Revascularization of chronic total occlusions rationale approach

Revascularization of Chronic Total Occlusions: Rationale & Approach Faisal Latif MD, FSCAI, FACC Assistant Professor of Medicine, University of Oklahoma Director, Cardiac Catheterizati

Revascularization of Chronic Total Occlusions: Rationale & Approach

Faisal Latif MD, FSCAI, FACC

Assistant Professor of Medicine, University of Oklahoma

Director, Cardiac Catheterization Laboratories

Veterans’ Affairs Medical Center Oklahoma City, Oklahoma

USA

– Identify indications to attempt PCI

– Basic Technical Consideration for CTO PCI

Definition

• Significant vessel narrowing causing:

– True CTO: TIMI 0 flow

– Functional CTO: TIMI-1 flow

• Presumed or known duration of occlusion

>3 months

Stone GW, et al Circulation 2005;112:2364-72

Prevalence of CTOs

14.7%

Fefer P JACC 2012;59(11):991-7

Indications

1 Relief of angina

2 Decrease ischemic burden

3 Improve Left Ventricular function

4 Improve tolerance for a future acute

coronary syndrome

5 Decrease need for CABG

6 ?Mortality benefit

CTOs do not fit the OAT trial!

• Total occlusion of the IRA

– 3 to 28 days post-MI, and

– LVEF <50% or proximal occlusion

CTOs do not fit the OAT trial!

Improvement in Angina and Exercise

Tolerance

CTO Success (n=248)

CTO Failure (n=60)

12 months after CTO PCI

Olivari Z, et al JACC 2003; 41:1672-1678

Grantham JA Circ CV Qual Outcomes 2010;3:284-290

Improvement in Quality of Life

Cardiac death rates in 10,627 patients undergoing PCI vs medical therapy, as a function of the

amount of inducible ischemia

Hachamovitch R et al Circulation 2003;107:2900-2907

Relevance of Myocardial Ischemia Irrespective of Angina

Unadjusted KM survival in patients undergoing revascularization vs medical therapy

Hachamovitch R et al Circulation 2003;107:2900-07

Survival Advantage for Revascularization Over Medical Therapy

for Ischemic Myocardium

COURAGE Trial Nuclear Substudy

reduction, lower unadjusted risk for

death or MI (P=0.037),

particularly if baseline ischemia >10%

myocardium (P<0.001)

Shaw LJ, et al dy Circulation 2008;117:1283-91

Shaw L J et al Circulation 2008;117:1283-1291

Reducing Ischemia Reduces CV Events

COURAGE Nuclear Substudy

All Patients Patients with significant ischemia

Overall event-free survival: 87% vs 75% for patients with vs w/o >5% ischemia

reduction (P=0.037)

Reduction in Myocardial Ischemia

• Single-center

(2002-07)

• MPI within 12 months

before and after

increased ischemic burden post-PCI

Safley DM, et al CCI 2011;78:337-43

Changes in Ischemic Burden

Safley DM, et al CCI 2011;78:337-43

Changes in myocardial ischemic burden following

CTO PCI

Safley DM CCI 2011;78:337-43

Improvement in LVEF

• Retrospective analysis 75

patients who had

successful CTO PCI

• Gp 1: LVEF increased from 59% to 67% (p < 0.001)

• Gp 2: LVEF did not increase (p = NS)

Chung CM, et al CCI 2003;60:368–374

Effect of recanalization of CTO on global and regional

LVEF in patients with/without previous MI

Inference: Consider viability study in previously infracted Myocardium

Chung CM, et al CCI 2003;60:368–374

Effect of successful versus failed CTO PCI all-cause mortality

during available follow-up

Joyal D, et al Am Heart J 2010;160:179-87

Impact on Mortality

Impact of Pre-existing CTO in STEMI

• Less complete ST resolution (p = 0.0001)

Claessen B E et al Eur Heart J 2012;33:768-775

Overall 3-year mortality

Claessen B E et al Eur Heart J 2012;33:768-775

MVD with a CTO:

Independent predictor of higher 30-day (HR 2.88; p=0.004) & 3-year mortality (HR 1.98; p= 0.009)

Starting a CTO PCI Program

• Physician training

• Ensure equipment available

• Establish rapport with referring physicians

• Make sure CTO PCI is not used as an

alternative to CABG!

Considerations for CTO PCI

– Crossboss – Stingray system

Rentrop Classification

• Grade 0: No visible collateral

• Grade 1: Faintly visible collaterals to branches but no filling of the recipient parent epicardial artery

• Grade 2: Collaterals with partial filling of the recipient artery

• Grade 3: Complete filling of the recipient

artery

Pre-PCI Angiographic Assessment

• Contralateral/Dual injection views

• Alter image brightness to view collaterals

• Septal Collaterals:

– LAD & RCA: RAO Cranial

• Epicardial Collaterals

• Saphenous vein grafts

– Customized views based on native arteries

Interventional Collaterals

Epicardial Septal

CTO CART

Sheaths

Wires

Patel VG, et al JACC CV Interv 2013;6:128-36

Is Risk of CTO PCI Higher than an Average PCI?

Summary

• CTOs common; cause symptom/ischemia

• Know the Indications for PCI

– Unacceptable angina/equivalent Sx

– Large Ischemic burden

– Low LVEF with Viable Myocardium

• Not every CTO needs to be revascularized

Summary

• No large RCTs for PCI vs MT yet

• Proper risk/benefit assessment and

discussion with patient

• In 10 years, ISCHEMIA, DISCOVER CTO, EURO-CTO and DECISION-CTO