1. European Registry Update
Jacques Koolen MD PhD
Aristotle University
of Thessaloniki
A’ Cardiology Department
AHEPA University Hospital 1

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Biotronik consultant

3. EuroCto Club Founding Meeting
Paris
Carlo Di Mario
Gerald Werner
Joachim Büttner
Dariusz Dudek
Nicolaus Reifart
George Sianos
Alfredo Galassi
Jaques Koolen Hans Bonnier 3

4. Euro Intervention
Published May 2007
Published May 2008

5. 1983 lesions with CTO
Galassi, A.R. et al. J Am Coll Cardiol. 2015; 65(22):2388–400.

6. Euro CTO Club Membership

7. ERCTO REGISTRY
p for trend <0.001

8. Numbers of Procedures and Rate of Procedural Success
(mean 75.3%)
(mean 16.5%)
Overall
Antegrade
Retrograde

9. Procedural Success According to J-CTO Score and Operator Experience
>50 cases, 35 centers, 530 patients enrolled
<100 cases, 5 centers, 303 patients enrolled
>100 cases 4 centers, 562 patients enrolled

10. Patient characteristics (17626 procedures)
85.1% male
Age 63.9±10.9%
BMI 28.0±14.0 kg/m2
Comorbidities:
Diabetes 28.6%
COPD 5.1%
Peripheral artery disease 9.2%
Prior MI 42.3%
Prior CABG 13.7%
Prior PCI 49.6%; at CTO territory 14.8%

11. Procedural characteristics
Occlusion duration 12 [5-14] months*
CTO length 25 [18-38] mm*
Procedure duration 90 [60-130] min*
Fluro time 33 [19-55] min*
Contrast volume 250 [ ] ml*
In-stent CTO 7.4%
Involving bifurcation 12.1%
Previous attempts 24.3% (20.5% one, 3.3% two, 0.5% three or more)
Transradial access 23.2%
* summarized as median [25th-75th percentile]

12. Patient characteristics
17,626 percutaneous revascularization procedures involving CTOs (mean age of patients at the time of the procedure 63.9±10.9 years; 85% male)
Parameter
Years
(N=3,027)
(N=4,812)
(N=5,473)
(1/2)
(N=4,314)
p value
(for trend)
Age (years)
63.2±11.7
64.0±10.7
63.9±10.8
64.3±10.7
<0.001
Male gender
84.3%
85.8%
85.6%
84.5%
0.924
BMI (kg/m2)
26.3
27.6
28.7
Diabetes
26.5%
28.3%
28.9%
29.9%
0.002
Smoking
38.1%
31.6%
24.6%
26.9%
Dyslipidemia
72.4%
72.9%
77.6%
73.8%
0.003
Hypertension
68.4%
71.9%
74.7%
75.9%
Peripheral arterial disease
9.7%
8.9%
9.0%
9.6%
0.880
Renal insufficiency
0.0%
1.1%
1.5%
1.7%
Prior stroke history
2.6%
3.1%
2.3%
2.5%
0.191
Prior MI history
40.2%
41.0%
35.2%
35.1%

13. Patient characteristics (cont’d)
Parameter
Years
(N=3,027)
(N=4,812)
(N=5,473)
(1/2)
(N=4,314)
p value
(for trend)
Prior PCI
48.9%
51.8%
46.9%
51.2%
0.881
Prior PCI to the CTO territory
19.0%
21.3%
11.3%
9.6%
<0.001
In-stent CTO
4.8%
7.9%
8.1%
Prior CABG history
14.9%
12.6%
14.2%
13.4%
0.540
Prior CABG to the CTO territory
9.1%
8.9%
0.837
CTO artery
LMA
0.5%
0.6%
0.3%
0.4%
LAD
25.7%
24.9%
26.5%
23.8%
LCx
14.5%
15.5%
15.6%
RCA
47.2%
49.8%
52.8%
56.7%
VenG
3.5%
2.8%
0.9%
ArtG
0.0%
0.1%
0.2%
Other
7.0%
3.2%
2.3%
Vessel diameter (mm)
2.87±0.40
2.92±0.42
2.92±0.44
2.94±0.43

14. Temporal trends in utilization of techniques and materials
Years
(N=3,027)
(N=4,812)
(N=5,473)
(1/2)
(N=4,314)
p value
(for trend)
Contralateral contrast injection
38.5%
44.9%
55.9%
66.1%
<0.001
Number of guidewires used
3.1±2.4
3.3±2.7
3.4±2.7
3.9±3.6
Number of balloons used
2.5±2.1
2.5±1.9
2.6±2.0
2.7±2.2
0.002
Transradial access
16.2%
19.4%
22.2%
33.5%
Intravascular ultrasound
2.1%
3.2%
10.8%
12.8%
Retrograde approach
10.2%
14.9%
26.3%
30.8%
Externalization of retrograde wire
0.3%
2.9%
12.2%
16.5%
Corsair microcatheter
2.6%
16.4%
34.2%
39.2%
Tornus catheter
7.0%
4.7%
3.0%
Crossboss crossing catheter
0.4%
1.5%
3.4%
Stingray re-entry system
0.7%
1.8%
Rotational atherotomy
1.0%
0.8%
1.2%

