Α Δ ΜΑΥΡΟΓΙΑΝΝΗ ΚΑΡΔΙΟΛΟΓΟΣ AIMOΔΥΝΑΜΙΚΟ...
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Α-Δ. ΜΑΥΡΟΓΙΑΝΝΗ ΚΑΡΔΙΟΛΟΓΟΣ AIMOΔΥΝΑΜΙΚΟ ΕΡΓΑΣΤΗΡΙΟ Γ .Ν.Θ. «Γ .ΠΑΠΑΝΙΚΟΛΑΟΥ» ΘΕΣΣΑΛΟΝΙΚΗ
Transcript of Α Δ ΜΑΥΡΟΓΙΑΝΝΗ ΚΑΡΔΙΟΛΟΓΟΣ AIMOΔΥΝΑΜΙΚΟ...
Α-Δ. ΜΑΥΡΟΓΙΑΝΝΗ ΚΑΡΔΙΟΛΟΓΟΣ
AIMOΔΥΝΑΜΙΚΟ ΕΡΓΑΣΤΗΡΙΟ Γ.Ν.Θ. «Γ.ΠΑΠΑΝΙΚΟΛΑΟΥ»
ΘΕΣΣΑΛΟΝΙΚΗ
Disclosures
None whatsoever…
CTO: definition/ prevalence the presence of TIMI 0 flow within the occluded segment with an
estimated occlusion duration of > 3 months
encountered in 15-30% of patients undergoing cor. angio
Sianos G. Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club. EuroIntervention.2012 May 15;8(1):139-45.
Chronic Total Occlusion (CTO) From Randomized Trials to Daily Practice
From BARI trial to SYNTAX trial, the single most common reason for a patient to be referred to surgery and not randomized was a CTO with low success rate of recanalization
Even in the recent era of increasing success rate of CTO recanalization, the PCI success rate for CTO lesions attempted in the SYNTAX trial was only 53%
CABG n=266
Not Bypassed n=81
ITT, Per Lesion
Reason not bypassed:
Not intended to treat (n=12) Diseased (n=11) Inadequate conduit (n=2) Too small (n=19) Unable to find (n=1) Other (n=36)
Bypassed n=173
CABG n=254
12 were not treated with CABG
Overall 68.1 % of TO were successfully
bypassed
CTO Surgical Revascularization the SYNTAX Trial
CTO PCI: the holy Grail of the great interventional quest
What Limits its adoption?
procedure time complexity uncertainty of outcome cost and resource utilization clinical justification variability in success rates complexity of teaching procedure and
inconsistency of approach/strategy
…Why bother?
Rationale for CTO Revascularization
‘Open Artery Hypothesis’
Understanding of patient identification has improved -procedural determinants by CTA -assessment of viability by MRI -reduction in ischemia by MRI, SPECT Understanding of clinical benefit increasingly refined -increase long-term survival -improve left ventricular function -angina/symptom reduction improvement in quality of life avoidance of procedures and reduced medications -reduced predisposition to arrhythmic events/ischemic events
Health Status Benefits of Successful CTO
Recanalization
Grantham JA et al. Quantifying the early health status benefits of successful chronic total occlusion recanalization: Results from the FlowCardia's Approach to Chronic Total Occlusion Recanalization (FACTOR) Trial.
Circ Cardiovasc Qual Outcomes 2010 May;3(3):284-90.
Meta-Analysis of CTO Outcomes 13 Observational Studies, 7288 patients, weighted average f/u 6 yrs
OR for Success vs. Failure
95% CI
P value
Mortality
0.56
0.43-0.72
<0.001
MI
0.74
0.44-1.25
0.26
Subsequent CABG
0.22
0.17-0.27
<0.001
Residual or Recurrent Angina
0.45
0.30-0.67
0.001 Joyal D. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis.
Am Heart J. 2010 Jul;160(1):179-87.
Shifting Focus Downstream from CTOs Insights to Myocardial Recovery Following CTO Recanalization
Cheng AS. Percutaneous treatment of chronic total coronary occlusions improves regional hyperemic myocardial blood flow and contractility: insights from quantitative cardiovascular magnetic resonance imaging. JACC Cardiovasc Interv.2008 Feb;1(1):44-53.
Shifting Focus Downstream from CTOs Insights to Myocardial Recovery Following CTO Recanalization
Cheng AS. Percutaneous treatment of chronic total coronary occlusions improves regional hyperemic myocardial bloodflow and contractility: insights from quantitative cardiovascular magnetic resonance imaging. JACC Cardiovasc Interv.2008 Feb;1(1):44-53.
