1. Debate #4: CTO Revascularization
CCCSymposium 2014
Debate #4: CTO Revascularization
Most CTO Should be Opened: Samin K Sharma, MD
Only Limited CTO Should be Opened: Carlo Di Mario, MD
Samin K Sharma, MD, FACC, FSCAI Director Clinical & Interventional Cardiology Zena and Michael a Weiner Professor of Medicine
Mount Sinai Hospital, NY

2. I will make my point for; Most CTOs Should be Opened

3. Chronic Total Occlusion (CTO)
Presence of CTO in CAD Imparts Adverse Prognosis

4. Impact of Completeness of PCI Revascularization on Long-Term Outcomes in the Stent Era
HRs for Mortality for Various Subgroups of Incomplete Revascularization N
Unadjusted HR Compared with CR [95%CI]
Adjusted HR Compared with CR [95%CI]
Complete Revascularization
6817
1.00
1 IR vessel with no CTO
8518
1.20 [ ]
1.00 [ ]
 2 IR vessel with no CTO
2057
1.88 [ ]
1.25 [ ]
1 IR vessel CTO
3232
1.81 [ ]
1.35 [ ]
 2 IR vessels at least 1 CTO
1321
2.77 [ ]
1.36 [ ]
Hannah, Holmes, King, Sharma et al. Circulation 2006;113:2406

5. Incomplete Revascularization in the Era of DES: NY State Database Report
Conclusion: Pts with ≥2 IR vessels with a CTO, have the worst long-term prognosis and greater need for CABG or re-PCI
Hannan, Sharma et al. JACC Cardio Interv 2009;2:17

6. Effect of a Concurrent CTO on Long-Term Mortality and LVEF in Pts After Primary PCI in AMI
3277 STEMI pts : SVD 65%, MVD 22%, MVD + CTO 13%
Landmark Survival Analysis
Endpoint: Survival at 5 yrs, LVEF at 12 mo (median F/U 3.1 yrs)
Claessen et al. JACC Cardio Interv 2009;2:1128.

7. Temporal Trends in Cumulative Angiographic Success Rates and Major Procedural Complication Rates
80%
0.5%
Patel et al., JACC Cardiovasc Interv 2013;6:128 7

8. Incidence of Procedural Complications in Successful vs
Incidence of Procedural Complications in Successful vs. Unsuccessful CTO PCI
Complications
Successful
Unsuccessful
p value
MACE (%)
3.7
4.3
0.68
Death (%)
0.4
1.5
<0.0001
Emergent CABG (%)
0.03
0.17
0.74
Stroke (%)
0.07
0.04
MI (%)
2.8
3.0
0.87
Q-wave MI (%)
0.3
0.5
0.26
Coronary perforation (%)
10.7
Tamponade (%)
0.0
1.7
Vascular complication (%)
0.9
0.20
Contrast nephropathy (%)
5.0
4.6
0.86
Patel et al., JACC Cardiovasc Interv 2013;6:128 8

9. CTO: Anatomic Descriptors of Procedural Success
In the current ERA;
Severe calcification
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10. Chronic Total Occlusion (CTO)
Why Bother to do PCI?
Presence of CTO in CAD Imparts Adverse Prognosis
Because successful CTO recanalization may result in
Angina/Ischemia relief Freedom from subsequent CABG Improved LV function Improvement in event-free survival

11. Chronic Total Occlusion (CTO)
CTO Recanalization and Angina Relief
Series
Name/Year
Successful PCI (N)
FU (months)
Asymptomatic
(%)
Olivari, 2003
248 12 89
Berger, 1996
139 6 87
Ivanhoe, 1992
264 36 69
Ruocco, 1992
160 24
Bell, 1992
234 32 76
TOTAL
>1000
>24 mo
>80%

12. TOAST-GISE 1 Year Clinical Status of Complication Free Patients
CTO Success
(n = 248)
CTO Failure (n = 60)
P Value
No angina
220 (88.7%)
45 (75.0%)
0.008
ETT performed
210 (84.7%)
42 (70.0%)
0.010
Maximal ETT
155 (62.5%)
20 (33.3%)
<0.0001
Negative ETT
181 (73.0%)
28 (46.7%)
0.0001
Olivari Z et al, J Am Coll Cardiol 2003;41:1672

13. Meta-Analysis of CTO Outcomes
13 Observational Studies, 7288 patients weighted averaged follow-up 6 years
OR for Success
vs. Failure
95% Cl
p Value
Mortality
0.56
<0.001 MI
0.74
0.26
Subsequent CABG
0.22
Residual Angina
0.45
0.001
Joyal et al., Am Heart J 2010;160:179. 13

