Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany BSIC, Manchester, September 15, 2006

Chronic total occlusions update A European perspective Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany BSIC, Manchester, September 15, 2006

CTO – The European perspective What you may want to know about collaterals Why should we open a CTO ? The past and presence of CTO treatment CTOs in the DES era The remaining challenges in CTOs

Pathophysiology of collaterals in CTOs How to assess collaterals ? What happens to collaterals after PCI ? Can collaterals replace an open artery ?

Assessment of collaterals: pressure and flow Baseline collateral function Recruitable collateral function Werner et al. Circulation 2001;104:

Collateral function in CTOs 79%46% Werner et al. Circulation 2003;108: Before PCIAfter PCI

Loss of collateral function not due to embolization Bahrmann et al. Z Kardiol 2002;91:

Collateral function in CTOs 79%46% 18% Werner et al. Circulation 2003;108: Before PCIAfter PCI 6 mo FUP

Evidence for preformed collaterals in man 79%46% 18% 20% Wustmann et al. Circulation 2003;107: Werner et al. Circulation 2003;108: Before PCIAfter PCI 6 mo FUP

Can good collaterals replace an open artery ? Collateral function assessed as collateral flow reserve In 98 Pat. with CTO during adenosine stress Adapted from Werner et al. JACC 2006;48:51-8

Can good collaterals replace an open artery ? 95% of collaterals are no substitute for the open artery

CTO – The European perspective What you may want to know about collaterals Why should we open a CTO ? The past and presence of CTO treatment CTOs in the DES era The remaining challenges in CTOs

CTOs – Should we treat them all ? Improvement of symptoms (angina, dyspnea) Improvement of LV function Improvement of prognosis

Benefit of recanalisation on LV function Werner et al. Am Heart J 2005;149: No improvement in case of Reocclusion !!!

Indication for revascularization: MRI function and vitality

LV recovery after recanalization of CTOs - MRI Baks T et al. JACC 2006;47:721-5

PCI success and survival Suero et al. JACC 2001;38: Ramanathan & Buller, ACC Pat, 74% successful 1458 Pat, 77% successful 871 Pat, 65% successful Hoye et al. Eur Heart J 2005;26:2630-6

If PCI fails … at least consider CABG Suero et al. JACC 2001;38: But CABG seems to be only the second best option

A CTO left occluded makes life more dangerous

Leaving a CTO alone means taking risks in low risk patients STAR Registry, Institute for infarct research, Ludwigshafen PCI of

CTO – The European perspective What you may want to know about collaterals Why should we open a CTO ? The past and presence of CTO treatment CTOs in the DES era The remaining challenges in CTOs

CTOs in the cathlab routine in 2003 In a German registry (STAR – Stable Angina pectoris Registry - IHF, Ludwigshafen) 2002 consecutive diagnostic angiographies were evaluated: 33% had at least one CTO CTO pts had more severe symptoms, and LV dysfunction the 1-year mortality with CTOs was 5.5% vs. 3.1% Only one third of CTOs underwent PCI Half of all CTOs were referred to CABG

Why bother, you can‘t open it … most times CTO success rates – historical perspective

Why bother with PCI – you can‘t keep it open anyhow Binary angiographic restenosis with balloon vs BMS Woehrle CTO Workshop Munich 2005

Stenting in CTOs: long and multiple stents required Werner et al. J Am Coll Cardiol 2003;42:219-25

CTO – The European perspective What you may want to know about collaterals Why should we open a CTO ? The past and presence of CTO treatment CTOs in the DES era The remaining challenges in CTOs

Published studies using DES in CTOs HoyeGeNakamuraPrison IIPACTO StentCypher Taxus Patients Reference diameter [mm] Stent length Stents per lesion ? TVF9 % 3 %8 %10 % Reocclusion3 %2.5 %0 %4 %1 % Follow-up59 %83 %75 %94 %100 %

Events in PRISON II: BMS vs. Cypher Suttorp et al. TCT 2005

Days Since Index Procedure % 90% 80% 70% Freedom of TLR TAXUS MR Control 9 mos. 12 mos. P= % 79.4 % Control=bare metal stent TAXUS= TAXUS TM stent TAXUS TM MR stent is not available for sale CTO vs. Complex Nonocclusive Lesions (Taxus VI) 12% NNT 8 Werner et al. J Am Coll Cardiol 2004;44: % NNT 3

Long stenting no longer a problem for recurrence 2.75x32 3.0x32 3.0x28 3.0x32 3.5x8 2214/05471/05 6 months later

Taxus restenosis in CTOs: focal All nonocclusive restenosis were focal at the edges and successfully treated with another Taxus stent ->99 % patency

95 pts 85 pts. No TVF 10 pts. TVF 93 pts. 9 pts. Repeat PCI 6 months 1 pt. Reoccl. No PCI 9 pts. *) No TVF 12 months 1 pt. Late Reoccl. Longterm patency Werner GS et al; ACC 2006

Overall Cardiac Death TLR MI 1.7% n=1 1.7% n=1 6.7% n=4 Incidence (%) N = 65/778 Patients WISDOM 12-Month TAXUS Related Cardiac Events: Total Occlusions 3.3% n=2 Only 8.4% !!!

Overall Cardiac Death Treated Vessel Re-intervention MI 2.2% n=4 1.1% n=2 4.3% n=8 Incidence (%) N = 186/3688 Patients MILESTONE II 12-Month TAXUS Related Cardiac Events: Total Occlusions 1.6% n=3 Stent thrombosis = 1.0% (2/186) Only 5% !!!

Opening a CTO … Improves symptoms (angina, dyspnea) Improves LV function Improves prognosis Can be kept open with DES Why are they still undertreated ?

CTO success rates 1995/961997/981999/012001/03

Penetration power of dedicated wires

New wire techniques Mitsudo;

Parallel wire technique - example 230/05 Parallel wire technique with ASAHI Miracle Bros and Conquest wires

Case example: Double blunt occlusion 12/05/06 Blunt proximal cap with 2 large sidebranches and blunt distal cap with one large side branch.

Case example: Double blunt occlusion 12/05/06 Bilateral approach: Confianza Pro over Spectranetics versus Miracle 3G over Transit

Case example: Double blunt occlusion 12/05/06 Bilateral approach: A major new option for 2nd attempts But the majority of CTOs are not treated in live courses

Determinants of procedural success Experience, dedication and patience of interventionist Duration of occlusion 2 weeks 3 months 12 months Angiographic criteria … not many Heavy calcification Vessel tortuosity

PCI of CTOs is dangerous … really ? Bahrmann et al. EuroInterv 2006;2:231-7

Why do we not apply what is possible ? 1995/961997/981999/

CTO – The European reality Opening a CTO … Costs a lot of lab time Costs a lot of work time Costs a lot of material Costs a lot of radiation exposure Requires a lot of patience Does not pay in our reimbursement system