1. Treating CTOs Is there evidence based data?
Craig A. Thompson, M.D., MMSc.
Director, Cardiovascular Catheterization and Intervention
Yale University School of Medicine/Yale New Haven Hospital
Consultant (Hon) Heart Hospital, London and London Chest Hospital

2. Craig A. Thompson, MD Consulting Fees: Abbott Vascular
Terumo Cardiovascular Systems Group
Ownership Interest (Stocks, Stock Options, or other Ownership Interest):
Bridgepoint

3. The Onus is on us to prove utility?
Single vessel CTO
1 or 2VD no proximal LAD
Class 0
Class I/II
Class III/IV
High Risk
Max Rx U A
Int Risk
Low Risk
No Rx I
Class 0
Class I/II
Class III/IV
High Risk
Max Rx A
Int Risk U
Low Risk
No Rx I
Modified from Patel et al J Am Coll Cardiol 2009;53:

4. Impact of Successful CTO PCI
Effect of Successful CTO PCI on angina
Effect of Successful CTO PCI on subsequent CABG
Effect of Successful CTO PCI on Mortality
Joyal, D., Afilalo J, Rinfret S. American Heart Journal 2010

5. SYNTAX CTO Subset Procedural characteristics Per lesion analysis
CABG
n=266
26.2% patients with CTO
CTO accounted for 266 lesions (7.4%)
12 were not treated with CABG
CABG
n=254
Not Bypassed n=81
Not Bypassed
n=173
Overall 68.1 % of TO were successfully bypassed
49.6% overall complete revascularization in CTO subset
Would you have sent patient to surgery if CTO was not grafted?
Would you ask a surgeon not to graft CTO because it “is collateralized and doesn’t matter”? “Let’s just see how they do…”
ITT, Per Lesion
Serruys P, CRT 2009 [modified]; courtesy Prof Serruys and the SYNTAX investigators 6

6. National Attempt Rates ACC-NCDR
National Attempt Rate Over Time
It is likely we are dramatically undertreating patients with CTO
Courtesy J Aaron Grantham and ACC/NCDR

7. Clinical Indications why open a chronically occluded coronary artery?
Symptom control
Angina
CHF
Fatigue
Improve LV function
Regional
Global
Survival
Improved tolerance of AMI
Complete revascularization
Ischemic Risk

8. Clinical Indications why open a chronically occluded coronary artery?
Symptom control
Angina
CHF
Fatigue
Improve LV function
Regional
Global
Survival
Improved tolerance of AMI
Complete revascularization
Ischemic Risk

9. CTO Recanalization and Angina Control
Series
Successful PCI (n)
Follow-up (months)
Asymptomatic (%)
Olivari 2003
248 12
88.7
Berger 1996
139 6 87
Stewart 1993 45 68
Ivanhoe 1992
264 36 69
Ruocco 1992
160 24
Bell 1991
234 32 76

10. CTO PCI Impact on Angina and Quality of Life FACTOR study
Grantham JA et al., Circulation: Cardiovascular Quality and Outcomes 2009 (

11. Clinical Indications why open a chronically occluded coronary artery?
Symptom control
Angina
CHF
Fatigue
Improve LV function
Regional
Global
Survival
Improved tolerance of AMI
Complete revascularization
Ischemic Risk

12. Long Term LV Function Improvement with CTO PCI
Improvements in LV volume indices maintained at 3 years
Degree of transmurality of scar by MRI predictor
Kirschbaum SW et al. American Journal of Cardiology 2008

13. Clinical Indications why open a chronically occluded coronary artery?
Symptom control
Angina
CHF
Fatigue
Improve LV function
Regional
Global
Survival
Improved tolerance of AMI
Complete revascularization
Ischemic Risk

14. False Assumptions about Coronary Chronic Total Occlusions
The CTO is well collateralized and therefore minimal risk
The CTO is a closed vessel and therefore not at risk for ACS/AMI
CTO outcomes are more benign than non CTO coronary disease

15. Pressure Wire in Stenoses FAME Trial Inability to identify ischemia
1329 FFR-Guided Lesions in FAME
16% of 71-90% lesions were
not physiologically significant
39% of 41-70% lesions were
physiologically significant
“5% reduction in 3 year MACE with Functionally complete revascularization”
Pijls, TCT, 2008

16. Collaterals are Usually not Sufficient to Substantially Reduce Ischemia in CTO
Modified from Werner GS et al, European Heart Journal 2006, courtesy Werner GS

17. Prognostic importance of complete revascularization
Hannan et al., JACC:CI 2009

18. CTO as Predictor of Mortality and ICD Therapy
Nombela-Franco et al. Circulation Arrhythmia and Electrophysiology 2011

19. CTO as Predictor of Mortality and ICD Therapy
Nombela-Franco et al. Circulation Arrhythmia and Electrophysiology 2011

20. Prognostic importance of CTO in AMI
Independent predictors of a fall in EF at follow up
Age>60
CTO
MVD without CTO
1.9 ( ) p=.03
1.3 ( ) p=.64
3.5 ( ) p<.01
JACC:Cardiovasc Int, 2010

21. Survival Benefit with Revascularization Stratified by Ischemic Risk
P <.0001
Cardiac Death Rate
1- 5%
5-10%
11-20%
>20%
% Total Myocardium Ischemic
Hachamovitch et al Circulation. 2003; 107:

22. Concepts in Outcomes in CAD plaque destabilization and ischemic risk
Unstable Coronary Disease
Adverse Events
Multivessel Disease with CTO
LAD
RCA
Stable Coronary Disease
LCx
Ischemic Risk
Minimal ischemia Nonviable Minimal territory at risk
Time
Thompson CA JACC CI 2009

23. Iterating for the US Environment
Procedural success (%)
Experienced operators
Thompson CA JACC CI 2009

24. Revascularization for CTO what do we know
CTO is associated with symptoms of angina, but also often with dyspnea, fatigue
Patients minimize symptoms
Often inappropriately labeled asymptomatic
CTO has poor prognosis and is associated with higher mortality than most diseases we manage
High fatal arrhythmia burden
Poor tolerance for AMI in other territories
Other cardiac mortality linked to ischemic burden index
Patient cohorts with revascularized CTO
have longevity benefit compared with unrevascularized CTO
Better quality of life
CTO territories are virtually all ischemic
Consider them the true 95% lesions from clinical indications perspective
We undertreat these patients

25. Treating CTO: Is there evidence based data? Conclusions I
We all want randomized clinical trials
But remember, RCT in and of itself does not sanctify therapy
In the meantime, patients are suffering and dying
The overwhemling wealth of current information supports revascularization of CTO in the majority of cases

26. Treating CTO: Is there evidence based data? Conclusions II
‘The new era of CTO revascularization in patients with symptoms and/or ischemic burden begins in which the question is not “why should we open the occluded vessel?”, but “what is the justification to leave the vessel closed?”. ‘
Thompson CA, JACC CI 2009