Chronic Total Occlusions

J. Jeffrey Marshall, MD, FSCAI

Past President SCAI, 2012-2013
Director Cardiac Cath Lab
Northeast GA Heart Center

SCAI Fellows Course at Qingdao, CHINA Northeast

Georgia
August 23, 2014 Heart Center
Disclosures

None

Northeast
Georgia
Heart Center
 Coronary CTO
Rationale for CTO Revascularization

Improve symptoms/functional QOL status

Improve ventricular function
Reduce incidence of late CABG
Improve event-free survival

Northeast
Georgia
Heart Center
 PCI of CTO and Long-term Survival
N=2007 pts; 1980-1999 (10% stents)
100
%
90
CTO Success
80
74%
70

p=0.002 65%
60
CTO Failure

50
2 4 6 8 10
Years
Suero et al: JACC 2001
 Impact of CTO Success on Outcome
n = 486 pts; 527 CTO; DES; Success 71%

2003-2006

Northeast
Georgia
Heart Center
Valenti R: EHJ 2008;29:2336
 CTO PCI: Survival by Success
Mortality at FU
50 Success Failure
p<0.001
40 34.9

30 26.5
p<0.025
% p=0.02 p=0.045
20
12 p<0.04 12.6
10 8.4
6.5 5.8
2 3.6
1.1
0
Suero Hoye Aziz Olivari Valenti
N: 2007 874 199 369 486
FU: 10 yr 4.5 yr 2 yr 1 yr 4 yr Northeast
Georgia
Heart Center
Grantham JA: JACC 2009: 2: 479 - 486
 CTO PCI
Improved QOL, Angina and Physical Activity
N: 125 pts; CTO Success: 55%

SAQ Angina Frequency

SAQ Physical Limitation

SAQ Quality of Life

Effect of Procedure Success

Northeast
Georgia
Heart Center
Grantham AJ, et al. Circ Qual Outcomes 2010;3:284
 Coronary CTO
Who to treat?

Symptomatic
Significant Ischemia
Reasonable likelihood of success
Low expected complication rate

Northeast
Georgia
Heart Center
 2011 ACCF/AHA/SCAI PCI Guidelines
What We Can Do

PCI of CTO
Class IIa Recommendation
PCI of a CTO in pts with appropriate clinical
indications and suitable anatomy is reasonable
when performed by operators with appropriate
expertise (Level of Evidence: B)

Northeast
Georgia
Heart Center
Levine GN, et al. JACC doi:10.1016/j.jacc.2011.08.007
 Northeast
Georgia
Heart Center
 PCI Appropriate Use Criteria 2012
What We Should Do

Technical panel of 17 MD:

4 IC; 4 CVS; 8 non-IC; 1 health plan MD
Classification:
61 clinical scenarios
Median score of panel (1 to 9)
Appropriate: median score of 7-9
Uncertain: median score 4-6
Inappropriate: median score 1-3
Northeast
Georgia
Heart Center
 Appropriate Use Criteria 2012
CTO (no other CAD)
Stress test results, Medications Asx CCS 1-2 CCS 3-4
Low risk, No / min meds I (1) I (2) I (3)

Low risk, Max meds I (1) U (4) U (6)

Intermed risk, No / min meds I (3) U (4) U (6)

Intermed risk, Max meds U (4) U (5) A (7)

High risk, No / min meds U (4) U (5) A (7)
High risk, Max meds U (5) A (7) A (8)
 CTO PCI in the US
NCDR Registry

Approximately 15-30% of all patients referred for cath have a CTO

20 CTO Attempts
13.6
11.7 12.4 11.8
% 10

0
2004 2005 2006 2007
PCI attempt rate is unchanged over the last 5 years Northeast
Georgia
Heart Center
Grantham JA: JACC 2009: 2: 479 - 486
 CTO PCI in the US
Usage by Operator Volume

50 CTO Attempts
40 p<0.05
p<0.05 p=0.115

30
23
% 20 20.5
15
10

0
Low Intermediate High
(<75) 75 200 >200 Northeast
Georgia
Heart Center
Grantham JA: JACC 2009: 2: 479 - 486
 CTO PCI in the US
NCDR Registry
Technical Success MACE
100 15

