By M. Nicholas Burke, MD. The use of pioneering percutaneous treatments for chronic total occlusions: indications, limitations, outcomes and current research.

1. The Road Less Travelled:
Update on Percutaneous Coronary Interventions (PCI)
for Chronic Total Occlusions (CTO)
M Nicholas Burke, MD
Minneapolis Heart Institute and Foundation

2. Chronic Total Occlusions
Background
NHLBI Dynamic Registry and BARI
Study 1997-1999, n=1,761
•Presence of Total Occlusion 31%
•Attempted Total Occlusion 7.5%
Srinivas et al. Circ 2002

3. Chronic Total Occlusions
Effect on therapy
Christofferson AJC 2005

4. CTO PCI: Why don’t we do it?
•Because the artery is closed
•Because the damage is done
•Because it can’t get any worse
•Because restenosis rates are
high
•Because it’s no big deal

5. Kleisli T. et al.; J Thorac Cardiovasc Surg 2005;129:1283-1291
Cumulative unadjusted survival from all-cause and
cardiac death in surgical patients with CRV and IRV

6. Incomplete Revascularization with PCIIncomplete Revascularization with PCI
What is the effect?What is the effect?
Long term outcomes of‐ complete versus incomplete revascularization after drug eluting‐
stent implantation in patients with multivessel coronary disease
Catheterization and Cardiovascular Interventions
16 APR 2013 DOI: 10.1002/ccd.24799

7. Chronic Total Occlusions PCI
Most frequently heard arguments
against doing CTO’s:
1: I don’t need to do it because it’s
well collateralized

8. Collaterals Are Rarely Sufficient
To Substantially Reduce Ischemia In CTO
Modified from Werner GS et al, European Heart Journal 2006, courtesy Werner GS

9. Chronic Total Occlusions PCI
Most frequently heard arguments
against doing CTO’s:
1: I don’t need to do it because it’s
well collateralized
2: I’ve turned multivessel disease
into single vessel disease

10. CTO of Non IRA and STEMI-CTO of Non IRA and STEMI-
Double JeopardyDouble Jeopardy
J. Am. Coll. Cardiol. Intv. 2009;2;1128-1134

11. Hannan E L et al. Circulation 2006;113:2406-2412
Impact of completeness of revascularization
and/or presence of CTO on mortality
21954 Patients without acute MI or LMD between 1997-2000

12. Chronic Total Occlusions PCI
Most frequently heard arguments
against doing CTO’s:
1: I don’t need to do it because it’s
well collateralized
2: I’ve turned multivessel disease
into single vessel disease
3: CTO’s represent “stable coronary
disease” (ie COURAGE patients)

13. Courage Trial
Rates of Death or MI by Residual Ischemia
DeathorMIRate(%)
0%
(n=23)
p=0.023
p=0.063
1%-4.9%
(n=141)
5%-9.9%
(n=88)
>10%
(n=62)
Shaw et al, Circ 2008;117
P=0.002

14. Chronic Total Occlusions PCI
Most frequently heard arguments
against doing CTO’s:
1: I don’t need to do it because it’s
well collateralized
2: I’ve turned multivessel disease
into single vessel disease
3: CTO’s represent “stable coronary
disease” (ie COURAGE patients)
4: There isn’t randomized data
showing benefit

15. Chronic Total Occlusions PCI
Really?
Really?
THEN WHY HAVE YOU BEEN
DOING PCI ON STABLE PATIENTS
FOR ALL OF THESE YEARS?
Did you have randomized data
showing benefit ?

16. CTOs: What are we trying to do?
1. Make People Feel Better
(improve symptoms)
2. Make People Live Longer
(avoid future events)

17. CTOs: What are we trying to do?
Medical therapy
Let’s look at the evidence

18. Myocardial IschemiaTherapy: NitratesMyocardial IschemiaTherapy: Nitrates
To Improve SymptomsTo Improve Symptoms
Am J Cardiol 72 1993

19. Long-Term Nitrate Use in CAD
AHJ 138(3) 1999
Myocardial IschemiaTherapy: Nitrates
To Reduce Future Events (?)To Reduce Future Events (?)

