1. CHRONIC TOTAL OCCLUSIONS: WHAT IS KNOWN AND
WHAT IS UNKOWN
Giuseppe Biondi Zoccai
University of Turin, Turin, Italy
4th International Interventional Forum – Turin February 2009

2. LEARNING OBJECTIVES What is known What is unknown
Prevalence of chronic total occlusions (CTO)
Pathophysiologic basis and clinical impact
Possible techniques
What is unknown
When is revascularization indicated?
If yes, which type of revascularization?
Which technique?
Which stent?

3. LEARNING OBJECTIVES What is known What is unknown
Prevalence of chronic total occlusions (CTO)
Pathophysiologic basis and clinical impact
Possible techniques
What is unknown
When is revascularization indicated?
If yes, which type of revascularization?
Which technique?
Which stent?

4. INCIDENCE AND IMPACT

5. CLUSTERING WITH MULTIVESSEL DISEASE

6. LEARNING OBJECTIVES What is known What is unknown
Prevalence of chronic total occlusions (CTO)
Pathophysiologic basis and clinical impact
Possible techniques
What is unknown
When is revascularization indicated?
If yes, which type of revascularization?
Which technique?
Which stent?

7. CORONARY OCCLUSION AND MYOCARDIAL APOPTOSIS

8. COLLATERALS MOST OFTEN FAIL TO PREVENT SYMPTOMATIC ISCHEMIA1
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0,8
0,7
0,6
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0,5
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0,4
0,3
0,2
0,1
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0,09
0,13
0,16
0,17
0,21
0,25
0,28
0,31
0,34
0,36
0,38
0,40
0,42
0,43
0,47
0,69
1,00
FFRcoll
Moretti et al, J Cardiovasc Med 2008 – in press

9. PCI MAY PROVIDE CARDIAC REMODELING BENEFITS
Before PCI for CTO
5 months after PCI for CTO
Baks et al, J Am Coll Cardiol 2006;47:

10. LONG-TERM DATA FROM NON-RANDOMIZED STUDIES SUPPORT THE BENEFITS OF PCI FOR CTO
Especially for
LAD CTO
Suero et al, J Am Coll Cardiol 2001;38:409-14; Safley et al, J Am Coll Cardiol Intv 2008;1:

11. LEARNING OBJECTIVES What is known What is unknown
Prevalence of chronic total occlusions (CTO)
Pathophysiologic basis and clinical impact
Possible techniques
What is unknown
When is revascularization indicated?
If yes, which type of revascularization?
Which technique?
Which stent?

12. POSSIBLE TECHNIQUES Standard antegrade Parallel wire Drilling wire
Retrograde
CART
IVUS-guided puncture
Subintimal IVUS
STAR
Micro-channel injection

13. POSSIBLE DEVICES Standard wires Monorail or OTW balloon Stent
CTO wires (eg Asahi’s, Shinobi)
Microcatheters
Tornus
Frontrunner
Crosser
Safecross

14. LEARNING OBJECTIVES What is known What is unknown
Prevalence of chronic total occlusions (CTO)
Pathophysiologic basis and clinical impact
Possible techniques
What is unknown
When is revascularization indicated?
If yes, which type of revascularization?
Which technique?
Which stent?

15. INTERVENTIONISTS’ NEW OATH: I WILL NOT TREAT CTO
Hochman, New Engl J Med 2006;355:

16. SHOULD THUS INTERVENTIONISTS BE DISCOURAGED?
Boden et al, New Engl J Med 2007;356:

17. IS ANY SYNTHESIS POSSIBLE?
Abbate et al, J Am Coll Cardiol 2008;51:956-64

18. IS ANY SYNTHESIS POSSIBLE?
Schomig et al, J Am Coll Cardiol 2008;52:

19. LEARNING OBJECTIVES What is known What is unknown
Prevalence of chronic total occlusions (CTO)
Pathophysiologic basis and clinical impact
Possible techniques
What is unknown
When is revascularization indicated?
If yes, which type of revascularization?
Which technique?
Which stent?

20. Serruys et al, New Engl J Med 2009;360:961-72
A SYNTAX FOR EVIDENCE
Serruys et al, New Engl J Med 2009;360:961-72

21. LEARNING OBJECTIVES What is known What is unknown
Prevalence of chronic total occlusions (CTO)
Pathophysiologic basis and clinical impact
Possible techniques
What is unknown
When is revascularization indicated?
If yes, which type of revascularization?
Which technique?
Which stent?

22. BEGIN WITH A THOROUGH BUT SIMPLE APPROACH, BUT BE READY FOR ESCALATION
Dedicated CTO wires
Contralateral injection
Parallel wires
Drilling wire
Retrograde approach
CART
Microcatheter
Tornus

23. LEARNING OBJECTIVES What is known What is unknown
Prevalence of chronic total occlusions (CTO)
Pathophysiologic basis and clinical impact
Possible techniques
What is unknown
When is revascularization indicated?
If yes, which type of revascularization?
Which technique?
Which stent?

24. USE DES WHENEVER POSSIBLE, BUT WHICH DES EXACTLY?

25. TAKE HOME MESSAGES

26. TAKE HOME MESSAGES
CTO are highly prevalent and have a significant clinical and management impact
It is thus paramount to appropriately risk-stratify each patient depending on his baseline and angiographic features, to clarify the clinical indication for CTO recanalization
Several types of interventional techniques and devices are currently available for CTOs
Improvements in stents (ie drug-elution), wires (ie dedicated wire for CTOs) and ancillary devices (eg microcatheters) together with new or refined techniques have improved acute and long-term results of PCI for CTOs