15. Wires to start according to stiffness
Soft: 1 g or less
Intermediate: >1 g and ≤3 g
Moderately stiff: >3 g and <9 g
Stiff: ≥9 g

16. Wires to cross according to stiffness

17. Small, but significant, increase (p<0
Small, but significant, increase (p<0.001) in procedure duration and fluoroscopy time, and a decrease in contrast volume

18. J-CTO score

19. Peri-procedural mortality

20. Perforations

21. Any peri-procedural complication*
* death, myocardial infarction, stent thrombosis, stroke, perforation, vascular complications, need for emergency surgical intervention or PCI, hemoglobin reduction by >3 g/dl

22. Changes in Angina and Dyspnea Status After Retrograde CTO PCI
Galassi, A.R. et al. J Am Coll Cardiol. 2015; 65(22):2388–400.

23. Conclusions
The number of CTO procedures are ~2.500 per/year. This number is expected to increase with the expansion of the membership
The complexity of the CTOs attempted over time significantly increased
Success rates are increasing reaching 88%
Procedural complication rates are remaining low (in the range of 4.5%) with a tendency of increased perforations
In hospital MACE rates are very low (0,5%).

24. Conclusions
The number of the retrograde procedures is increasing over time (reaching 30.8 %) as well as the use of IVUS (12.8%) and the radial approach (33,5%)
Medium stiffness GW are increasingly used contributing to the success in more than 50% of the cases. This reflects the adoption in routine clinical practice of the GAIA family
JCTO score is a poor predictor of outcomes especially for the retrogarde procedures

25. In-hospital MACCE

26. JCTO score
p=0.011

27. Overall, J-CTO was higher in failed cases…
p<0.01

28. while in antegrade ones…

29. Mean values with 95% confidence intervals of estimated duration and length of CTOs, over the time period
Duration
Length
Occlusion duration increased from 23.2±40.6 months in to 34.7±53.1 in (p for trend<0.001),
CTO length increased from 29.1±17.7 mm to 31.2±20.8 (p for trend<0.001)

30. Procedural Complications and In-Hospital Outcomes in Retrograde Lesions

31. Angina severity

33. Procedural success

34. SAVE THE DATE … ›› 8th Experts "Live" CTO Workshop 2016 Krakow, Poland
Sept 30th – Oct 01st, 2016
Krakow, Poland
ECC-President
Alfredo R. Galassi, Italy
Course Directors Co-Director
Jaroslaw Wójcik, Poland George Sianos, Greece
Leszek Bryniarski, Poland Nicolas Boudou, France

35. In the ROC analysis the J-CTO score is a poor predictor of failure (non-significant) in retrograde cases
c-statistic (95% CI )
Specifically in retrograde cases:

36. Web based ERCTO Registry

37. 2015 and on
10 % reabstraction of CTO records (n = 250/ year), masked and reviewed by a second abstractor

39. Statistical analysis
Continuous variables were summarized as mean±standard deviation and compared with one-way analysis of variance. Categorical ones were summarized as percentages and compared with the chi square test.
Temporal trends were tested for significance with polynomial contrast analysis (for continuous variables) or the Cochran-Armitage test (for categorical ones).
Although the reported results are based on analysis of original data, analyses were repeated after accounting for missing values, using multiple imputation methods, to confirm that the original results were not sensitive to missing value-related bias.
IBM SPSS Statistics v. 22 software package (IBM Corporation, Armonk, NY, USA) and R language were used for all analyses.
Two-sided p values of less than 0.05 were considered as indicative of statistical significance.

40. However, the predictive value of the J-CTO score for procedural failure was mediocre c-statistic (95% CI )

41. Euro CTO Club Membership

42. European Registry of CTO (ERCTO)
a prospective real-world registry that includes patients with one or more CTO lesions in major coronary arteries or saphenous vein grafts
44 centers across Europe
all patients undergoing CTO PCI at these centers between January 2008 and June 2015 were registered prospectively using a web-based electronic data collection interface (17,626 percutaneous revascularization procedures)
no exclusion criteria
the treatment indication was symptomatic myocardial ischemia and/or evidence of reversible myocardial ischemia by perfusion imaging or stress testing, as proposed at the EuroCTO Club’s position paper
procedural details (demographic data, techniques applied, equipment used, fluoroscopy, complication rate) were prospectively recorded

43. Flowchart of the Study Population Patients included in the multicenter European Registry of CTOs (ERCTO)
Registry from 2008 to 2012.

44. 16 european centres across europe