CTO Perspectives: When not to Start, and When to Stop and Try Again Patrick L. Whitlow, MD Director, Interventional Cardiology Cleveland Clinic Disclosures: Research support from BridgePoint Medical, Inc.

Chronic Total Coronary Occlusion Of all patients undergoing coronary angiography, ~50% have significant CAD. Of all patients undergoing coronary angiography who have significant CAD, ~22% (Canadian Registry) - 50% (Seattle) have at least one CTO. So CTO remains a huge issue in treating CAD

Treatment Chosen for Patients with CAD after Diagnostic Cath 100 100 No CTO No CTO 75 CTO present 75 CTO present 35 49 28 40 36 11 % % 50 50 25 25 Medical Rx Medical Rx CABG CABG PCI PCI AJC 5/05

Chronic Total Coronary Occlusion in Randomized PCI vs CABG Trials From BARI to SYNTAX, the single most common reason for a patient to be referred for surgery and not randomized was a CTO which the PCI operator felt he could not recanalize. Even as recently as SYNTAX, the PCI success rate in CTO lesions was only 53% ( 133/250) Newer data suggest markedly improved CTO success approaching 90% for very experienced operators proficient in both antegrade and retrograde techniques

Considerations for When Not to Start and When to Stop a CTO PCI What is Your Experience With CTO PCI? - What is your success rate? - Can you perform retrograde CTO techniques? - Is there another operator who would provide better care for this patient? Do you have all the updated equipment needed for this procedure?

Considerations for When Not to Start a PCI for a CTO Patient Characteristics Indication / Informed Consent Documented Estimated Chance of Procedural Success and complication rate Length of CTO Procedure: 87+-45 minutes for Paris Sud Registry DAPT Reliability of patient assessed Radiation Dose / Contrast Exposure disclosed

Considerations for When Not to Start a PCI for a CTO What are the chances of success? ? Lesion Length ? Degree of Calcification ? Degree of Tortuosity Does CTO begin abruptly, especially at a side branch? Or is there a tapered , funnel type entry? Is there apparent retrograde access?

Considerations for When Not to Start and When to Stop a CTO PCI Xray Exposure to the patient <5 Gray Best; 7-8 Gray Maximum How Large is the patient? What views are needed and at What Magnification? Median fluoro time 45 minutes J-CTO Registry 10% of CTO cases > 120 minutes fluoro

Considerations for When Not to Start and When to Stop a CTO PCI Contrast Used / Patient’s Creat. Clearance: <2.5 desirable; >3.7 predicts dysunction. Contrast - 3-5 ml/kg with normal Cr. Cl. - Be careful with diabetics, esp. with renal insufficiency and/or proteinuria. 250 ml mean for Paris SudCTO’s 293 ml median for J-CTO Registry

Considerations for When to Alter Your Approach or Stop a CTO PCI Attempt Are you making progress with the procedure? If not, what is your next strategy? Change the wire bend? Change the wire Type? Change the support Device? Change to a retrograde(orantegrade, or Re-entry) approach Is the patient comfortable? What has been the procedure Time? X Ray exposure? Contrast Dose? Is it time to stop this attempt?

When and with Whom to Reschedule another PCI Attempt Consider experience/ success rate/alternative approaches available to you or your partners, or your potential referral possibilities Consider patient’s renal function and contrast dose Consider patient’s Xray exposure and potential for radiation dermatitis/ skin necrosis Consider how disabling the patient’s symptoms are and is he on maximal Meds? Would CABG be better?