Chronic Total Occlusions J. Jeffrey Marshall, MD, FSCAI Past President SCAI, 2012-2013 Director Cardiac Cath Lab Northeast GA Heart Center SCAI Fellow’s Course at Qingdao, CHINA August 23, 2014

Disclosures None

Rationale for CTO Revascularization Coronary CTO Rationale for CTO Revascularization Improve symptoms/functional QOL status Improve ventricular function Reduce incidence of late CABG Improve event-free survival

PCI of CTO and Long-term Survival N=2007 pts; 1980-1999 (10% stents) 50 60 70 80 90 100 2 4 6 8 10 % CTO Success 74% Matched Success p=0.002 65% DELETE CTO Failure Years Suero et al: JACC 2001 4

Impact of CTO Success on Outcome n = 486 pts; 527 CTO; DES; Success 71% 2003-2006 Aims: This study sought to determine the impact on survival of successful drug-eluting stent-supported percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Methods and results: Comparison of long-term cardiac survival of consecutive patients who underwent PCI for at least one CTO and who were stratified into successful and failure procedures. From 2003 to 2006, 486 patients underwent PCI for 527 CTO.CTO–PCI was successful in 344 patients (71%) and 361 lesions (68%). Multivessel PCI was performed in 62% in the CTO–PCI failure group and in 71% in the CTO–PCI success group (P 1⁄4 0.062). Cardiac survival rate was higher in the CTO – PCI success group compared with CTO – PCI failure group (91.6 + 2.0 vs. 87.4 + 2.9%; P 1⁄4 0.025), inpatients with multivessel disease and CTO–PCI success compared with CTO–PCI failure (91.4+2.2 vs.86.6 + 3.1%; P 1⁄4 0.021), and in patients with complete revascularization when compared to patients with incomplete revascularization (94.0 + 1.7 vs. 83.8 + 3.6%; P , 0.001). Conclusion: Successful CTO–PCI confers a long-term survival benefit. Improvement in survival is driven by the differences in the outcome of patients with multivessel disease and who were completely revascularized. Valenti R: EHJ 2008;29:2336

CTO PCI: Survival by Success Mortality at FU p=0.045 p<0.04 p<0.001 % p<0.025 p=0.02 N: 2007 874 199 369 486 FU: 10 yr 4.5 yr 2 yr 1 yr 4 yr Grantham JA: JACC 2009: 2: 479 - 486

Improved QOL, Angina and Physical Activity CTO PCI Improved QOL, Angina and Physical Activity N: 125 pts; CTO Success: 55% SAQ Angina Frequency SAQ Physical Limitation SAQ Quality of Life Background—Data on the health status benefits of percutaneous coronary intervention for coronary chronic total occlusions (CTOs), a principal indication for the procedure, are lacking.Methods and Results—In the FlowCardia Approach to CTO Recanalization (FACTOR) trial, patients (n􏰀125) completed the Seattle Angina Questionnaire (SAQ) at baseline and 1 month after percutaneous coronary intervenion. One-month health status outcomes were compared by multivariable analysis, adjusting for group differences between those whose CTO was successfully and unsuccessfully recanalized. These changes were also analyzed according to baseline symptoms. Procedural success was 55% (n􏰀64) and independently associated with angina relief (difference between those with successful and unsuccessful percutaneous coronary intervention [􏰁] in SAQ angina frequency􏰀9.5 points; 95% confidence interval, 1.6 to 17.5; P􏰀0.019), improved physical function (􏰁 in SAQ physical limitation􏰀13.1 points; 95% confidence interval, 5.1 to 21.1; P􏰀0.001), and enhanced quality of life (􏰁 in SAQ quality of life [QoL]􏰀20.3 points; 95% confidence interval, 11.9 to 28.6; P􏰂0.001). The benefit of successful percutaneous coronary intervention was greatest in symptomatic patients as compared with asymptomatic patients although statistically significantly so only for QoL (􏰁SAQ angina frequency domain􏰀10.3 versus 4.3 points, P􏰀0.51, 􏰁physical limitation 􏰀15.9 versus 6.3 points, P􏰀0.25; 􏰁QoL􏰀27.3 versus 8.5 points, P􏰀0.047).Conclusions—Successful CTO recanalization is associated with significant early improvements in patient symptoms, function, and QoL but only among symptomatic patients. Percutaneous treatment of a CTO offers the potential to provide significant health status benefits in symptomatic patients. (Circ Cardiovasc Qual Outcomes. 2010;3:284-290.) Effect of Procedure Success 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

