Chronic Total Occlusions: The Road Less Traveled

The Road Less Travelled: Update on Percutaneous Coronary Interventions (PCI)

for Chronic Total Occlusions (CTO)

M Nicholas Burke, MDMinneapolis Heart Institute and Foundation

Chronic Total OcclusionsBackground

NHLBI Dynamic Registry and BARI Study 1997-1999, n=1,761

•Presence of Total Occlusion 31%•Attempted Total Occlusion 7.5%

Srinivas et al. Circ 2002

Chronic Total OcclusionsEffect on therapy

Christofferson AJC 2005

CTO PCI: Why don’t we do it?

•Because the artery is closed•Because the damage is done•Because it can’t get any worse•Because restenosis rates are

high•Because it’s no big deal

Kleisli T. et al.; J Thorac Cardiovasc Surg 2005;129:1283-1291

Cumulative unadjusted survival from all-cause and cardiac death in surgical patients with CRV and IRV

Incomplete Revascularization with PCIIncomplete Revascularization with PCIWhat is the effect?What is the effect?

Long term outcomes of ‐ complete versus incomplete revascularization after drug eluting ‐stent implantation in patients with multivessel coronary disease

Catheterization and Cardiovascular Interventions16 APR 2013 DOI: 10.1002/ccd.24799

Chronic Total Occlusions PCI

Most frequently heard arguments against doing CTO’s:

1: I don’t need to do it because it’s well collateralized

Collaterals Are Rarely Sufficient To Substantially Reduce Ischemia In CTO

Modified from Werner GS et al, European Heart Journal 2006, courtesy Werner GS

Chronic Total Occlusions PCI

Most frequently heard arguments against doing CTO’s:

1: I don’t need to do it because it’s well collateralized

2: I’ve turned multivessel disease into single vessel disease

CTO of Non IRA and STEMI-CTO of Non IRA and STEMI-Double JeopardyDouble Jeopardy

J. Am. Coll. Cardiol. Intv. 2009;2;1128-1134

Hannan E L et al. Circulation 2006;113:2406-2412

Impact of completeness of revascularization and/or presence of CTO on mortality

21954 Patients without acute MI or LMD between 1997-2000

Chronic Total Occlusions PCI

Most frequently heard arguments against doing CTO’s:

1: I don’t need to do it because it’s well collateralized

2: I’ve turned multivessel disease into single vessel disease

3: CTO’s represent “stable coronary disease” (ie COURAGE patients)

Courage Trial Rates of Death or MI by Residual Ischemia

De

ath

or

MI

Ra

te (

%)

0%(n=23)

p=0.023

p=0.063

1%-4.9% (n=141)

5%-9.9%(n=88)

>10%(n=62)

Shaw et al, Circ 2008;117

P=0.002

Chronic Total Occlusions PCI

Most frequently heard arguments against doing CTO’s:

1: I don’t need to do it because it’s well collateralized

2: I’ve turned multivessel disease into single vessel disease

3: CTO’s represent “stable coronary disease” (ie COURAGE patients)4: There isn’t randomized data showing benefit

Chronic Total Occlusions PCI

Really?

Really?

THEN WHY HAVE YOU BEEN DOING PCI ON STABLE PATIENTS

FOR ALL OF THESE YEARS?

Did you have randomized data showing benefit ?

CTOs: What are we trying to do?

1. Make People Feel Better (improve symptoms)

2. Make People Live Longer (avoid future events)

CTOs: What are we trying to do?

Medical therapy

Let’s look at the evidence

Myocardial IschemiaTherapy: NitratesMyocardial IschemiaTherapy: NitratesTo Improve SymptomsTo Improve Symptoms

Am J Cardiol 72 1993

Long-Term Nitrate Use in CAD

AHJ 138(3) 1999

Myocardial IschemiaTherapy: NitratesTo Reduce Future Events (?)To Reduce Future Events (?)

Myocardial IschemiaTherapy: CCBTo Reduce Future Events (?)To Reduce Future Events (?)

Myocardial IschemiaTherapy: CCBTo Reduce Future Events (?)

Circ. Vol. 90 (2) 1994

Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future Events To Reduce Future Events

Wait for It….

Yup, that’s all there is

Myocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events

The REACH Registry

Bangalore et al, JAMA. 2012;308(13):1340-1349

Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events

The REACH Registry

Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events

The REACH Registry

Bangalore et al, JAMA. 2012;308(13):1340-1349

Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events

The REACH Registry

Bangalore et al, JAMA. 2012;308(13):1340-1349

Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events

The REACH Registry

Bangalore et al, JAMA. 2012;308(13):1340-1349

Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events

The REACH Registry

Bangalore et al, JAMA. 2012;308(13):1340-1349

Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BBTo Reduce Future EventsTo Reduce Future Events

The REACH Registry

Bangalore et al, JAMA. 2012;308(13):1340-1349

Editorial conclusion:

“BB are of no use in stable CAD Patients”

And remember, these are INTERNISTS talking

Chronic Total Occlusion Revascularization:To Improve Mortality

73.5%

65%

71.9%

Per

cen

t S

urv

ivin

g50

SuccessMatched SuccessFailure

70

80

90

100

P = 0.002

60

“A successful revascularized [CTO] confers a significant 10-year survival advantage compared with failed revascularization.”Suero et al., J Am Coll Cardiol 2001.