80 70.3 71.1 73.3

10
60
% %
40
5 3.7
3.2 3.3
20

0 0
2004 2005-2007 2008 2004 2005-2007 2008

Grantham JA: JACC 2009: 2: 479 - 486

 CTO PCI in the US
Barriers to Wider Use

Operator inexperience

Difficulty in wire crossing

Perceived increased risk

Financial disincentives
Northeast
Georgia
Heart Center
 CTO: Predictors of Outcome

Procedural Success Procedural Failure

Functional occlusion Total occlusion
Occlusion <12 wks Occlusion > 12 wks
Length <15 mm Length >15 mm
Tapered stump Abrupt cut-off
No branch at occl site Side branch present
No bridge collaterals Bridge collaterals
No / mild Calcium Heavy calcification
Straight lesion Tortuosity

Northeast
Georgia
Heart Center
 Northeast
Georgia
Heart Center
Rathore S: JACC CV Intv 2009; 2: 489-497
 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%

Northeast
Georgia
Heart Center
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

Northeast
Georgia
Heart Center
 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 Northeast
Georgia
Heart Center
CTO Pathology Impacts the Required Techniques
for Recannalization

Micro-channels increase success

Hydrophilic wires and low profile tips
facilitate crossing Northeast
Georgia
Heart Center
CTO Techniques
Equipment - Wires

Northeast
Georgia
Heart Center
 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
Northeast
Georgia
Heart Center
Hydrophilic vs Hydrophobic GW Tips

High lubricity tip Low lubricity tip

Northeast
Georgia
Heart Center
 CTO Guidewire Techniques

Anchor technique

Side branch technique

Retrograde wire technique

IVUS-guided technique

Northeast
Georgia
Heart Center
Anchor Technique

Northeast
Georgia
Heart Center
Anchor Technique Using OTW Balloon

Northeast
Georgia
Heart Center
Side Branch Technique

Northeast
Georgia
Heart Center
 MicroCatheters

Cordis Transit

Finecross (Terumo)
Spectranetics Quick
Cross
Subintimal Tracking

Northeast
Georgia
Heart Center
 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 Northeast
Georgia
Heart Center
Retrograde Technique

Northeast
Georgia
Heart Center
Retrograde Approach
Retrograde CTO Guidewire Techniques

Northeast
Georgia
Heart Center
 CART Technique
Controlled Antegrade and Retrograde Subintimal Tracking
 Northeast
Georgia
Heart Center
Brilakis ES et al: JACC Intv 2012; 5:36779)
 Algorithm for CTO Techniques
1 Dual Injection 1) Ambiguous prox cap
2 2) Poor distal target
3) Appropriate collaterals
no yes

Antegrade 6 Retrograde
3 Lesion length <20 mm
yes no
Retrograde
4 Antegrade 5 Antegrade dissection and Retrograde true
dissection and
Wiring reentry lumen puncture
reentry

Controlled Wire based

(Stingray) (LaST)

7 Switch Strategy Northeast

Georgia
Heart Center
Brilakis ES et al: JACC Intv 2012; 5:36779
 Northeast
Georgia
Heart Center
Karmpaliotis D: JACC CV Intv 2012; 5:12739)
 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

Northeast
Georgia
Karmpaliotis D: JACC CV Intv 2012; 5:12739) Heart Center
 Coronary CTO
I Cant Make This Worse, Right?

Perforation with tamponade

Aortic dissection

Compromise of collateral flow of the target or

non target vessel
Northeast
Georgia
Heart Center
 Coronary CTO: When to Quit
Considerations

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
Northeast
Georgia
Heart Center
 Coronary CTO
When to Quit?
Technical success
Major complication
Operational limits reached
Patient tolerance
Fluoro time
Contrast volume
Procedural time

Northeast
Georgia
Heart Center
 Issues with CTO

Long Procedure times

Large contrast volume
Significant radiation dosing
Cost:
Multiple guides
Multiple wires
Multiple balloons
Delivery catheters
Multiple stents

Northeast
Georgia
Heart Center
 CTO PCI
Summary

Have clear cut indications for PCI

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

Northeast
Georgia
Heart Center