14. Evaluation of LV Function 3-Yrs after Percutaneous Recanalization of CTO
Changes in LV Volume Indexes and EF between Baseline and 3-Yr FU Measured Using Magnetic Resonance Imaging (N=21) 86 63 78 60 35 30
Mean ejection fraction improved slightly, but end-systolic and end-diastolic volume indexes decreased significantly.
Kirschbaum S et al, Am J Cardiol 2008;101:179

15. MRI Predicts LV EF & Wall Motion Improvement with CTO Revascularization (N=21) with prior MI
SWT at Baseline (n=21)
SWT 5 mths post Stent Implantation
P=ns
P<0.001
SWT 3 yrs post stent Implantation 90
P=ns
P<0.05 80
P<0.05 70 60
P<0.05
P<0.001 50
P<0.05
Segmental wall thickening (%) 40
P<0.05
P=ns 30
P=ns 20
P=ns 10
-10
-20
<25%
25-75%
>75%
Remote
Transmural extent of infarction
Kirschbaum et al, Am J Cardiol 2008;101:179

16. Effect of Successful vs
Effect of Successful vs. Failed CTO PCI in All-Cause Mortality During Long-Term Follow-up
Author, Year
Yr Follow-up
PCI Success (n)
PCI Failure (n)
OR/HR, 95% CI
Finci, et al., 1990 2
100
OR: 1.70,
Warren et al., 1990
2.6 26 18
N/A
Ivanhoe et al., 1992 4
317
163
OR: 0.21,
Angioi et al., 1995
3.6 93
108
OR: 0.37,
Noguchi et al., 2000
4.3
134 92
OR: 0.28, 0.11 – 0.72
Suero et al., 2001 10
1,491
514
OR: 0.67, 0.54 – 0.83
Olivari et al., 2003 1
289 87
OR: 0.19, 0.03 – 1.14
Hoye et al., 2005
4.5
567
304
OR: 0.52, 0.32 – 0.84
Drozd et al., 2006
2.5
298
161
OR: 0.74, 0.23 – 2.37
Aziz, et al.,2007
1.7
377
166
OR: 0.31, 0.13 – 0.76
Prasad et al., 2007
914
348
OR: 0.82, 0.62 – 1.08
Valenti et al., 2008
344
142
OR: 038, 0.19 – 0.77
de Labriolle et al., 2008
127 45
OR: 1.25, 0.25 – 6.27
Mehran et al., 2011
2.9
1,226
565
HR: 0.63, 0.40 – 1.0
Jones et al., 2012
3.8
582
254
HR: 0.28, 0.15 – 0.52
Joyal et al., 2010
5,056
2,236
OR: 0.56, 0.43 – 0.72
Moses et al., JACC Cardio Interv 2012;5:389 16

17. Successful Recanalization of CTO Associated with Improved Long-Term Survival
Jones et al., JACC Cardio Interv 2012;5:380 17

18. Advanced Techniques for Chronic Total Occlusion Japanese Specialized Technique
Anchor balloon technique
Mother-Child catheter technique
Parallel wire
IVUS guidance
Retrograde approach

19. Retrograde Wire Technique for Chronic Total Occlusion Recanalization
Four Patterns of Success in Retrograde CTO Recanalization
Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.

20. Increased Use of Retrograde Approach and Technical Success Rate Over Time
2006
2007
2008
2009
2010
2011
≈35% %
Michael et al., Am J Cardiol 2013;112:488 20

21. Appropriateness Score (1-9)
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
• Receiving a course of maximal anti-ischemic medical therapy U
• Intermediate-risk findings on noninvasive testing
• Intermediate-risk criteria on noninvasive testing A
• High-risk findings on noninvasive testing
• High-risk criteria on noninvasive testing
Patel et al. JACC 2012;53:

22. Chronic Total Occlusions
IIa
IIb
III
PCI of a CTO in patients with appropriate clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise B

23. Fundamental Wire Technique and Current Strategy for Chronic Total Occlusion PCI
Procedural Steps of Current CTO-PCI
Cotralateral
Dual Injection
CTO - PCI
Single Wire Technique
Antegrade approach x2
Parallel Wire Technique
Retrograde approach (ostial)
Retrograde Wire Cross
Kissing Wire Cross
IVUS guide re-entry
CART
Reverse CART
Success
Failure

24. Procedural Success of CTO PCI at MSH
Asahi wires
Retrograde
technique
Planned 2nd (18%) or
3rd (8%) attempt 93 86 78 68
EXPERT
CTO
US Trial:
90+ success %
397
806
665
782

25. Conclusions: Rationale for CTO Recanalization in ALL
Presence of a CTO imparts adverse prognosis.
Non randomized data support improved overall CV outcomes (including mortality) with successful CTO procedures. A randomized trial will be needed to establish the PCI efficacy in CTO pts.
Therefore developing technical skills (dedicated centers and dedicated Interventionalists) is essential to tackle this “last frontier of Interventional Cardiology” to improve overall outcomes of our complex CAD pts.
KEY to better CTO outcomes is successful recanalization