Completeness of Revascularization
Valenti R. Impact of complete revascularization with percutaneous coronary intervention on survival in patients with at least one chronic total occlusion. Eur Heart J. 2008 Oct;29(19):2336-42.
CTO Impact on [non CTO vessel] AMI Mortality
Concept of “double jeopardy”
Claessen BE. Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention.
JACC Cardiovasc Interv. 2009 Nov;2(11):1128-34.
Mortality risk hazard associated with presence of a CTO in AMI patients exceeds all other factors except shock!
MRI Predicts Wall Motion Improvement with
CTO Revascularization
Kirschbaum SW. Evaluation of left ventricular function three years after percutaneous recanalization of chronic total coronary occlusions.
Am J Cardiol.2008 Jan 15;101(2):179-85.
VACTO:
Freedom from first appropriate device therapy in CTO and non-CTO populations
Nombela-Franco L.Ventricular arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention: impact of chronic total coronary occlusion (VACTO Primary Study).
Circ Arrhythm Electrophysiol.2012 Feb;5(1):147-54.
CTO vs Non-occlusive Angioplasty Appropriateness Criteria, Levels of Evidence
Single vessel CTO
1 or 2VD no proximal LAD
ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization. J Am Coll Cardiol. 2009 Feb 10;53(6):530-53.
ACCF/SCAI/STS/AATS/AHA/ASNC 2012 Appropriateness Criteria for Coronary Revascularization
Chronic Total Occlusions: Indications for PCI
INDICATION
Appropriateness Score (1-9)
CCS Angina Class
Asymptomatic I or II III or IV
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses • Low-risk findings on noninvasive testing • Receiving no or minimal anti-ischemic medical therapy
I I I
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses • Low-risk findings on noninvasive testing • Receiving a course of maximal anti-ischemic medical therapy
I U U
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses • Intermediate-risk findings on noninvasive testing • Receiving no or minimal anti-ischemic medical therapy
I U U
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses • Intermediate-risk criteria on noninvasive testing • Receiving a course of maximal anti-ischemic medical therapy
U U A
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses • High-risk findings on noninvasive testing • Receiving no or minimal anti-ischemic medical therapy
U U A
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses • High-risk criteria on noninvasive testing • Receiving a course of maximal anti-ischemic medical therapy
U A A
Why the Occluded Artery Trial (OAT) applies to CTO Revascularization
OAT: Subacute (3-28 days) total occlusions following MI
OAT: Relatively asymptomatic population excluding severe ischemia by functional study/rest angina/multivessel disease
Absence of improvement in LV function in OAT substudy −Baseline LVEF 48% (difficult to improve upon relatively normal) −Spontaneous recanalization (TIMI 2/3) observed at 1 year in 25% of MRx −Reocclusion in ~9% of PCI cohort; no DES −Greatest predictor of improved LVEF: patent target vessel at 1 year f.u
Hochman JS. et al., Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med.2006 Dec 7;355(23):2395-407.
Dzavík V. et al., TOSCA-2 Investigators. Randomized trial of percutaneous coronary intervention for subacute infarct-related coronary artery occlusion to achieve long-term patency and improve ventricular function: the Total Occlusion Study of Canada
(TOSCA)-2 trial. Circulation. 2006 Dec 5;114(23):2449-57.
Evolution of DES as a Standard in CTO Revascularization
CTO: Milieu Considerations Planned procedure – not “ad hoc” Careful assessment of symptoms/ target site viability + ischemia
Proper diagnostic angiograms visualize collaterals/ distal parent vessel beyond the CTO segment (consider bilateral angiography during diagnostic procedure)
Strong guiding catheter support 7-8 Fr, trans-femoral preferred for antegrade Sideholes for RCA and small ostial LM
Bilateral angiography in ALL
Radiation/contrast volume
Which way?
Ohhh, what to do, what to do…
CTO: Lesion Assessment Anatomy Dictates Initial Strategy
Proximal and distal “caps” Calcification (esp. at entry point)
Angulation – proximal vessel and throughout CTO segment CTO segment length Collateral pattern and anatomy Sidebranch relationships (esp. at proximal and distal “caps”) Distal vessel anatomy and disease Donor and CTO vessel anatomy for catheter and guidewire selection
Brilakis ES. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv.2012 Apr;5(4):367-79.
