CHRONIC TOTAL OCCLUSIONS: WHAT IS KNOWN AND WHAT IS UNKOWN Giuseppe Biondi Zoccai University of Turin, Turin, Italy gbiondizoccai@gmail.com 4th International Interventional Forum – Turin 26-27 February 2009

LEARNING OBJECTIVES What is known What is unknown Prevalence of chronic total occlusions (CTO) Pathophysiologic basis and clinical impact Possible techniques What is unknown When is revascularization indicated? If yes, which type of revascularization? Which technique? Which stent?

LEARNING OBJECTIVES What is known What is unknown Prevalence of chronic total occlusions (CTO) Pathophysiologic basis and clinical impact Possible techniques What is unknown When is revascularization indicated? If yes, which type of revascularization? Which technique? Which stent?

INCIDENCE AND IMPACT

CLUSTERING WITH MULTIVESSEL DISEASE

LEARNING OBJECTIVES What is known What is unknown Prevalence of chronic total occlusions (CTO) Pathophysiologic basis and clinical impact Possible techniques What is unknown When is revascularization indicated? If yes, which type of revascularization? Which technique? Which stent?

CORONARY OCCLUSION AND MYOCARDIAL APOPTOSIS

COLLATERALS MOST OFTEN FAIL TO PREVENT SYMPTOMATIC ISCHEMIA 1 0,9 0,8 0,7 0,6 sens 0,5 spec 0,4 0,3 0,2 0,1 0,00 0,09 0,13 0,16 0,17 0,21 0,25 0,28 0,31 0,34 0,36 0,38 0,40 0,42 0,43 0,47 0,69 1,00 FFRcoll Moretti et al, J Cardiovasc Med 2008 – in press

PCI MAY PROVIDE CARDIAC REMODELING BENEFITS Before PCI for CTO 5 months after PCI for CTO Baks et al, J Am Coll Cardiol 2006;47:721-725

LONG-TERM DATA FROM NON-RANDOMIZED STUDIES SUPPORT THE BENEFITS OF PCI FOR CTO Especially for LAD CTO Suero et al, J Am Coll Cardiol 2001;38:409-14; Safley et al, J Am Coll Cardiol Intv 2008;1:295-302

LEARNING OBJECTIVES What is known What is unknown Prevalence of chronic total occlusions (CTO) Pathophysiologic basis and clinical impact Possible techniques What is unknown When is revascularization indicated? If yes, which type of revascularization? Which technique? Which stent?

POSSIBLE TECHNIQUES Standard antegrade Parallel wire Drilling wire Retrograde CART IVUS-guided puncture Subintimal IVUS STAR Micro-channel injection

POSSIBLE DEVICES Standard wires Monorail or OTW balloon Stent CTO wires (eg Asahi’s, Shinobi) Microcatheters Tornus Frontrunner Crosser Safecross

LEARNING OBJECTIVES What is known What is unknown Prevalence of chronic total occlusions (CTO) Pathophysiologic basis and clinical impact Possible techniques What is unknown When is revascularization indicated? If yes, which type of revascularization? Which technique? Which stent?

INTERVENTIONISTS’ NEW OATH: I WILL NOT TREAT CTO Hochman, New Engl J Med 2006;355:2395-2407

SHOULD THUS INTERVENTIONISTS BE DISCOURAGED? Boden et al, New Engl J Med 2007;356:1503-1516

IS ANY SYNTHESIS POSSIBLE? Abbate et al, J Am Coll Cardiol 2008;51:956-64

IS ANY SYNTHESIS POSSIBLE? Schomig et al, J Am Coll Cardiol 2008;52:894-904

LEARNING OBJECTIVES What is known What is unknown Prevalence of chronic total occlusions (CTO) Pathophysiologic basis and clinical impact Possible techniques What is unknown When is revascularization indicated? If yes, which type of revascularization? Which technique? Which stent?

Serruys et al, New Engl J Med 2009;360:961-72 A SYNTAX FOR EVIDENCE Serruys et al, New Engl J Med 2009;360:961-72

LEARNING OBJECTIVES What is known What is unknown Prevalence of chronic total occlusions (CTO) Pathophysiologic basis and clinical impact Possible techniques What is unknown When is revascularization indicated? If yes, which type of revascularization? Which technique? Which stent?

BEGIN WITH A THOROUGH BUT SIMPLE APPROACH, BUT BE READY FOR ESCALATION Dedicated CTO wires Contralateral injection Parallel wires Drilling wire Retrograde approach CART Microcatheter Tornus

LEARNING OBJECTIVES What is known What is unknown Prevalence of chronic total occlusions (CTO) Pathophysiologic basis and clinical impact Possible techniques What is unknown When is revascularization indicated? If yes, which type of revascularization? Which technique? Which stent?

USE DES WHENEVER POSSIBLE, BUT WHICH DES EXACTLY?

TAKE HOME MESSAGES

TAKE HOME MESSAGES CTO are highly prevalent and have a significant clinical and management impact It is thus paramount to appropriately risk-stratify each patient depending on his baseline and angiographic features, to clarify the clinical indication for CTO recanalization Several types of interventional techniques and devices are currently available for CTOs Improvements in stents (ie drug-elution), wires (ie dedicated wire for CTOs) and ancillary devices (eg microcatheters) together with new or refined techniques have improved acute and long-term results of PCI for CTOs