21.

1
Chronic Total Occlusions

Emmanouil S. Brilakis, MD, PhD

CTO: occlusion in the coronary artery with TIMI 0
flow of ≥3 months duration
 PCI: the steps
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement • Key indication: symptom
6. Angiography improvement
7. Determine target lesion • Ad hoc PCI: NO with rare
8. Wiring exceptions
9. Lesion preparation • Coronary CTA – facilitate
10. Stenting planning
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement • Hemodynamics
6. Angiography • Anticoagulation
7. Determine target lesion • Contrast
8. Wiring • Radiation
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
Anticoagulation: UFH
5. Engagement ACT goal
6. Angiography Antegrade: >300 sec
7. Determine target lesion Retrograde: >350 sec
8. Wiring Check every 20-30 min
9. Lesion preparation
10. Stenting
11. Closure No GP IIb/IIIa inhibitors
12. Physiology
13. Imaging
14. Hemodynamic support
 Prolonged DAPT post CTO PCI?

n=1,069
2009-2016
Median FU: 3.6 years
Kaiser Permanente
44%: >12 month DAPT

Death or MI:
Adjusted HR=0.66
95% CI 0.47-0.93

Sachdeva et al. Am J Cardiol 2020

 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement • Need 2 access site in most
6. Angiography patients
7. Determine target lesion
8. Wiring • Femoral - Radial
9. Lesion preparation • Femoral - Femoral
10. Stenting • Radial – Radial
11. Closure
12. Physiology • Femoral: long sheaths
13. Imaging
14. Hemodynamic support
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring How to get strong support:
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 CTO PCI
1. Planning
2. Monitoring • Dual injection
3. Pharmacology • Careful angiographic review
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 Dual injection Imaging
1. Low magnification
(10 inch)
2. Inject donor vessel
first
3. Wait 1-2 sec before
injecting CTO vessel
4. No panning
5. Cine until contrast
clears
Remains critical for
success and safety of
CTO PCI
 7 Global Principles for CTO PCI
1. Principal indication: to improve symptoms
2. Dual angiography + careful angiographic review
3. Use of microcatheter for guidewire support
4. 4 CTO crossing strategies: AWE, ADR, RWE,
RDR
5. Change increases likelihood of success
6. CTO PCI should be done at experienced-well
equipped centers
7. Stent deployment should be optimized
101 operators - 50 countries – Circulation 2019
Subintimal crossing Stingray balloon

Dual angiography
DURING PCI
Knuckle redirection Contralateral injection to guide
stenting
Final
 1. Proximal cap
Studying the
lesion
1. Proximal vessel
tortuosity - caliber

2. Ambiguous or clear?

3. Tapered or blunt?

4. Side branches?

5. Calcification
Which proximal vessel would you rather have?

Jang Y. PCI for CTO. Springer 2019

Where is the proximal cap?

Jang Y. PCI for CTO. Springer 2019

Jang Y. PCI for CTO. Springer 2019
 2. Lesion length – tortuosity -
Studying the composition
lesion
 Calcification

Jang Y. PCI for CTO. Springer 2019

 Predictors of Remodeling
antegrade
failure

• Length >32 mm
• Ostial or
bifurcation
lesions
• Negative
remodeling

Luo et al. JACC CV Imaging 2015

3. Distal vessel

1. Caliber and quality of

distal vessel

2. Bifurcation

3. Prior bypass
graft insertion
sites
Bifurcation at distal cap

Kotsia, Christopoulos, Brilakis. JIC 2014

 3. Distal vessel
Studying the
lesion
1. Caliber and quality of
distal vessel

2. Bifurcation

3. Prior bypass
graft insertion
sites
 4. Collaterals
Studying the
lesion
1. Type (septal, bypass
grafts, epicardial)

2. Size (Werner
classification)

3. Tortuosity

4. Dominance

5. Angle and
location of entry
 Collateral vessel selection
Bypass Septal Epicardial
24.8
7.6
graft
67.5

Septal
Epicardial
SVG

Rathore, Circ Intv 2009

Tortuosity + ++ +++
Perforation + ++ +++
risk
Wiring + ++ / +++ +++
difficulty
Able to Yes Yes No
dilate
 Werner collateral classification

CC0 CC1 CC2

no Threadlike Side-branch
continuous continuous like
connection connection connection
Werner et al. Circulation 2003 (≥0.4mm)
Retrograde through SVG
 Don’t forget occluded SVGs…

SVG-PDA –
CTO
 Collaterals can be dynamic…
Before LAD PCI After LAD PCI
 J-CTO Score

