coronary chronic total occlusions: state-of-the-art 2014 · 2014-11-04 · balloon angioplasty...
TRANSCRIPT
Emmanouil S. Brilakis, MD, PhD
Director, Cardiac Catheterization Laboratories
VA North Texas Healthcare System
Associate Professor of Medicine, UT Southwestern Medical School
35οΠανελλήνιο Καρδιολογικό Συνέδριο
Αθήνα, 24 Οκτωβρίου 2014
Coronary Chronic Total Occlusions:
state-of-the-art 2014
Consulting/speaker honoraria: St Jude
Medical, Terumo, Janssen, Sanofi,
Abbott Vascular, Somahlution,
Elsevier, Boston Scientific
Employment (spouse): Medtronic
Grants: NIH –1R01HL102442
VA - I01-CX000787-01
VA CSP#571 – DIVA
ES Brilakis: Disclosures
I believe in the
value of CTO PCI
Another disclosure…
1. Definition – prevalence
2. Indications
3. Technique
• Wire crossing strategies
• Balloon Crossing
• Stents
4. Complications
5. Economics
6. The Future
Outline
Proximal RCA CTO – LAO viewCTO: occlusion in the coronary artery with
TIMI 0 flow of ≥3 months duration
CTO prevalence: Canadian registry
0
2000
4000
6000
8000
10000
12000
14000
16000
CABG STEMI Coronary angio
CTO
No CTO
Fefer P et al. J Am Coll Cardiol. 2012;59(11):991-997
# of pts
54%10%
14.7%
18.4% among pts with CAD
Jeroudi O et al. CCI 2013
Prevalence of CTOs and choice of
revascularization in Dallas VAMC
Diagnostic caths 1/2011 to 12/2012: 2,193
Unique patients: 1,699
No prior CABG; n=1,355
CAD ; n=1,015Prior CABG; n=344
CTO, n=319, 31% CTO, n=305, 89%
PCI
n=161
50%
Medical Rx
n=61
19%
CABG
n=97
30%
PCI
n=182
60%
Medical Rx
n=121
40%
CABG
n=2
0.6%
1. Definition – prevalence
2. Indications
3. Technique
• Wire crossing strategies
• Balloon Crossing
• Stents
4. Complications
5. Economics
6. The Future
Outline
Patient testimonial after right coronary artery
chronic total occlusion intervention
Why open a CTO?
Patient Physician
1.↓ angina
2.↑ LV function
3.↓consequences of
future ACS
4.↓arrhythmias
5.↓CABG
6.↓nitrate use…
1. Help pts
2. Improve PCI
skills
3. ↑ PCI volume
Residual – recurrent angina
Joyal et al. AHJ 2010
From: Long-Term Follow-Up of Elective Chronic Total Coronary Occlusion Angioplasty: Analysis From the U.K.
Central Cardiac Audit Database
J Am Coll Cardiol. 2014;64(3):235-243. doi:10.1016/j.jacc.2014.04.040
Complete vs incomplete revascularization
Garcia, .., Brilakis. J Am Coll Cardiol. 2013;62:1421-1431
89,883 Patients
RR = 0.71 [0.65-0.77], p<0.001 .
12,259 out of 89,883
(13%) died during follow
up.
CR was associated with
reduced long-term
mortality relative to IR
(risk ratio (RR):0.71; 95%
[CI]:0.65-0.77, p<0.001
Mortality benefit in
patients treated with
CABG (RR 0.70; 95%
CI:0.61-0.80, p<0.001)
and PCI (RR 0.72, 95%
CI:0.64-0.81, p<0.001.
Mortality benefit did not
vary with definition of
CR.
Claessen, B. et al. J Am Coll Cardiol Intv 2009;2:1128-1134
Impact of CTO on outcomes post STEMI
Improvement in LV systolic wall
thickening
Kirschbaum SW AJC 2008;101:179
“Dysfunctional but viable
myocardium”
2011 PCI guidelines
5 of 18 categories: lower recommendation for CTO PCI
Patel MR et al. JACC 2012;59:857-881
Appropriateness Use Criteria for
Coronary Revascularization
59.0
1.6
96.0
0.8
0
20
40
60
80
100
Procedural Success MACE
%
CTO Non-CTO
p < 0.001
p < 0.001
Procedural success and MACE
Brilakis et al, JACC Cardiovasc Intv 2014 – in press
594,510 procedures
22,365 CTO PCI
3.2 3.5 3.8 4.2 4.8
55.557.1
59.2 59.861.9
1.9 1.6 1.7 1.4 1.3
0
10
20
30
40
50
60
70
2009 2010 2011 2012 2013
%
% of total PCI Procedural success MACE
Trends over time
Brilakis et al, JACC Cardiovasc Intv 2014 – in press
3. How?
CTOs
A B?
