08:25 Di Mario - Recent Pubblications and Research

Recent Publications & Research in CTO: 2013-14Carlo Di Mario, MD, FACC, FRCP

Ismail Dogu Kilic, MDGianluca Caiazzo, MD

Nikolaos Konstantinidis, MD

CTO published literature, 2013

original paperscase reportsreviews, editorials

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• Pathology• Physiology• Epidemiology • Outcome Data• Imaging• Technical approach• Stents in CTO

EuroCTO Course 2014: Rapid Review of the Recent CTO Literature

Sakamura, …, Virmani et al, Eur Heart J. 2013 Oct 14

Comparison of pathology of chronic total occlusionwith and without coronary artery bypass graft

95 CTOs from 82 patients were divided into CTO with CABG(n:34) ,CTO without CABG—of long-duration (n:49) and short-duration (n:12); histopathological comparison of the plaque characteristics of CTO, proximal and distal lumen morphology, and negative

remodeling between groups; a total of 1127 sections were evaluated

Representative images of long-duration CTO and short-duration CTO

Differences in plaque characteristics

• necrotic core area was highest in SD CTO

(18.6%) (LD-CTO: 7.8%; CTO+CABG: 4.5%; P ¼ 0.02)

• calcified area was greatest in CTO+CABG

(29.2%) (LD-CTO: 16.8%; SD-CTO: 12.1%; P ¼ 0.009);

• negative remodeling was least in SD-CTO

[remodeling index (RI) 0.86] [CTO+CABG (RI): 0.72

and LD-CTO (RI): 0.68; P , 0.001]

• Approximately 50% of proximal lumens

showed characteristics of abrupt closure

• the majority of distal lumen patterns were

tapered(79%) (P , 0.0001).


New York CTO/LM Course: Rapid Review of the Recent CTO Literature

Reversal of Ischemia of Donor Artery Myocardium After Recanalization of a Chronic Total Occlusion

Consecutive series of patients with severe angina in which a donor artery with intermediate stenosis (30–70%) had FFR measurements before and after successful CTO PCI

Sachdeva, .., Uretzki et al, Cathet Cardiovasc Intervent 82:E453–E458 (2013)

9 donor arteries with ischemic FFR pre-PCI 6 reverted to non-ischemic (FFR pre- PCI 0.76 and 0.86 post-PCI)

5 patients had normal FFR in the donor artery pre- and post-CTO PCI

Recanalizing the CTO first might avoid the need for PCI to the donor artery or MV CABG.


EuroCTO Course 2014: : Rapid Review of the Recent CTO Literature

Chronic Total Occlusions in Sweden –Swedish Coronary Angiography and Angioplasty Registry (SCAAR)

Ramunddal T, Plos One, Aug 2014

Stable CAD46%

ACS/NSTEMI

28%

STEMI14%

Other13%

SalesIndications for Angiography

1 Vessel20%

2 Vessel35%

3 Vessel36%

LM 8%

SalesExtent of CAD

CTO in 10.6% of angiographies in 126,745 patients

CTO in 16.0 of 91,154 angiographies in pts with >50% CAD

Decrease of prevalence of CTO in pts with significant CAD from 17.2% in 2005 to 15.1% in 2012, p<0.001

Male 77.5%; median age 68 (IQR 60-76) years; diabetes 23.9%; previous MI 37.2%

Ramunddal T, Plos One, Aug 2014

Coronary location of CTO at angiographyAnnual number of coronary angiograms

Prevalence and Management of Coronary Chronic Total Occlusions in a Tertiary Veterans Affairs Hospital

1,699 patients who underwent angiography between Jan 2011 and Dec 2012; 20% did not have CAD, 20% had CAD and prior CABG, and 60% had CAD but no prior CABG

Jeroudi et al, Cathet Cardiovasc Intervent (2013)

CTO prevalence • 31% in patients without prior CABG • 89% in patients with prior CABG

CTO PCI was performed in• 30% of patients without prior CABG • 15% of patients with prior CABG

Technical success• 82% of patients without prior CABG • 75% of patients with prior CABG

Procedural success• 80% of patients without prior CABG • 73% of patients with prior CABG

CTO pts had more co-morbidities, more extensive CAD and were more frequently referred for CABG.

