Chronic Total Occlusion: Let’s

Learn from Some Challenging

Cases!
Artis KALNINS MD
Riga, LATVIA
DISCLOSURE STATEMENT OF FINANCIAL INTEREST
• I, Artis KALNINS, DO NOT HAVE A FINANCIAL INTEREST/ARRANGEMENT OR AFFILIATION WITH ONE OR
MORE ORGANIZATIONS THAT COULD BE PERCEIVED AS A REAL OR APPARENT CONFLICT OF INTEREST
IN THE CONTEXT OF THE SUBJECT OF THIS PRESENTATION.
DISCLOSURE STATEMENT OF FINANCIAL INTEREST
• Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

• Grant/Research Support • Astra Zeneca

• Consulting Fees/Honoraria • Terumo
• Major Stock Shareholder/Equity • Medtronic
• Royalty Income
• Ownership/Founder
• Intellectual Property Rights
• Other Financial Benefit
What should be rationale for CTO revascularization?

Symptoms Prognosis
relief improvement

Quality of life Mortality

Evidence ?
 EURO CTO trial.
For multiple testing the significance level is 0.01
P=0.022 P=0.003
P=0.007 P=0.47
100
90
80
70 P=0.89
60
50
40
OMT PCI
30
20
10
0

BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU

Physical Anginal Quality of Anginal Treatment

limitation frequency life stability satisfaction

Eur Heart Journal 2018; 39:2484-2493

 EUROCTO Trial
Changes in CCS class during follow –up.

Eur Heart Journal 2018; 39:2484-2493

What should be rationale for CTO revascularization?

Symptoms Prognosis
relief improvement

Quality of life Mortality

Evidence

RCT +
All CTO and all CTO PCI are not equal

CTO as single vessel disease

CTO as part of MVD

CTO PCI for patient with low EF

OMT vs CTO PCI+OMT

Successful vs non successful CTO PCI

CTO with good collateral flow

Prognostic significance of CTO
SCAAR registry.

Ramundal et al. JACC Int.2018

CTO: Single vessel vs multivessel disease

Toma A et al. Clin Res Card 2016

 DECISION CTO – Trial
Death,MI,Stroke,Any Repeat Revascularization

Seung_Whan Lee, Pil Hyung Lee , Circulation ,2019

What should be rationale for CTO revascularization?

Symptoms Prognosis
relief improvement

Quality of life Mortality

Evidence

RCT + RCT -
Does collaterals matter?
Schumacher SP et al. EuroIntervention. 2020 Aug 7;16(6):e462-e471.
Schumacher SP et al. EuroIntervention. 2020 Aug 7;16(6):e462-e471.
Does collaterals matter?

The infarcted area in myocardium

subtended by a CTO is generally
limited.

Well-developed collaterals are

associated with less myocardial scar
and enhanced preserved function.

Vability was regularly present also in

patients with poorly developed
collaterals.

Schumacher SP et al. EuroIntervention. 2020 Aug 7;16(6):e462-e471.

 Case 1
• Male, 42 y.o.
• Current smoker
• Stable angina 2 years, no history of MI
• Echo – normal.
• Excercise test and stress Echo - positive
 Case 2
• Male, 65 year old.
• Clinical presentation : Exertional angina (CCS2) and dyspnoe
• Coronary risc factors: NIDDM, hyperlipidemia, hypertension.
• Past/clinical hystory:
Anterior wall STEMI 2000, CABG 2001, PCI graft to RCA 2012.
• Proof of ishemia: positive
• ECHO KG : anterior wall hypoacinesia, ejection fraction 40%.
• Coronary angio findings:
Diffuse atherosclerosis, all three native arteries occl., intermedial branch 80-90% lesion, SVG to
left anterion descending and left circumflex occluded, SVG to right coronary artery patent
Collateral crossing with microcatheteter
Microcatheter advancement
 Final result

After predilatation After stent implantations: 3,0-38mm LCX

3,0-12mm IM
THANK YOU