valeri gelev - ostial cto lesions
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Ostial CTO Lesions
Valeri GelevTokuda Hospital Sofia
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Ostial Lesions
Definition Ostial disease is defined as a lesion
arising within 3 mm of the vessel origin
Classification– Aorto-ostial – involving the ostia of the RCA, LMS, and ACB grafts.
– Non-aorto-ostial – involving the ostiaof the major coronary arteriesnot arising directly from the aorta; i.e., the LAD, Cx and RIM.
– Branch ostial – involving the ostia of branches of the major coronary vessels; (diagonals, marginals, PL and PD)
Percy Eurointerverntion 2009
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Ostial Lesions - Incidence
33%12%
32%
18%
Overall Incidence around 3%
Patel CCI 2016
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CTO - Ostial Lesions Incidence
Limited data
Galassi Coron Artery Dis 2015
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CTO - Ostial Lesions Incidence
Limited dataEuro CTO Registry 2012-07.2015
Mayer-Gessner EuroCTO meeting 2015
RCA Ostial Other Lesions
n 378 (4%) 9030 (96%)
lesion length(mm) 43,4 30,7
J CTO score (men) 3,2 2,3
antegrade only (%) 38 73
retrograde only (%) 37 11
antegradea and
retrograde (%)
25 16
stent length (mm) 78,4 62,3
procedural time 140,1 106,2
fluoro time 62,5 41,2
Contrast (ml) 317,5 292,2
Success rate (%) 78 87
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CTO - Ostial Lesions Incidence
Limited data
Chun Luo JACC – Cardiovascula Imaging 2015
Independent predictor of Failure
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CTO - Ostial Lesions Incidence
Non Aorto-ostial Lesions
Side Branch at Proximal
Cap
=
Increasing the Proximal Cap Ambiguity
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Angiographic Predictors of Unsuccesful CTO
CUMC experience
Odds Ratio 95% CI p-value
CTO length 1.06 per 1mm increase
1.03-1.09 <0.01
Blunt stump 1.35 0.68-2.66 0.39
Side Branches 2.81 1.45-4.96 <0.01
Bridging collaterals 0.60 0.32-1.15 0.12
>1 CTO in vessel 3.22 1.13-9.19 0.03
Vessel calcification 4.54 2.40-8.56 <0.01
Diffuse disease 0.85 0.34-2.12 0.73
Prior CABG 1.03 0.53-2.03 0.93
Obunal K: ACC 2008
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1 1,5 2 2,5 3 3,5
Proximal v distal vessel
Length <15, 16-30, >30
Absent proximal tortuosity
Less calcification
Unambiguous proximal cap
No previous CABG
BMI < 30
Adjusted OR for success
Predictors of success – UK HYBRID
Multivariate analysis: C statistic = 0.72
All p<0.01
Wilson CTO summit 2016
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PROspective Global REgiStry for the Study of CTO interventions
Proximal cap ambiguity
Brilakis CTO summit 2016
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CTO - Ostial Lesions - Management
– Microchannels
– Bridging Collaterals
– Calcium in the vessel course
– Additional imaging modalities
• IVUS
• CT angio of CTO
– Utility of Retrograde Approach
Non Ao-ostial Ao - ostial
+ +/-
++ +/-
++ ++
+++ -
+/- +/-
++ +++
Meticulous attention should be paid to prevent retrograde wire going subintimally in the proximal vessel, LM respectively.
How to predict the vessel origin in the absence of stump
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CTO - Ostial Lesions Case presentation
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CTO - Ostial Lesions Case presentation
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CTO - Ostial Lesions Case presentation
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CTO - Ostial Lesions Case presentation
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CTO - Ostial Lesions Case presentation
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CTO - Ostial Lesions Case presentation
Final Result
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CTO – Ao-Ostial Lesions - Case presentation
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CTO – Ao-Ostial Lesions - Case presentation
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CTO – Ao - Ostial Lesions - Case presentation
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CTO – Ao - Ostial Lesions - Case presentation
Final Result
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CTO - Ostial Lesions
• Ostial CTO lesions represent an inhomogeneous subsetof chronically occluded coronaries.
• There is a paucity of data about their incidence,treatment options and longstanding results.
• PCIs in Ao-ostila CTOs are complex, procedures,demanding high expertise of the operator and a lot ofresources.
• Reported success rates are lower compared with theconventional CTO PCI.