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

2. Disclosures
None

3. 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

4. PCI of CTO and Long-term Survival
N=2007 pts; (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

5. Impact of CTO Success on Outcome
n = 486 pts; 527 CTO; DES; Success 71%
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⁄ ). Cardiac survival rate was higher in the CTO – PCI success group compared with CTO – PCI failure group ( vs %; P 1⁄ ), inpatients with multivessel disease and CTO–PCI success compared with CTO–PCI failure ( vs %; P 1⁄ ), and in patients with complete revascularization when compared to patients with incomplete revascularization ( vs %; 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

6. CTO PCI: Survival by Success
Mortality at FU
p=0.045
p<0.04
p<0.001 %
p<0.025
p=0.02 N:
FU: yr yr yr yr yr
Grantham JA: JACC 2009: 2:

7. 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: )
Effect of Procedure Success
Grantham AJ, et al. Circ Qual Outcomes 2010;3:284

8. Coronary CTO Who to treat? Symptomatic Significant Ischemia
Reasonable likelihood of success
Low expected complication rate

9. 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: /j.jacc

11. 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

12. 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)

14. 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:

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

16. CTO PCI in the US NCDR Registry Technical Success MACE % %
Grantham JA: JACC 2009: 2:

17. CTO PCI in the US Barriers to Wider Use Operator inexperience
Difficulty in wire crossing
Perceived increased risk
Financial disincentives

18. 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

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

20. 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:

21. Chronic Total Occlusion PCI
Basic (Conventional) Techniques
Antegrade wires, dual injection
Advanced Techniques
Retrograde, CART, new devices
Requires dedicated operators / centers

22. 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

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

24. CTO Techniques Equipment - Wires

25. 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)

26. Asahi Fielder Guidewires

29. 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

30. Hydrophilic vs Hydrophobic GW Tips
High lubricity tip
Low lubricity tip

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

33. Anchor Technique

34. 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.

35. Side Branch Technique

36. MicroCatheters Cordis Transit Finecross (Terumo)
Spectranetics Quick Cross

37. Subintimal Tracking

38. 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

39. 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

40. Retrograde Technique

41. Retrograde Approach

42. Retrograde CTO Guidewire Techniques

43. CART Technique Controlled Antegrade and Retrograde Subintimal Tracking

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

45. 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

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

47. 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)

48. 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

49. 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 ……

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

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

52. 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