1. Complex Coronary intervention
Ahsan (Sonny) Achtchi, DO, FACC

2. Disclosures & Conflict of Interest
No relevant financial relationships with any commercial interests.
No honorarium.

3. Patient 92 year old female
No significant past medical history
Lifelong nonsmoker
Very active, participates in ballroom dancing several times per week
Maintains her own household
Independent with IADLs and ADLs
Worsening exertional dyspnea and chest pain x 1 month
Relieved with rest
No rest pain
EF gradually decreasing 40%->25%

4. Angiography

5. Management? Presumptive medical therapy? Stress testing?
Diagnostic angiography?

6. Treatment options
Medical therapy?
Courage trial
Surgery
PCI

7. Selected graphs from Bell et al9 showing event-free survival stratified by several vessels grafted overall (upper left graphic), survival in patients with an ejection fraction (EF) <35% (upper right graphic), and event-free survival for the combined end point of death/myocardial infarction (MI)/reoperation and recurrence of angina (lower graphic).
Selected graphs from Bell et al9 showing event-free survival stratified by several vessels grafted overall (upper left graphic), survival in patients with an ejection fraction (EF) <35% (upper right graphic), and event-free survival for the combined end point of death/myocardial infarction (MI)/reoperation and recurrence of angina (lower graphic).
Mario Gössl et al. Circ Cardiovasc Interv. 2012;5:
Copyright © American Heart Association, Inc. All rights reserved.

8. One-year outcomes results from the Arterial Revascularization Therapies Study trial.10 CABG, coronary artery bypass graft; CVA, cerebrovascular accident; MI, myocardial infarction; PTCA, percutaneous transluminal coronary angioplasty.
One-year outcomes results from the Arterial Revascularization Therapies Study trial.10 CABG, coronary artery bypass graft; CVA, cerebrovascular accident; MI, myocardial infarction; PTCA, percutaneous transluminal coronary angioplasty.
Mario Gössl et al. Circ Cardiovasc Interv. 2012;5:
Copyright © American Heart Association, Inc. All rights reserved.

9. What is a CTO?

10. Possible results of CTO
Transmural MI
Hibernating myocardium
Collateralization with functional but ischemic tissue

11. Collateral flow is almost always inadequate!

12. CTO is associated with higher mortality!

13. Patient 92 year old female
No significant past medical history
Lifelong nonsmoker
Very active, participates in ballroom dancing several times per week
Maintains her own household
Independent with IADLs and ADLs
Worsening exertional dyspnea and chest pain x 1 month
Relieved with rest
No rest pain
EF gradually decreasing 40%->25%

14. Angiography

15. Management? Presumptive medical therapy? Stress testing?
Diagnostic angiography?

16. Treatment options
Medical therapy?
Courage trial
Surgery
PCI

17. CTO PCI with impella support

18. LAD

19. RCA

20. Case #2 59 F HTN, HL Heavy smoker
CABG 5 years ago, presented with ACS (CCS IV unstable angina) to local ER
Referred for diagnostic coronary angiography

21. Angiography

22. Distal visualization

25. Case #3 85 year old patient COPD, DM2, HTN, former heavy smoker, HL
CAD with prior CAGB and multiple PCIs
Mild renal impairment
Ischemic cardiomyopathy, EF 35%
Disabling CCS IV angina
Postural hypotension prohibiting antianginal use

26. Angiography

27. RCA CTO PCI

28. End result

29. Case #4 70 year old male Former heavy smoker DM2, HTN, HL
Recent onset of CCS IV angina, NYHA class III CHF
EF 20% by echo
Severe PAD
PET with entirely viable myocardium

30. Angiography

31. Retrograde left to left

34. Take home points
Complex coronary intervention and CTO is an important and underutilized resource
Many patients not eligible or unwilling to have surgery
Incomplete revascularization leads to worse outcomes

35. Thank you!