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) Levine GN, et al. JACC doi:10.1016/j.jacc.2011.08.007

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

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 U (4) U (6) Intermed risk, No / min meds Intermed risk, Max meds U (5) A (7) High risk, No / min meds High risk, Max meds A (8)

CTO PCI in the US % NCDR Registry Approximately 15-30% of all patients referred for cath have a CTO % PCI attempt rate is unchanged over the last 5 years Grantham JA: JACC 2009: 2: 479 - 486

Usage by Operator Volume CTO PCI in the US Usage by Operator Volume p<0.05 p<0.05 p=0.115 % (<75) 75 – 200 >200 Grantham JA: JACC 2009: 2: 479 - 486

CTO PCI in the US NCDR Registry Technical Success MACE % % 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

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

Rathore S: JACC CV Intv 2009; 2: 489-497

Contemporary CTO Results Impact of Novel Guidewire Techniques 2002 – 2008; n=904 procedures % Success Fluoro (min) Procedure (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% 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

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

CTO Pathology Impacts the Required Techniques for Recannalization Micro-channels increase success Hydrophilic wires and low profile tips facilitate crossing

CTO Techniques Equipment - Wires

Comparison of Penetration Power 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

Hydrophilic vs Hydrophobic GW Tips High lubricity tip Low lubricity tip

CTO Guidewire Techniques Anchor technique Side branch technique Retrograde wire technique IVUS-guided technique

Anchor Technique

Anchor Technique Using OTW Balloon Another option for theses situations is the daughter in mother guiding catheter technique. Or you can use an over-the-wire balloon for wire handling if there is some space proximal to occlusion. This is another kind of anchor balloon technique.

Side Branch Technique

MicroCatheters Cordis Transit Finecross (Terumo) Spectranetics Quick Cross

Subintimal Tracking

Difficult to make re-entry 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

Retrograde Technique

Retrograde Approach

Retrograde CTO Guidewire Techniques

CART Technique Controlled Antegrade and Retrograde Subintimal Tracking

Brilakis ES et al: JACC Intv 2012; 5:367–79)

Algorithm for CTO Techniques Dual Injection 1 Ambiguous prox cap Poor distal target Appropriate collaterals 2 no yes Antegrade Retrograde 6 Lesion length <20 mm 3 yes no Retrograde true lumen puncture Retrograde dissection and reentry 4 Antegrade Wiring 5 Antegrade dissection and reentry Controlled (Stingray) Wire based (LaST) Switch Strategy 7 Brilakis ES et al: JACC Intv 2012; 5:367–79

Karmpaliotis D: JACC CV Intv 2012; 5:1273–9)

Retrograde CTO Results Published Reports Including >90 Pts n=1247 pts Study N Technical Success Major Compl Fluoro min Contrast 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% 60 256 Morino 2010 136 79% Karmpaliotis 2012 462 81% 2.6% 61 345 Karmpaliotis D: JACC CV Intv 2012; 5:1273–9)

I Can’t Make This Worse, Right? Coronary CTO I Can’t Make This Worse, Right? Perforation with tamponade Aortic dissection Compromise of collateral flow of the target or non target vessel

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 ……

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

Issues with CTO Long Procedure times Large contrast volume Significant radiation dosing Cost: Multiple guides Multiple wires Multiple balloons Delivery catheters Multiple stents

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