Impact of chronic total occlusion artery on 12-month mortality in patients with non STEMI treated by PCI (From the PL-ACS Registry)

925 pts, 438 (47.4%) with CTO of a major non-IRA coronary artery

Gierlotka et al, Internat J Cardiol 168 (2013) 250–254

The Negative Impact of Incomplete Angiographic Revascularization on Clinical Outcomes and Its Association With Total Occlusions

The SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) Trial

Farooq et al, J Am Coll Cardiol 2013;61:282–94

2005-09 BCIS PCI Database13,443 patients (78.8% male)

14,439 CTO procedures Follow-up of 2.65 years

CTO PCI was successful in 10,199 cases (70.6%)

Survival and CTO Success

• Successful PCI of at least 1 CTO was associated with improved survival (hazard ratio [HR]: 0.72; 95% CI: 0.62 to 0.83; p < 0.001)

Sudhakar et al. J Am Coll Cardiol. 2014;64:235-243

J Invasive Cardiol. June 2014

• Multicenter Korean CTO registry • 2568 patients with CTO • Between 2007 and 2009

Successful CTO group2045 patients

Failed CTO group523 patients

Results from the multicenter Korean Chronic Total Occlusion (K-CTO) registry

J Invasive Cardiol. June 2014

Long-Term Outcomes After Percutaneous Coronary Intervention for Chronic Total Occlusion (from the CREDO-Kyoto Registry Cohort-2)

(n: 1524, 3-year follow up period)

Yamamoto et al, Am J Cardiol 2013;112:767-774

In-hospital death tended to occur less frequently in the successful CTO-PCI group than in the failed CTO-PCI group (1.4% vs 3.0%, p: 0.053)

Cumulative incidence of all-cause death was not significantly different between the successful and failed CTO-PCI groups (9.0% vs 13.1%, p: 0.18)

Cumulative incidence of cardiac death was significantly less in the successful CTO-PCI group than in the failed CTO-PCI group (4.5% vs 8.4%, p: 0.03)

After adjusting confounders, Successful CTO-PCI was associated with lesser risk for neither all-cause death (hazard ratio 0.93, 95% confidence interval 0.64 to 1.37, p: 0.69) nor cardiac death (hazard ratio 0.71, 95% confidence interval 0.44 to 1.16, p: 0.16).

Successful CTO-PCI was associated with significantly less subsequentCABG (1.8% vs 19.6%, p <0.0001).

Successful CTO-PCI compared with failed PCI was not associated with lesser risk for 3-year mortality.

Effects of Percutaneous Revascularization of Chronic Total Occlusions on Clinical Outcomes: A Meta-Analysis Comparing Successful Versus Failed

Percutaneous Intervention for Chronic Total Occlusion

Khan et al, Cathet Cardiovasc Interv 82:95–107 (2013)

As compared to conservative management (as a result of failed intervention), successful PCI recanalization of a CTO appears to be associated with improved long-term clinical outcomes

Forest plots for all-cause mortality forsuccessful and failed PCI groups.

Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions

A Weighted Meta-Analysis of 18,061 Patients From 65 Studies

Patel et al, J Am Coll Cardiol Intv 2013;6:128–36)

Tanaka et al, Am J Cardiol 2013;112:761e766

Technical success • 77% in the older group and 79% in the younger group (p: 0.66)• No significant differences in procedural complications

In the older group• Successful PCI resulted in superior 3-year cardiac

survival (97.6% vs 76.9%, p 0.005).• Successful PCI was found to be associated with a lower

incidence of cardiac death (hazard ratio 0.09, 95% confidence interval 0.01 to 0.91, p 0.042).

Comparison of Short- and Long-Term Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusions Between Patients Aged >75 Years and Those

Aged <75 Years (n: 284, 67>75 years old and 217<75 years old)

Long-Term Clinical Outcomes After Percutaneous Coronary Intervention for Chronic Total Occlusions in Elderly Patients (>75 Years): Five-Year Outcomes from a 1,791 Patient Multi-

National Registry(n:1791 patients with 1852 lesions, 213 patients (12%) >75, median follow up 890 days)

Hoebers et al, Cathet Cardiovasc Interv 82:85–92 (2013)

Procedural success rates were similar in elderly patients compared with patients <75 years (63.8% vs. 69.1%, P:0.12)

MACE rates after successful versus failed PCI were 25.8% vs 42.3% in the elderly (P: 0.02) and 11.2 vs 20.8% in younger patients (P < 0.01).

In elderly patients, this reduction in MACE after successful PCI was mainly driven by a reduction in CABG (0.0% vs. 20.4%, P < 0.01), there were no significant differences in terms of mortality (19.6% vs. 24.6%, P: 0.13) or MI (11.5% vs. 8.0%, P: 0.87).

Wijeysundera et al, EuroIntervention 2014;9:1165-1172

Relationship between initial treatment strategy and quality oflife in patients with coronary chronic total occlusions

(387 CTO patients enrolled consecutively undergoing non-urgent coronary angiogramcompleted the Seattle Angina Questionnaire (SAQ) and EQ-5D at baseline and at one year.

