1. CTO Perspectives: When not to Start, and When to Stop and Try Again
Patrick L. Whitlow, MD
Director, Interventional Cardiology
Cleveland Clinic
Disclosures: Research support from
BridgePoint Medical, Inc.

2. Chronic Total Coronary Occlusion
Of all patients undergoing coronary angiography, ~50% have significant CAD.
Of all patients undergoing coronary angiography who have significant CAD, ~22% (Canadian Registry) - 50% (Seattle) have at least one CTO.
So CTO remains a huge issue in treating CAD

3. Treatment Chosen for Patients with CAD after Diagnostic Cath
100
100
No CTO
No CTO 75
CTO present 75
CTO present 35 49 28 40 36 11 % % 50 50 25 25
Medical Rx
Medical Rx
CABG
CABG
PCI
PCI
AJC 5/05

4. Chronic Total Coronary Occlusion in Randomized PCI vs CABG Trials
From BARI to SYNTAX, the single most common reason for a patient to be referred for surgery and not randomized was a CTO which the PCI operator felt he could not recanalize.
Even as recently as SYNTAX, the PCI success rate in CTO lesions was only 53% ( 133/250)
Newer data suggest markedly improved CTO success approaching 90% for very experienced operators proficient in both antegrade and retrograde techniques

5. Considerations for When Not to Start and When to Stop a CTO PCI
What is Your Experience With CTO PCI?
- What is your success rate? - Can you perform retrograde CTO techniques? - Is there another operator who would provide better care for this patient?
Do you have all the updated equipment needed for this procedure?

6. Considerations for When Not to Start a PCI for a CTO
Patient Characteristics
Indication / Informed Consent Documented
Estimated Chance of Procedural Success and complication rate
Length of CTO Procedure: minutes for Paris Sud Registry
DAPT Reliability of patient assessed
Radiation Dose / Contrast Exposure disclosed

7. Considerations for When Not to Start a PCI for a CTO
What are the chances of success?
? Lesion Length
? Degree of Calcification
? Degree of Tortuosity
Does CTO begin abruptly, especially at a side branch?
Or is there a tapered , funnel type entry?
Is there apparent retrograde access?

8. Considerations for When Not to Start and When to Stop a CTO PCI
Xray Exposure to the patient
<5 Gray Best; 7-8 Gray Maximum
How Large is the patient?
What views are needed and at What
Magnification?
Median fluoro time 45 minutes J-CTO Registry
10% of CTO cases > 120 minutes fluoro

9. Considerations for When Not to Start and When to Stop a CTO PCI
Contrast Used / Patient’s Creat. Clearance: <2.5 desirable; >3.7 predicts dysunction.
Contrast ml/kg with normal Cr. Cl.
- Be careful with diabetics, esp. with renal insufficiency and/or proteinuria.
250 ml mean for Paris SudCTO’s
293 ml median for J-CTO Registry

10. Considerations for When to Alter Your Approach or Stop a CTO PCI Attempt
Are you making progress with the procedure?
If not, what is your next strategy?
Change the wire bend?
Change the wire Type?
Change the support Device?
Change to a retrograde(orantegrade, or Re-entry) approach
Is the patient comfortable? What has been the procedure Time? X Ray exposure? Contrast Dose?
Is it time to stop this attempt?

11. When and with Whom to Reschedule another PCI Attempt
Consider experience/ success rate/alternative approaches available to you or your partners, or your potential referral possibilities
Consider patient’s renal function and contrast dose
Consider patient’s Xray exposure and potential for radiation dermatitis/ skin necrosis
Consider how disabling the patient’s symptoms are and is he on maximal Meds?
Would CABG be better?