Wired… Guide Wire Clinical Segmentation
During the course of CTO therapy, a variety of diverse guidewires are needed to manage both CTO crossing and
subsequent lesion treatment
CTO guide wire milestones
1999
GUIDANT HT CROSS-IT XT
Tapered Tip Design
2008
1995
ASAHI Fielder XT
Polymer Covered Tapered
Guide Wire
SCIMED Choice PT
1st Polymer Covered GW
ASAHI Miracle
1st Dedicated CTO spring
coil GW
TERUMO Crosswire
1st Nitinol
Hydrophilic CTO Guide
Wire
2009
ABBOTT PROGRESS
Polymer Sleeve CTO GWi
incorporating Penetration
Power
1996
ASAHI Confianza/Pro
Tappered hydrophilic
wires
2010/11
ASAHI SION
Fielder XT-A/R
Tip Double Coil GW
CTO toolbox wires
•4 Wire Platform •Tapered soft (~1gram) hydrophilic
guidewire •Antegrade microchannel/soft plaque probing •Knuckle wire technique •Non tapered, plastic jacketed low
gram force wire •Retrograde collateral workhorse wire •Non tapered, high gram force
plastic jacketed wire •Lesion crossing •Facilitation of wiring in complex and/or dissection •High gram force (12g+), tapered
penetration wire •Lesion crossing
What is meant by guidewire escalation? Antegrade or Retrograde
Soft Polymer Jacket Probe (FIELDER FC/XT, PILOT 50)
Clear Path and Target? CONFIANZA PRO 12g,
Pro Via 12/15, PROGRESS 200T
Unclear Path and Target,+/-Tortuosity
PILOT 200
CTO toolbox: microcatheters
CTO toolbox: IVUS
7-8 Fr. Catheter Identification of the occlusion site in stumpless CTO IVUS guided wiring IVUS guided re entry IVUS retrograde CTO recanalization
CTO: ANTEGRADE TECHNIQUES
CTO: Antegrade Wiring Techniques
CTO: Antegrade Wiring Techniques
PROGRESS - 120 140T 200T MIRACLE Bros – 3 12 gm
PROVIA - 3 6 and 9 gm
Lesion specific CTO approach
Most CTOs with discrete entry point; after initial attempt with soft or hydrophilic wires
“Workhorse” technique Parallel wiring technique
CTO: Antegrade Wiring Techniques
PROGRESS - 140T 200T CONFIANZA (regular and PRO)- 9 12 gm
PROVIA - 12 15 gm
Lesion specific CTO approach
Blunt entry point, short straight CTO segments Heavily calcified or resistant lesions Alternative to “drilling” after initial soft wire failure or
after “drilling” wire failure Parallel wiring technique
CTO: Antegrade Wiring Techniques
PILOT / Whisper Fielder – FC/ XT
PROGRESS - 40 80
Lesion specific CTO approach
Microchannels present or sub-total occlusion (residual channel) ISR total occlusions Some calcified and angulated lesions STAR technique (subintimal reentry)
Antegrade techniques parallel (double) wires
Antegrade techniques see saw technique
Requires two micro-catheters; similar stiffness wires Alternating wires repetitively redirecting into true lumen tortuous long segment CTOs based on visual/tactile feedback
Antegrade techniques side branch anchoring
Fujita S. New technique for superior guiding catheter support during advancement of a balloon in coronary angioplasty: the anchor technique.
Catheter Cardiovasc Interv. 2003 Aug;59(4):482-8.
Antegrade techniques Subintimal TRAcking and Reentry
Sumitsuji S.Fundamental wire technique and current standard strategy of percutaneous intervention for chronic total occlusion with histopathological insights. JACC Cardiovasc Interv 2011 Sep;4(9):941-51
Options for optimal antegrade strategies Anchoring technique in a side branch proximal to the occlusion Use of soft tapper tip polymeric/hydrophilic wire to start in combination with a
microcatheter (mosty Finecross antegradely; 1.6 Fr) Filder XT Whisper LS Pilot 50
Escalation to stiff/stiffer spring coil wires with or without polymer/coating-single wire technique
Parallel wire technique “step-up” wire approach Miracle/Miracle Ultimate Confianza / Confianza pro PROGRESS 140-200T
Implementation of limited subintimal antegrade techniques (dissection/reently) Mini STAR: stiff wire to cross the lesion followed by soft wires for re-enty LAST (limited antegrade subintimal tracking): stiff wire to cross the lesion
followed by soft wires for reentry Hydrodynamic recanalisation
Use of dedicated devices Shift to the retrograde techniques
Courtesy of Dr. G. Sianos
What about backwards? CTO: RETROGRADE TECHNIQUES
CTO: RETROGRADE TECHNIQUES
Direction of Wire Crossing: Retrograde
Direction of Wire Crossing: Antegrade
Dilatation of CTO Body: (+)
Reverse CART
CART
Dilatation of CTO Body: (-)
Retrograde Wire Crossing
Kissing Wire
-
Concept of CART technique -Controlled Antegrade and Retrograde subintimal Tracking
Surmely JF. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique.