494 native CTO lesions

Crossing within 30 minutes

Morino, Y. et al. JACC Intv 2011;4:213-221

 PROGRESS CTO
score
98.2 97.5
100 91.6
76.7
75

50

25

0
0 1 2 ≥3

Christopoulos, Kandzari, Yeh, Jaffer, Karmpaliotis,

Wyman, Alaswad, Lombardi, Grantham, Moses,
Christakopoulos, Tarar, Rangan, Lembo, Garcia, Cipher,
Thompson, Banerjee, Brilakis. JACC Intv 2016;9:1–9
 PROspective Global REgiStry for the
Study of CTO interventions
www.progresscto.org
Progress CTO complications score
11 centers, 1,569 lesions
In-hospital major adverse
cardiovascular events 2.8%

MACE = MI, stroke, urgent re-

PCI or CABG, tamponade
requiring pericardiocentesis,
death

Danek, Karatasakis, Karmpaliotis,

Alaswad, Yeh, Jaffer, Patel,
Mahmud, Lombardi, Wyman,
Grantham, Doing, Kandzari, Lembo,
Garcia, Toma, Moses, Kirtane,
Parikh, Ali, Karacsonyi, Rangan,
Thompson, Banerjee, Brilakis.
JAHA 2016
Choose the CTO lesions
you attempt wisely…

Early: J-CTO 0-1

Next: J-CTO 2

Later: J-CTO ≥3
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography • CTO PCI almost always
7. Determine target lesion elective procedure
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 7 Global Principles for CTO PCI
1. Principal indication: to improve symptoms
2. Dual angiography + careful angiographic review
3. Use of microcatheter for guidewire support
4. 4 CTO crossing strategies: AWE, ADR, RWE,
RDR
5. Change increases likelihood of success
6. CTO PCI should be done at experienced-well
equipped centers
7. Stent deployment should be optimized
101 operators - 50 countries – Circulation 2019
When should CTO
PCI be done?
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 Hybrid CTO crossing algorithm

Brilakis, Grantham, Rinfret, Wyman, Burke, Karmpaliotis, Lembo, Pershad, Kandzari,

Buller, De Martini, Lombardi, Thompson. JACC Intv 2012
Scott A. Harding et al. JCIN 2017;10:2135-2143
Euro CTO algorithm

Galassi et al. Eurointervention 2018

CTO PCI: the world is converging
 7 Global Principles for CTO PCI
1. Principal indication: to improve symptoms
2. Dual angiography + careful angiographic review
3. Use of microcatheter for guidewire support
4. 4 CTO crossing strategies: AWE, ADR, RWE,
RDR
5. Change increases likelihood of success
6. CTO PCI should be done at experienced-well
equipped centers
7. Stent deployment should be optimized
101 operators - 50 countries – Circulation 2019
 A. “Big” B. “Small” C. Angulated D. Dual lumen E. Plaque modification
NEW NEW NEW
Mamba Mamba Flex Sasuke

Teleport Control Teleport NHancer Rx

M-Cath
Corsair XS Microcatheter
ReCross
classification
EXISTING EXISTING EXISTING EXISTING EXISTING
Corsair Pro Caravel SuperCross FineDuo

Tornus
Turnpike Turnpike LP Crusade

Turnpike Gold
Turnpike Spiral FineCross Venture Twin-Pass Torque
& Twin-Pass
Nhancer Pro X MicroCross 14
Swift Ninja

Vemmou E. et al. Expert Rev Med Devices 2019

 Guidewire classification
2. Polymer
1. Workhorse jacketed 3. Stiff 4. Support
+/- hydrophilic coating

Soft, non-
1. Nitinol 1. Whisper 1. Gaia, Judo 1. Ironman

tapered
• BMW, Minamo 2. Pilot 50 2. Confianza 2. Grand Slam
• Turntrac/Versaturn 3. Fielder FC Pro 12 3. Mailman
• Runthrough 4. Sion black 3. Hornet 14 4. Wiggle
2. Composite core 5. Fielder XT, XT-A, 4. Astato 20

tapered
• Sion blue, Suoh 03* Soft, XT-R
3. Dual coil 6. Fighter 5. Atherectomy
7. Bandit Rotafloppy - Viper
• Samurai RC
8. Pilot 200
4. Stainless steel 6. Externatization
Stiff