Years

0.001

Chronic Total Occlusion Revascularization:To Improve Mortality

META ANALYSIS Successful vs Failed CTO PCI

Joyal D, Afilalo J, Rinfret S. Am Heart J 2010

Favors Failure

PCI success PCI failure Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total WeightM-H. Random,

95% Cl    M-H, Random,

95% CI    Angioi et al. 3 93 9 108 3.4% 0.37 [0.10, 1.40]Aziz et al. 9 377 12 166 6.7% 0.31 [0.13, 0.76]Drozd et al. 7 280 5 149 4.3% 0.74 [0.23, 2.37]Finci et al. 5 100 3 100 2.9% 1.70 [0.40, 7.32]Hoye et al. 37 567 36 304 14.4% 0.52 [0.32, 0.84]Ivanhoe et al. 3 317 7 163 3.2% 0.21 [0.05, 8.83]Labriolle et al. 7 127 2 45 2.4% 1.25 [0.25, 6.27]Noguchi et al. 7 134 15 92 6.1% 0.28 [0.11, 0.72]Olivari et al. 2 286 3 83 1.9% 0.19 [0.03, 1.14]Prasad et al. 229 914 101 348 21.6% 0.82 [0.62, 1.08]Suero et al. 395 1491 180 514 23.8% 0.67 [0.54, 0.83] Valenti et al. 17 344 17 142 9.3% 0.38 [0.19, 0.77] Warren et al. 0 26 0 18 Not estimable

Total (95% CI) 5056 2232 100.0% .56 [0.43, 0.72]Total events 721 390

Heterogeneity: Taux = 0.06; Chix = 18.74, df = 11 (P= .07); P= 41%Test for overall effect: Z = 4.39 (P< .0001) 0.1 1 10 100

Favors Success

Source: American Heart Journal ©2010 Elsevier

CTO PCI: Why don’t we do it?(the REAL reason)

BECAUSEIT’S

HARD TO DO(and Interventionalists hate to fail)

CTO PCI: why is it so difficult?

• All PCI is predicated on getting a wire from the proximal to distal lumen to deliver balloons and stents

• Wires follow the path of least resistance• CTOs are very sclerotic and calcified• The path of least resistance is generally

between layers of vessel wall in a dissection

• It is extremely difficult to exit a dissection

Chronic Total Occlusion RevascularizationNew Tools and Technology

Things that have not worked:• Drills• Jackhammers• Lasers• RFA• IR• Blunt micro-dissection• Lytics

Chronic Total Occlusion RevascularizationBasic Precept of the Hybrid Strategy

The ultimate crossing goal in CTO PCI is to have a single wire connecting the proximal and distal true lumens. It

doesn’t matter whether: 1) the wire is true lumen or subintimal

within the body of the CTO2) the wire is coming from an antegrade or

retrograde direction

Chronic Total Occlusion RevascularizationThe CrossBoss™ CTO Catheter DesignThe CrossBoss™ CTO Catheter Design

• Multi-wire coiled shaft

• Tracks via FAST Spin Technique

– Highly torqueable coiled-wire shaft

– FAST Spin reduces push required to cross CTO

• Atraumatic distal tip advanced across a CTO ahead of the guidewire

• OTW 0.014” guidewire compatible

CrossBoss is designed to quickly and safely deliver a guidewire via true lumen or subintimal pathways

Chronic Total Occlusion RevascularizationThe Stingray™ CTO Re-Entry System Design

Unique self-orienting balloon has a flat shape for

true lumen targeting

180° opposed and offset exit ports for selective

guidewire re-entry

Re-entry probe at Stingray

Guidewire tip

Compatibility:6Fr. Guide/0.014” Wire

2.9Fr. shaft profile

Stingray System (catheter and guidewire) is designed to accurately target and re-enter the true lumen from a subintimal position

BridgePoint System

Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: Retrograde

Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART

Surmely JF: J Invasive Cardiol. 2006 Jul 18(7):33408

Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART

Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART

Chronic Total Occlusion RevascularizationAdvanced Strategies and Techniques: CART

Case Presentation: SD

• 42 yo pt WF with FH and Tobacco Abuse

• Admitted 12/12 with NSTEMI

• Angiogram:

SD continued

SD continued

SD continued

SD continued

• Discharged to Home on Medical Therapy

• Try to Quit Smoking

SD continued

• Readmitted 3/13 with USA

• ECG with CP: Inferior ST depression

• Angiogram: NO CHANGE

• TIME to FIX THIS THING

SD continued

SD continued

SD continued

SD continued

SD continued

Case Presentation: TL

• 42 yo pt w/Hx PE

• Referred for c/o DOE

• Stress Echocardiogram EF 35% global•7’35” SOB, worsening inferior wall function

• Angiogram:

Case Presentation: TL

TL continued

• Cardiac Rehab

– Exercise induced VT

TL continued: PCI

TL continued: PCI

TL contiued: PCI

TL continued

• Exercise stress test 2 weeks after PCI:

– 13’30” no VT

• Echo approximately 2 months after PCI:

– EF ~55%