2. Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany BSIC, Manchester, September 15, 2006

3. Chronic total occlusions update A European perspective Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany BSIC, Manchester, September 15, 2006

4. CTO – The European perspective What you may want to know about collaterals Why should we open a CTO ? The past and presence of CTO treatment CTOs in the DES era The remaining challenges in CTOs

5. Pathophysiology of collaterals in CTOs How to assess collaterals ? What happens to collaterals after PCI ? Can collaterals replace an open artery ?

6. Assessment of collaterals: pressure and flow Baseline collateral function Recruitable collateral function Werner et al. Circulation 2001;104:2784-90

7. Collateral function in CTOs 79%46% Werner et al. Circulation 2003;108:2877-82 Before PCIAfter PCI

8. Loss of collateral function not due to embolization Bahrmann et al. Z Kardiol 2002;91:937-945

9. Collateral function in CTOs 79%46% 18% Werner et al. Circulation 2003;108:2877-82 Before PCIAfter PCI 6 mo FUP

10. Evidence for preformed collaterals in man 79%46% 18% 20% Wustmann et al. Circulation 2003;107:2213-20 Werner et al. Circulation 2003;108:2877-82 Before PCIAfter PCI 6 mo FUP

11. Can good collaterals replace an open artery ? Collateral function assessed as collateral flow reserve In 98 Pat. with CTO during adenosine stress Adapted from Werner et al. JACC 2006;48:51-8

12. Can good collaterals replace an open artery ? 95% of collaterals are no substitute for the open artery

13. CTO – The European perspective What you may want to know about collaterals Why should we open a CTO ? The past and presence of CTO treatment CTOs in the DES era The remaining challenges in CTOs

14. CTOs – Should we treat them all ? Improvement of symptoms (angina, dyspnea) Improvement of LV function Improvement of prognosis

15. Benefit of recanalisation on LV function Werner et al. Am Heart J 2005;149:129-37 No improvement in case of Reocclusion !!!

16. Indication for revascularization: MRI function and vitality

17. LV recovery after recanalization of CTOs - MRI Baks T et al. JACC 2006;47:721-5

18. PCI success and survival Suero et al. JACC 2001;38:409-14 Ramanathan & Buller, ACC 2003 2000 Pat, 74% successful 1458 Pat, 77% successful 871 Pat, 65% successful Hoye et al. Eur Heart J 2005;26:2630-6

19. If PCI fails … at least consider CABG Suero et al. JACC 2001;38:409-14 But CABG seems to be only the second best option

20. A CTO left occluded makes life more dangerous

21. Leaving a CTO alone means taking risks in low risk patients STAR Registry, Institute for infarct research, Ludwigshafen PCI of

22. CTO – The European perspective What you may want to know about collaterals Why should we open a CTO ? The past and presence of CTO treatment CTOs in the DES era The remaining challenges in CTOs

23. CTOs in the cathlab routine in 2003 In a German registry (STAR – Stable Angina pectoris Registry - IHF, Ludwigshafen) 2002 consecutive diagnostic angiographies were evaluated: 33% had at least one CTO CTO pts had more severe symptoms, and LV dysfunction the 1-year mortality with CTOs was 5.5% vs. 3.1% Only one third of CTOs underwent PCI Half of all CTOs were referred to CABG

24. Why bother, you can‘t open it … most times CTO success rates – historical perspective

25. Why bother with PCI – you can‘t keep it open anyhow Binary angiographic restenosis with balloon vs BMS Woehrle CTO Workshop Munich 2005

26. Stenting in CTOs: long and multiple stents required Werner et al. J Am Coll Cardiol 2003;42:219-25

27. CTO – The European perspective What you may want to know about collaterals Why should we open a CTO ? The past and presence of CTO treatment CTOs in the DES era The remaining challenges in CTOs

28. Published studies using DES in CTOs HoyeGeNakamuraPrison IIPACTO StentCypher Taxus Patients561226010095 Reference diameter [mm] 2.352.673.123.382.65 Stent length244236.53240 Stents per lesion2.01.41.4 ?1.41.7 TVF9 % 3 %8 %10 % Reocclusion3 %2.5 %0 %4 %1 % Follow-up59 %83 %75 %94 %100 %

29. Events in PRISON II: BMS vs. Cypher Suttorp et al. TCT 2005

30. 3090150060120210180240270 Days Since Index Procedure 300330360 100% 90% 80% 70% Freedom of TLR TAXUS MR Control 9 mos. 12 mos. P=0.0003 91.3 % 79.4 % Control=bare metal stent TAXUS= TAXUS TM stent TAXUS TM MR stent is not available for sale CTO vs. Complex Nonocclusive Lesions (Taxus VI) 12% NNT 8 Werner et al. J Am Coll Cardiol 2004;44:2301-6 35% NNT 3

31. Long stenting no longer a problem for recurrence 2.75x32 3.0x32 3.0x28 3.0x32 3.5x8 2214/05471/05 6 months later

32. Taxus restenosis in CTOs: focal All nonocclusive restenosis were focal at the edges and successfully treated with another Taxus stent ->99 % patency

33. 95 pts 85 pts. No TVF 10 pts. TVF 93 pts. 9 pts. Repeat PCI 6 months 1 pt. Reoccl. No PCI 9 pts. *) No TVF 12 months 1 pt. Late Reoccl. Longterm patency Werner GS et al; ACC 2006

34. Overall Cardiac Death TLR MI 1.7% n=1 1.7% n=1 6.7% n=4 Incidence (%) N = 65/778 Patients WISDOM 12-Month TAXUS Related Cardiac Events: Total Occlusions 3.3% n=2 Only 8.4% !!!

35. Overall Cardiac Death Treated Vessel Re-intervention MI 2.2% n=4 1.1% n=2 4.3% n=8 Incidence (%) N = 186/3688 Patients MILESTONE II 12-Month TAXUS Related Cardiac Events: Total Occlusions 1.6% n=3 Stent thrombosis = 1.0% (2/186) Only 5% !!!

36. Opening a CTO … Improves symptoms (angina, dyspnea) Improves LV function Improves prognosis Can be kept open with DES Why are they still undertreated ?

37. CTO success rates 1995/961997/981999/012001/03

38. Penetration power of dedicated wires

39. New wire techniques Mitsudo; www.tctmd.com

40. Parallel wire technique - example 230/05 Parallel wire technique with ASAHI Miracle Bros and Conquest wires

41. Case example: Double blunt occlusion 12/05/06 Blunt proximal cap with 2 large sidebranches and blunt distal cap with one large side branch.

42. Case example: Double blunt occlusion 12/05/06 Bilateral approach: Confianza Pro over Spectranetics versus Miracle 3G over Transit

43. Case example: Double blunt occlusion 12/05/06 Bilateral approach: A major new option for 2nd attempts But the majority of CTOs are not treated in live courses

44. Determinants of procedural success Experience, dedication and patience of interventionist Duration of occlusion 2 weeks 3 months 12 months Angiographic criteria … not many Heavy calcification Vessel tortuosity

45. PCI of CTOs is dangerous … really ? Bahrmann et al. EuroInterv 2006;2:231-7

46. Why do we not apply what is possible ? 1995/961997/981999/01 2006

47. CTO – The European reality Opening a CTO … Costs a lot of lab time Costs a lot of work time Costs a lot of material Costs a lot of radiation exposure Requires a lot of patience Does not pay in our reimbursement system