Samih Lawand MD Saudi Arabia Senior Interventional Cardiologist - - PowerPoint PPT Presentation

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

% Success Fluoro (min) Procedure (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%

Impact of Novel Guidewire Techniques

Rathore: JACC Intv 2009: 2: 489-497

2002 – 2008; n=904 procedures

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 1st 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

Finecross (Terumo) Cordis Transit Spectranetics Quick Cross

Subintimal Tracking

Easy to make re-entry Small false lumen Large false lumen Difficult to make re-entry

True lumen

Creation of 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
• r 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 Antegrade

Retrograde true lumen puncture

Retrograde

Antegrade Wiring Controlled (Stingray) Antegrade dissection and reentry Retrograde dissection and reentry Wire based (LaST) Switch Strategy

Brilakis ES et al: JACC Intv 2012; 5:367–79

no yes 1) Ambiguous prox cap 2) Poor distal target 3) Appropriate collaterals no yes Lesion length <20 mm 1 2 3 4 6 5 7

Karmpaliotis D: JACC CV Intv 2012; 5:1273–9)

Retrograde CTO Results

Study N Technical Success Major Compl Fluoro min Contrast 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% 60 256 Morino 2010 136 79%

• Karmpaliotis 2012

462 81% 2.6% 61 345

Published Reports Including >90 Pts

Karmpaliotis D: JACC CV Intv 2012; 5:1273–9)

n=1247 pts

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

• 1. Clear Proximal Cap?
• 2. Good Distal Target ?
• 3. Length < 20mm?

Antegrade Retrograde yes no Wire Escalation Dissection Reentry (CrossBoss™/ Stingray™) Wire Escalation Dissection Reentry (Reverse CART) yes yes no

Brilakis ES, et.al., JACC Cardiovasc Interv 2012 Apr, 5(4): 357-79

no

• Comparing 4 major registries
• f 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:

What Evidence Supports the Hybrid Approach?

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

Hybrid Registry (N=144 pts, 145 lesions) J-CTO Registry (N=498 pts, 528 lesions) Euro CTO Registry (N=1914 pts, 1983 lesions) p Procedural Success (%) 94.4% 88.6% 85.6%

* 0.039 Ŧ0.003

Procedure Time (minutes) 85 ± 54 NA 105 ± 58

Ŧ<0.0001

Contrast 238 ± 105 293 313 ± 84

Ŧ<0.0001

*Hybrid Registry vs J-CTO Registry, Ŧ Hybrid Registry vs Euro CTO Registry

The Hybrid Approach was shown to have a high success rate, lower procedure time and use less contrast

Source: Dave Daniels, MD; CTO/LM Summit 2013

Dissection Re-entry

Lesion >20 mm

Antegrade

Defined cap Adequate distal target

Retrograde

Interventional collateral

While there are 3 hybrid strategies, the CrossBoss™ & Stingray ™ catheters are used in one of the 3

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 was lucky I did not make the patient worse
• No Perforation with tamponade
• No Aortic dissection
• No Compromise of collateral flow of the target
• r non target vessel

I Can’t Make This Worse, Right?

Coronary CTO: When to Quit

• Watch the time clock
• Watch the radiation meter
• Watch the contrast bucket
• Watch the cost (cash) register
• Keep track of remaining options

–Plan B, C, D, E ……

Considerations

When to Quit?

• Technical success
• Major complication
• Operational limits reached

– Patient tolerance – Fluoro time – Contrast volume – Procedural time

Coronary CTO

Three Months Later NSTEMI

What Should I Do?

• Back to the Left coronaries
• Which should I choose the LAD with excellent

bridging collaterals or the LCX.

• I chose the LCX

How Did The Patient Do?

• For the first time felt well enough to return to

work

CTO PCI Made Simple

• I do not think the CTO can be simple enough
• Have clear cut indications for PCI(Ischemia Guided)
• Proper case selection for operator skills
• Have pre-defined limits for stopping
• Avoid preventable complications

– excess contrast, radiation

• Failed PCI is not a bad outcome

– Stage 2 may yield better result

Summary

THANK YOU