Which setting? – Top 10 lessons learned from my time as CTO beginner

Which setting ? – Top 10 lessons

learned from my time as CTO beginner

Gerald S. Werner, MD, FESC, FACC, FSCAI

Klinikum Darmstadt - Germany

Do I remember my time as beginner?

Why should I do a CTO ?

1992-2017

• Should we do it ?

• How to do it

• How to keep it open

The 3 main issues for the treatment of CTOs

1992

• Should we do it ?

• Guidelines: NO

• How to do it

• No specific technique

• How to keep it open

• Balloons

Katoh‘s view on the evolution of CTO PCI

The primitive stage in Göttingen 1995/97

• Of 2464 PCIs within 2 years we did

365 PCIs of “occluded” arteries (14.8%)

• Prof. Kreuzer 44, Buchwald 181, Figulla 29,

Scholz 51, Werner 100

• Of 365 PCIs 153 were successful: 58%

• My personal “record”: 64% …

… selected cases:

the stiffest wire was the ACS Standard

Lesson 1: Too many operators for the same

lesion subset do not help developing enough

experience

Tools: IVUS and subintimal course

Werner et al. Cathet Cardiovasc Diagn 1997;40:46-51

Das BridgePoint StingRay Reentry System

Werner GS et al. EuroIntervention 2011; 7:192-200.

The 3 main issues for the treatment of CTOs

2002

• Should we do it ?

• Guidelines: NO

• How to do it

• Dedicated wires, devices

• How to keep it open

• Stents

Restenosis Reocclusion TLR MACE

DES (n=330) BMS recent gen. (n=527)

8

36

29 5

25

10

35

[%]

BMS 1st gen. (n=620) POBA (n=604)

32

17

30

1515

8

64

38

CTO patency: DES – BMS - POBA

Adapted from J Woehrle, Univ. Ulm

Stent (number) no longer an issue in CTOs ?

1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tie

nts

[%

]

Number of implanted stents

No TVF Restenosis Reocclusion

1 2 >20

10

20

30

40

50

60

70

80

90

100

113747

Pa

tie

nts

[%

]

Number of implanted stents

No TVF Restenosis Reocclusion

2012: 2.7 stents (1-6) in 183 CTOs

12 % 28 % 60 %

Werner GS et al Catheter Cardiovasc Interv 2006;67:1-7

49% 39% 12%

Did new technologies get you through a CTO ?

• Early ideas: Magnum wire, ROTACS

• Safecross

OCR and RF

• Frontrunner

mechanical

• Crosser vibration

Lesson 2: Too many fancy devices do not

make the trick, it is the operator and the wire

only

”Collateral Connection Size“ (CC)

Werner et al. Circulation 2003;107:1972-7

CC0 14% CC1 51% CC2 35%

B

D E

A C

F

How to improve CTO success in Europe ?

Lesson 3: Collaborate and share your

experience and problems, keep an open ear to

alternative opinions

Learning together from the masters …

You profit from a peer

Lesson 4: Look for a senior guide to help you

through the difficulties of the procedure, revisit

during the stages of your development

The 3 main issues for the treatment of CTOs

2017

• Should we do it ?

• Guidelines: if symptomatic

• How to do it

• Specialized approach

• How to keep it open

• DES

Do you think twice about opening this lesion ?

And why do I have to defend opening this lesion ?

Do you think twice about opening this lesion ?

And why do I have to defend opening this lesion ?

Lesson 5: A CTO is just like any other coronary

lesion regarding the indication, but you need to

prepare..

Lessons for the proper approach: Patience

1. A CTO procedure takes time, and you need

to have enough time

2. Take your time before you start and plan,

what are the options, what is the most likely

way to success

3. Be patient, if you cannot stay with a case as

long as it takes, do not start it

4. Always stay vigilant, the worst complications

can occur at the end through carelessness

5. The patient’s safety is more important than

your ego