Strategies were: i) medical therapy, ii) PCI to non-CTO, iii) PCI to CTO, and iv) CABG.)

Changes in EQ-5D (EQ-5D covers five dimensions of health: mobility, self-care, usual activities, pain/discomfort, andanxiety/depression)

Baseline 1 year

Patients with CTO territory revascularization had significant improvements in self-reported quality of life

Changes in physical limitation sub-domain of Seattle Angina Questionnaire

Baseline 1 year

Pre-procedural coronary CT angiography significantly improves success rates of PCI for chronic total occlusion

30 patients, 10 previously failed, 90% success rate

Rolf et al, Int J Cardiovasc Imaging (2013) 29:1819–1827

Invasive coronary angiogram of the RCA and corresponding VRT (Volume Rendering Technique) image shows that the true course of the RCA is much longer than the invasive angiogram suggests

Approach for Chronic Total Occlusion With IVUS–Guided Reverse Controlled Antegrade and Retrograde Tracking Technique: Single Center Experience

(n: 49 patients with previously failed procedure, IVUS guidance implemented in 95.9% )

Dai et al, J Interven Cardiol 2013;26:434–443

IVUS identified 61.7% retrograde wire in the intimal space59.5% antegrade wire in the subintimal space

77.6% Corsair use95.9% technical success rate93.9% procedural success rate10.2% minor complications2% NSTEMI

Usefulness of Intravascular Ultrasound Guidance in Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents for Chronic Total Occlusions (from the Multicenter Korean-Chronic Total Occlusion Registry)

Hong SJ, Am J Cardiol. 2014 Aug

Increase in J-CTO lesion complexity score explains the disparity between recanalisation success and evolution of chronic total occlusion (CTO) strategies: insights from a single-centre

10-year experience(483 patients consecutively treated with CTO from 2003 to 2012, period n:288 and period 2 n:195)

Syrseloudis , …, Di Mario et al, Heart. 2013 Apr 99(7):474-9

Increase in J-CTO lesion complexity score explains the disparity between recanalisation success and evolution of chronic total occlusion (CTO) strategies: insights from a single-centre

10-year experience(483 patients consecutively treated with CTO from 2003 to 2012, period n:288 and period 2 n:195)

Syrseloudis, …, Di Mario et al, Heart 2013 Apr;99(7):474-9

Validation of the J-Chronic Total Occlusion Score for Chronic Total OcclusionPercutaneous Coronary Intervention in an Independent Contemporary Cohort

(209 consecutive patients, high volume operator, antegrade 47% and retrograde 53%)

Nombela-Franco et al, Circ Cardiovasc Interv. 2013;6:635-643

Mean J-CTO score 2.18±1.26

Successful guidewire crossing within 30 minutes

44.5%

Final angiographic success 90.4%

J-CTO score demonstrated good discrimination (c statistic, >0.70) and calibration (Hosmer–Lemeshow P>0.1)

Final success rate was not associated with the J-CTO score

Japanese Multicenter Registry Evaluating the Retrograde Approach for Chronic Coronary Total Occlusion

(801 patients treated in 28 Japanese centers between January 2009 and December 2010,Corsair use increased from 36% to 95.3% from 2009 to 2010)

Tsuchikane et al, Cathet Cardiovasc Interv 82:E654–E661 (2013)

Procedural success rate 84.8 % (retrograde success 71.2%)

Clinical success rate 83.8% (retrograde success 70.3%)

All (n:801) 2009 (n:378) 2010 (n:423)Collateral channel cross by guidewire 82.3% (659) 80.4% (304) 83.9% (355) Successfully crossed collateral channel Septal 63.0% (415/659) 68.4% (208/304) 58.3% (207/355)Epicardial 32.6% (215/659) 27.6% (84/304) 36.9% (131/355)Bypass graft 4.4% (29/659) 3.9% (12/304) 4.8% (17/355)

Procedure time (min) 195.1±84.5 203.3±84.4 187.9±84.1 (p:0.024)

Multivariate analysis identified age 65 years or more and lesion calcification as unfavorable factors and the use of a channel dilator as a favorable factor for retrograde procedural success.