2004-2007 The “early” years
2007-2010 “Crazy years”
2010- Moving on….
CTO in Dallas VAMC
Hybrid CTO crossing algorithm
Brilakis, Grantham, Rinfret, Wyman, Burke, Karmpaliotis, Lembo, Pershad, Kandzari,
Buller, De Martini, Lombardi, Thompson. JACC Intv 2012
Birth of the hybrid algorithmJan 2011 – Bellingham, WA
CTO basics
1.Approach: femoral – consider 45 cm
sheath
2.Guide: 7 or 8 French – support
short/shortened 90 cm
3.Virtually always: dual injections
4.Anticoagulation: heparin
5.Monitor radiation: AK
6.Ready to manage complications:
perforation - tamponade
The retrograde approach
67.5
24.8
7.6
Septal
Epicardial
SVG
Rathore, Circ Intv 2009
EpicardialSeptal
Tortuosity + ++ +++
Tamponade
risk
+ + +++
Wiring
difficulty
+ ++ +++
Able to
dilate
Yes Yes No
Bypass
graft
71
29
82
2
59
41
86
1.5
60
40
86
1.6
64
36
90
2.2
91
9
69
0
80
20
85
00
20
40
60
80
100
Antegrade Retrograde Overall Majorcomplications
%
2006
2007
2008
2009
2010
2011
Karmpaliotis, Michael, Brilakis, Lombardi, Kandzari et al. JACC Intv 2012;5:1273-9
Michael, Karmpaliotis, Brilakis, Lombardi, Kandzari et al. Am J Cardiol 2013;112:488-492
CTO PCI: success and complications
30%
N=1,363•Peacehealth Bellingham, WA
•Piedmont Atlanta, GA
•Dallas VAMC/UTSW
El Sabbagh,.., Brilakis. Int J Cardiol 2014;174:243-8
Retrograde CTO PCI: success and
complications meta-analysis
2006 – 4/2013
26 studies - 3,482 pts60
80
100
Overall successRetrograde success
83,3
74,5
%
0,7 0,7
1,4
6,9
2 2
5,4
0,5
0,0
1,0
2,0
3,0
4,0
5,0
6,0
7,0
8,0
%
Antegrade Dissection Re-Entry
Michael et al – Circulation Interventions 2012
BridgePoint Procedure
FAST CTOs: results
• Primary Effectiveness Endpoint
Technical Success 77%
• Primary Safety Endpoint
30-Day MACE 4.8%
• Secondary Endpoints
Mean Procedure Time 105 ± 54 min
Mean Fluoroscopy Time 44 ± 25 min
Whitlow et al. JACC Intv 2012
Bridgepoint system: mid-term outcomes
Mogabgab et al. JIC 2013
STAR technique: long-term outcomes
• Florence CTO PCI
registry
• 802 successful CTO
PCI between 2003-
2010
• 82% angiographic FU
• EES less reocclusion
than 1st generation
DES
• STAR: 57%
reocclusion rate
(16/28)
Valenti et al. JACC Intv 2013
How often is “hybrid” needed?
Michael,…,Brilakis Journal of Interventional Cardiology 2013
66/73 success rate (90.4%)
32 of 73 pts (44%) required 3.6±1.4 approach changesAntegrade wire: 50.0%; antegrade diss/re-entry: 24.2% retrograde: 25.8%
Torrance Medical
Center, CA
M.R. Wyman
PROspective Global REgiStry for the
Study of CTO interventions
Appleton
Cardiology, WI
K. Alaswad
Piedmont Heart
Institute, GA
D. Karmpaliotis
Mid America Heart
Institute, MO
J.A. Grantham
Dallas VAMC and
UTSW, TX
E. Brilakis
Massachusetts
General Hospital, MA
F. Jaffer, B. Yeh
Medical Center of
the Rockies, CO
A. Doing
Minneapolis VA
Medical Center, MN
S. Garcia
Banner Samaritan
Medical Center, AZ
A. Pershad Providence Health
Center, TX
C. Shoultz
PeaceHealth St.