J Invasive Cardiol. 2006 Jul; 18(7): 334-8.
Concept of CART technique
1. Both wires in subintimal space
2. Dilation by retrograde balloon
3. Dilated subintimal space
4,5,6. Then the antegrade wire is easily directed into the dilated subintimal space.
Surmely JF. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique.
J Invasive Cardiol. 2006 Jul; 18(7): 334-8.
Retrograde Wire Technique for Chronic Total Occlusion Recanalization
Four Patterns of Success in Retrograde CTO Recanalization
Sumitsuji S.Fundamental wire technique and current standard strategy of percutaneous intervention for chronic total occlusion with histopathological insights. JACC Cardiovasc Interv 2011 Sep;4(9):941-51
Clinical Results: Collateral Crossing and Retrograde Success
Successful channel crossing with both wire and catheter is a very important factor in retrograde approach; over 90% of cases succeeded after catheter crossed the collateral channel
ECC consensus on the retrograde approach The retrograde technique represents a breakthrough in CTO recanalisation with
success rates exceeding 90% in complex CTOs and it has comparable complication rates with contemporary antegrade techniques.
Current evidence suggests that they should be reserved for second attempts after antegrade failure, or as strategies of choice in very complex CTOs where the expected antegrade success rate is <50%.
Recent trends in practice suggest implementation of the retrograde techniques after short antegrade failures (aimed at reducing procedure duration, contrast consumption and radiation exposure), but until more data become available this approach should be reserved for very experienced operators
Retrograde techniques should be reserved for very experienced antegrade operators (>300 CTOs and >50 per year). A minimum of 50 retrograde procedures (25 as second operator and 25 as first under supervision) are required before a cardiologist becomes an independent retrograde operator.
Sianos G. Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club. EuroIntervention.2012 May 15;8(1):139-45.
Continuum of CTO PCI: Hybrid Strategy
Toyohashi Heart Center Crossing Techniques (2009, n=118)
When to STOP!!! “CSP” = CTO Saturation Point – futility threshold
wire or device perforation with pericardial effusion hemodynamic instability collateral vessel compromise extensive dissection compromising distal run off contrast threshold radiation threshold
stage for second attempt refer to more experienced operator
ZEN philosophy
“persistence reigns supreme” Spiritual adventure: you cannot be “beaten” by the vessel!
EXPERIENCE, EXPERIENCE, EXPERIENCE… PATIENCE, PATIENCE, PATIENCE…
…If everything else fails … REPEATED SAUNA THERAPY IMPROVES MYOCARDIAL
PERFUSION IN PATIENTS WITH CHRONICALLY OCCLUDED CORONARY ARTERY-RELATED ISCHEMIA
Mitsuo Sobajima, Takashi Nozawa, Hiroyuki Ihori, Takuya Shida, Takashi Ohori, Takayuki Suzuki,
Akira Matsuki. Satoshi Yasumura, Hiroshi Inoue
BACKGROUND: Repeated low-temperature sauna (Waon) therapy relieves ischemic symptoms in patients with peripheral arterial disease. We
investigated whether Waon therapy could improve myocardial perfusion in patients with ischemia related to chronic total occlusion (CTO) of coronary arteries.
METHODS: Twenty-four patients who had ischemia in the CTO-related area were examined. The severity of ischemia was quantified by
thallium-201 myocardial perfusion scintigraphy with adenosine. The Waon group (n=16) was treated daily for three weeks with a 60°C far infrared-ray dry sauna bath for 15min and then kept in a bed covered with blankets for 30min. The control group (n=8) underwent myocardial perfusion scintigraphy twice with a three-week interval.
RESULTS: In the control group, neither summed stress score (SSS) nor summed difference score (SDS) of myocardial scintigraphy
changed. However, Waon therapy improved both SSS (16±7 to 9±6, p<0.01) and SDS (7±4 to 3±2, p<0.01), and the improvement was greater in patients with higher SSS and SDS scores at the baseline. Waon therapy extended treadmill exercise time (430±185 to 511±192s, p<0.01) and improved flow-mediated dilation of the brachial artery (4.1±1.3 to 5.9±1.8%, p<0.05), but tended to decrease the number of circulating CD34-positive bone marrow-derived cells.
CONCLUSIONS: Waon therapy improves CTO-related myocardial ischemia in association with
improvement of vascular endothelial function. This therapy could be a complementary and alternative tool in patients with severe coronary lesions not suitable for coronary intervention.
Int J Cardiol.2012 Jan 12. [Epub ahead of print]