9. Gladius Mongo RG3, R350

• HT Floppy
10. Raider
7. Pressure
 CTO wire escalation

1 Fielder XT - Fighter
Course of occluded
vessel known?
yes no

2 Gaia 2nd 3 Pilot 200

Heavily
calcified
4 Confianza Pro 12 – Hornet 14

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2017

How to shape * Gaia
to CTO guidewires
guidewire are pre-
shaped
 7 Global Principles for CTO PCI
1. Principal indication: to improve symptoms
2. Dual angiography + careful angiographic review
3. Use of microcatheter for guidewire support
4. 4 CTO crossing strategies: AWE, ADR, RWE,
RDR
5. Change increases likelihood of success
6. CTO PCI should be done at experienced-well
equipped centers
7. Stent deployment should be optimized
101 operators - 50 countries – Circulation 2019
 All crossing
strategies have a
role
 Antegrade crossing

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2017

Parallel wire See-saw
Antegrade Wire Escalation Outcome

True Lumen Subintimal Exit

Crossing Crossing

Pull back
Confirm in
(BEFORE
orthogonal
advancing
views
Parallel wire Re-entry microcatheter!)
 CTO dissection/re-entry
strategies

Antegrade Retrograde

Dissection Dissection
Knuckle wire Knuckle wire
CrossBoss

Re-entry Re-entry
•STAR CART
•Contrast-guided STAR Reverse CART
•mini-STAR
•LAST Michael et al
•Stingray Circ Intv 2012
 The retrograde approach
10. Remove externalized 1. Decide Retrograde Is the Next Step
guidewire 2. Selecting the Collateral
9. Treat CTO

3. Reaching the Collateral

8. Wire
externalization
4. Cross collateral with
guidewire
7. Cross CTO
5. Confirm guidewire true
6. Cross collateral with lumen position
microcatheter
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2017
 PROspective Global REgiStry for the Study of CTO
interventions
www.progresscto.org

Successful crossing strategy stratified by J-CTO score

p<0.0001 ADR AWE

Series1
100% 3.1%

90% 5.8% 9.0%

80% 14.7% 19.7%

35.3%
70%

60% 20.5% 41.5% 43.6%

50%
88.3% 24.1%
40%
71.6%
30% 21.6%
50.6% 20.2%
20%
31.9%
10% 17.3% 16.9%
0%
J-CTO Score 0 J-CTO Score 1 J-CTO Score 2 J-CTO Score 3 J-CTO Score 4 J-CTO Score 5
 PROspective Global REgiStry for the Study of CTO
interventions
www.progresscto.org
Procedural complications
8%

AWE ADR Retrograde p<0.0001

6%

p<0.0001

4%

p<0.0001

2%
p=0.0171
p=0.2629
p=0.1228 p=0.2999
p=0.6637
0%
MACE overall Death Acute MI Stroke Re-PCI Emergency CABG Pericardial Perforation
tamponade
 7 Global Principles for CTO PCI
1. Principal indication: to improve symptoms
2. Dual angiography + careful angiographic review
3. Use of microcatheter for guidewire support
4. 4 CTO crossing strategies: AWE, ADR, RWE,
RDR
5. Change increases likelihood of success
6. CTO PCI should be done at experienced-well
equipped centers
7. Stent deployment should be optimized
101 operators - 50 countries – Circulation 2019; in press
 Hybrid CTO crossing algorithm

Brilakis, Grantham, Rinfret, Wyman, Burke, Karmpaliotis, Lembo, Pershad, Kandzari,

Buller, De Martini, Lombardi, Thompson. JACC Intv 2012
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
1. Planning
2. Monitoring
3. Pharmacology • All CTOs have FFR<0.80 if
4. Access myocardium viable
5. Engagement
6. Angiography • Non-culprit FFR increase by
7. Determine target lesion 0.03-0.10
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access Crossing
5. Engagement 1. Resolve proximal cap ambiguity
6. Angiography 2. Guide wiring
7. Determine target lesion 3. Facilitate reverse CART
8. Wiring
9. Lesion preparation Stent optimization
10. Stenting 1. Stent sizing
11. Closure 2. Stent expansion/apposition
12. Physiology 3. Assess complications
13. Imaging
14. Hemodynamic support
IVUS to clarify proximal cap ambiguity
Standard
Tip

Short Tip

2.5 mm

Image courtesy of Volcano

 Imaging for stent optimization

Malapposition Underexpansion

Mintz et al. J Am Coll Cardiol. 2014;64:207-222

 CTO PCI
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring ≈4% of CTO PCI
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
 PCI: the steps
1. Planning
2. Monitoring
3. Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion
8. Wiring
9. Lesion preparation
10. Stenting
11. Closure
12. Physiology
13. Imaging www.progresscto.org
14. Hemodynamic support www.ctomanual.org