Joseph Medical
Center, WA
W. Lombardi
1/2012 to 2/2014
n=632
Technical success: 92.4%
Major complications: 1.9%
•Appleton Cardiology, WI
•Dallas VAMC/UTSW, TX
•Peaceheath Bellingham, WA
•Piedmont Heart Institute, GA
•St Luke’s Mid America Heart
Institute, MO
•Torrance Medical Center, CA
Christopoulos, Karmpaliotis, Alaswad, Wyman, Lombardi, Grantham, Thompson, Brilakis et al
Journal of Invasive Cardiology 2014;26:427-432
65
3744
0
20
40
60
80
100
Techniques Used
%
Antegrade
Antegrade DR
Retrograde
Successful technique
PROspective Global REgiStry for the Study of CTO interventions
87.2
93.7
78.1
90.0
70
80
90
100
2006-2011 2012-2013
%
No prior CABG
Prior CABG
Pre “Hybrid” era
Michael, Karmpaliotis, Brilakis, Lombardi,
Kandzari et al. Heart 2013;99:1515-8
Δ=9.1%
P<0.001
Christopoulos, Menon, Karmpaliotis, Alaswad,
Lombardi, Grantham, Brilakis et al, AJC 2014;113-1990-4
CTO PCI: success and prior CABG
N=1,363
3 US sites
Prior CABG: 37%
Complications: 1.5% vs. 2.1%
Retrograde: 27.1% vs. 46.7%
Δ=3.7%
P=0.092
“Hybrid” era
N=630
6 US sites
Prior CABG: 37%
Complications: 2.5% vs. 0.8%
Retrograde: 34% vs. 39%
Δ=4.3%
p=0.31
N=521
In-stent restenosis=57 (10.9%), De novo lesions=464
5 US centers
Major complications: ISR 3.5% vs. De novo 2.2%
Christopoulos, Karmpaliotis, Alaswad, Lombardi, Grantham, Brilakis et al, CCI 2014;84:646-51
In-stent restenosis
PROspective Global REgiStry for the Study of CTO interventions
89.4
86.0
92.5
90.3
70
80
90
100
Technical success Procedural success
%
ISR De novo
Δ=3.1%
p=0.43
Martinez-Rumayor et
al. JACC Intv 2012
How CTO
equipment
can help in
non-CTO
cases!
1st vs 2nd generation DES
Lanka et al. Journal of Invasive Cardiology 2014; 26:304-10
Target Vessel Revascularization
Target Lesion Revascularization
1st vs 2nd generation DESMACE
Stent thrombosis
Lanka et al. Journal of Invasive Cardiology 2014; 26:304-10
1. Definition – prevalence
2. Indications
3. Technique
• Wire crossing strategies
• Balloon Crossing
• Stents
4. Complications
5. Economics
6. The Future
Outline
72. Succumb to fear and
insecurity or be afraid and go
ahead anyway!
Frequency of CTO complications
65 studies - 18,061 Patients
Patel V et al – JACC Intv 2013
Patel V et al – JACC Intv 2013
only 8 operators performed 50 or more
CTO PCI per year.
Brilakis et al, JACC Cardiovasc Intv 2014 – in press
IC-214402-AC AUG2014
Hybrid CTO Training & Education
>1000 physicians trained globally
Radiation Exposure
• Minimize fluoro
• 7.5 fps
• Fluoro-store
• Watch AKBrilakis ES. Manual of coronary CTO interventions. Elsevier 2013
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
Diagnostic PCI Overall
mre
m
Control
Bleeper Sv1.1
1.4
0.7
p<0.001 p<0.001p=0.323
36% relative
reduction in
overall
radiation!
1.0
1.4
0.9
Christopoulos et al. Late breaking clinical trial – SCAI 2014
Circ Cardiovasc Interv 2014; in press
1. Definition – prevalence
2. Indications
3. Technique
• Wire crossing strategies
• Balloon Crossing
• Stents
4. Complications
5. Economics
6. The Future
Outline
CTO Revascularization: Economic Outcomes
0
2.000
4.000
6.000
8.000
10.000
12.000
Total DirectCosts
ProceduralCosts
ContributionMargin
CTO, N=154
Non-CTO, N=1,847Co
st (
Do
llars
)
P<0.001
P<0.001P=0.58
$10,870
$7,436
$6,230
$3,060
$5,173
$5,730
~
Balloon angioplasty catheters
$600 vs $304
Guidewires
$715 vs $174
Stents
$3,590 vs $2,036
Karmpaliotis D.
CCI 2013
CTO Revascularization: Economic Outcomes
0
2.000
4.000
6.000
8.000
10.000
12.000
Total DirectCosts
ProceduralCosts
ContributionMargin
CTO, N=154
Non-CTO, N=1,847Co
st (
Do
llars
)
P<0.001
P<0.001P=0.58
$10,870
$7,436
$6,230
$3,060
$5,173
$5,730
Karmpaliotis D.
CCI 2013
1. Definition – prevalence
2. Indications
3. Technique
• Wire crossing strategies
• Balloon Crossing
• Stents
4. Complications
5. Economics
6. The Future
Outline
• Equipment
• Forward looking IVUS (?)
• Collagenase
• Trials-Registries
• DECISION CTO
• Euro CTO
• OPEN CTO
• Education - training
The future
1. CTOs are common
2. CTO revascularization can
provide significant clinical
benefits
3. CTO PCI can be achieved with
high success and low
complication rates and can be
cost-effective
Conclusions
www.ctofundamentals.org