure NA Time (minutes) 238 ± 105 313 ± 84 Ŧ <0.0001 Contrast 293 *Hybrid Registry vs J-CTO Registry, Ŧ Hybrid Registry vs Euro CTO Registry Source: Dave Daniels, MD; CTO/LM Summit 2013
While there are 3 hybrid strategies, the CrossBoss ™ & Stingray ™ catheters are used in one of the 3 Dissection Retrograde Re-entry Interventional collateral Lesion >20 mm Antegrade Defined cap Adequate distal target Source: Dave Daniels, MD; CTO/LM Summit 2013
CrossBoss ™ catheter Indications, contraindications, warnings and instructions for use can be found in the product labeling supplied with each device. Information for the use only in countries with applicable health authority product registrations
Stingray ™ catheter Indications, contraindications, warnings and instructions for use can be found in the product labeling supplied with each device. Information for the use only in countries with applicable health authority product registrations
The FAST CTO Trial Study Objective To demonstrate the safety and efficacy of the CrossBoss ™ and Stingray ™ Coronary Crossing and Re-Entry devices to recanalize coronary chronic total occlusions (CTOs) in comparison to historical controls Study Design • 147 patients with 150 CTOs, 16 centers • Multi center, non randomized, US IDE study • Historical control: similarly designed CTO device trials with comparable technical success and safety measures Conclusion In CTOs failing standard techniques, use of the Cross Boss and Stingray Coronary Crossing and Re-Entry devices resulted in a high technical success rate, 77% without increasing complication. In addition, data shows that crossing success improved to 87% in the last half of the trial as investigators became more familiar with the devices and associated techniques.
Reference: Fast CTO Trial REFERENCES 1. Whitlow P, Lombardi W, Wyman M et al. Use of Novel Crossing and Re-Entry System in Coronary Chronic Total Occlusions That Have Failed Standard Crossing Techniques. J Am Coll Cardiol Interv. 2012;5:393-401. 2. Wyman M. The BridgePoint Medical CTO System: Results of the “ Fast-CTO ” US IDE Study. TCT 2010.
Case • 62 year old male • Diabetic Hypertensive Dyslipedemic • Previous CABG 5 years • SOB Chest pains recurrent NSTEMIs • LVEF 35-40%
Triple CTO What Should I Do? • The obvious is start with the RCA
Coronary CTO I Can’t Make This Worse, Right? • I was lucky I did not make the patient worse • No Perforation with tamponade • No Aortic dissection • No Compromise of collateral flow of the target or non target vessel
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