Contemporary retrograde approach for the recanalisation of coronary chronic total occlusion: on behalf of the Japanese Retrograde Summit Group

(n: 378 consecutive patients -32% previously failed, 27 Japanese institutions)

Yamane et al, EuroIntervention 2013;9:102-109

Collateral channel crossed• Septal 68.9% • Epicardial 27.2% • Bypass graft 3.9%

Contrast (ml) 315.7±138.7 Fluoroscopic time (min) 98.7±54.9Procedure time (min) 203.3±84.4Major CC injury 1.3% (5)#

Minor CC injury 10.3% (39)Death 0

# Treated with coil embolization

Periprocedural Myocardial Injury in CTO Percutaneous InterventionsA Systematic Cardiac Biomarker Evaluation Study

(n: 325 consecutive patients, PMI occurred in 28 patients (8.6%) with symptomatic ischemia in 7 of them;higher incidence with the retrograde than the antegrade approach (13.8% vs. 6.7%, p 0.04))

Lo et al, J Am Coll Cardiol Intv 2014;7:47–54

Temporal trends in the incidence of PMI,use of the retrograde approach, and use of the antegrade dissection/re-entry in CTO PCI.

Procedural Outcomes of Revascularization of Chronic Total Occlusion of Native Coronary Arteries (from a Multicenter United States Registry)

(n: 1,361 consecutive native coronary artery CTO PCIs performed at 3 US institutions from January 2006 to November 2011)

Michael, …, Kandzari et al, Am J Cardiol 2013;112:488-492)

Technical success 85.5%Procedural success 84.2%Retrograde approach 34%Total procedure time (min) 113 ±61 Total fluoroscopy time (min) 42 ± 29Total contrast volume (ml) 294 ± 158Major complications* 1.8%

*antegrade (66%)1 death, 1 tamponade requiring emergent pericardiocentesis, 1 equipmententrapment requiring emergent surgery, 1 stent thrombosis, 1 transient ischemic attack, and 3 myocardial infarctionsretrograde (34%)2 deaths, 2 donor vessel dissections, 9 perforations or tamponaderequiring pericardiocentesis or emergent surgery, 1 equipment entrapmentand 2 myocardial infarctions

Long-Term Outcomes With Use of the CrossBoss and Stingray Coronary CTO Crossing and Re-Entry Devices

Mogabgab et al, J INVASIVE CARDIOL 2013;25(11):579-585

All Crossboss Other(189) (62) (127)

Technical success 76.1% 75.8% 76.2% p>.99Procedural success 75.0% 74.2% 75.4% p: 0.85Retrograde attempted 29.8% 46.8% 21.4% p<.001Any complication 8.2% 8.2% 8.3% p>0.99Major complication 3.7% 4.8% 3.2% p: 0.69All-cause mortality 6.6% 8.4% 5.5% p: 0.35Cardiovascular death 4.8% 5.0% 4.6% p: 0.75

US CTO Hybrid Registry: 497 Pts

Christopoulos G, Journal of Invasive Cardiology 2014

Procedural Characteristics and Outcomes of the study patients

Comparison of procedural complications between the present study and previously published CTO-PCI cases.

Angiographic F-up after Successful CTO Recanalisation with mini-STAR Technique25% CTO Restenosis at 8.9 mths (half of them occlusive)

Galassi et al, Can J Cardiol April 2014

Angiographic F-up after Successful CTO Recanalisation with mini-STAR Technique78% of Patients had TIMI 3 Flow post-procedure

Galassi et al, Can J Cardiol April 2014

Predictors of Reocclusion After Successful Drug-Eluting Stent–Supported Percutaneous Coronary Intervention of Chronic Total Occlusion

1,035 patients from 2003 to 2010; success rate 77% (802); angiographic f-up rate 82%; reocclusion rate 7.5%

Valenti et al, J Am Coll Cardiol 2013;61:545–50

Predictors of clinical and angiographic outcome

• The use of EES, as compared to first-generation sirolimus- and paclitaxel-eluting stents, was associated with a 5-fold decrease in CTO vessel reocclusion rate• The reocclusion rate with EES was only 3%, and this finding drives the difference in event-free survival between patients treated with first-generation DES and EES• The STAR technique allowed CTO vessel recanalization in nearly all cases but a final TIMI flow grade of 3 was achieved in approximately 60% of patients• Patients with a successful STAR procedure (final TIMI flow grade of 3) had a very high rate of reocclusion

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Resolute stent in CTOs

CLINICALOUTCOMES

Kelbaek H, Eurointervention, 2014

TLF

Cardiac death or MI

TLR

• Pathology of real occlusions shows fibrocalcific transformation, negative remodelling and lack of microchannels are ubiquitous in old CTOs especially after CABG

• Complete revascularisation, including CTO, improves prognosis

• Progress in technique and the use of the retrograde/hybrid approach increase success in the most complex occlusions

• Second generation DES reduces late failure

Rapid Review of the 2013-14 CTO Literature

Conclusions

08:25 Di Mario - Recent Pubblications and Research

Health & Medicine

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