20. Myocardial IschemiaTherapy: CCB
To Reduce Future Events (?)To Reduce Future Events (?)

21. Myocardial IschemiaTherapy: CCB
To Reduce Future Events (?)

22. Circ. Vol. 90 (2) 1994
Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BB
To Reduce Future EventsTo Reduce Future Events
Wait for It….
Yup, that’s all there is

23. Myocardial IschemiaTherapy: BB
To Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349

24. Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BB
To Reduce Future EventsTo Reduce Future Events
The REACH Registry

25. Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BB
To Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349

26. Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BB
To Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349

27. Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BB
To Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349

28. Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BB
To Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349

29. Myocardial IschemiaTherapy: BBMyocardial IschemiaTherapy: BB
To Reduce Future EventsTo Reduce Future Events
The REACH Registry
Bangalore et al, JAMA. 2012;308(13):1340-1349
Editorial conclusion:
“BB are of no use in stable CAD Patients”
And remember, these are INTERNISTS talking

30. Chronic Total Occlusion Revascularization:
To Improve Mortality
73.5%
65%
71.9%
PercentSurviving
50
Success
Matched Success
Failure
70
80
90
100
P = 0.002
60
“A successful
revascularized [CTO]
confers a significant 10-year
survival advantage
compared with failed
revascularization.”
Suero et al., J Am Coll Cardiol 2001.
Years

31. 0.001
Chronic Total Occlusion Revascularization:
To Improve Mortality
META ANALYSIS Successful vs Failed CTO PCI
Joyal D, Afilalo J, Rinfret S. Am Heart J 2010
Favors Failure
PCI success PCI failure Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight
M-H. Random,
95% Cl
M-H, Random,
95% CI
Angioi et al. 3 93 9 108 3.4% 0.37 [0.10, 1.40]
Aziz et al. 9 377 12 166 6.7% 0.31 [0.13, 0.76]
Drozd et al. 7 280 5 149 4.3% 0.74 [0.23, 2.37]
Finci et al. 5 100 3 100 2.9% 1.70 [0.40, 7.32]
Hoye et al. 37 567 36 304 14.4% 0.52 [0.32, 0.84]
Ivanhoe et al. 3 317 7 163 3.2% 0.21 [0.05, 8.83]
Labriolle et al. 7 127 2 45 2.4% 1.25 [0.25, 6.27]
Noguchi et al. 7 134 15 92 6.1% 0.28 [0.11, 0.72]
Olivari et al. 2 286 3 83 1.9% 0.19 [0.03, 1.14]
Prasad et al. 229 914 101 348 21.6% 0.82 [0.62, 1.08]
Suero et al. 395 1491 180 514 23.8% 0.67 [0.54, 0.83]
Valenti et al. 17 344 17 142 9.3% 0.38 [0.19, 0.77]
Warren et al. 0 26 0 18 Not estimable
Total (95% CI) 5056 2232 100.0% .56 [0.43, 0.72]
Total events 721 390
Heterogeneity: Taux
= 0.06; Chix
= 18.74, df = 11 (P= .07); P= 41%
Test for overall effect: Z = 4.39 (P< .0001) 0.1 1 10 100
Favors
Success
Source: American Heart Journal ©2010
Elsevier

32. CTO PCI: Why don’t we do it?
(the REAL reason)
BECAUSE
IT’S
HARD TO DO
(and Interventionalists hate to fail)

33. CTO PCI: why is it so difficult?
• All PCI is predicated on getting a wire
from the proximal to distal lumen to
deliver balloons and stents
• Wires follow the path of least resistance
• CTOs are very sclerotic and calcified
• The path of least resistance is generally
between layers of vessel wall in a
dissection
• It is extremely difficult to exit a
dissection

34. Chronic Total Occlusion Revascularization
New Tools and Technology
Things that have not worked:
• Drills
• Jackhammers
• Lasers
• RFA
• IR
• Blunt micro-dissection
• Lytics

35. Chronic Total Occlusion Revascularization
Basic Precept of the Hybrid Strategy
The ultimate crossing goal in CTO PCI is
to have a single wire connecting the
proximal and distal true lumens. It
doesn’t matter whether:
1) the wire is true lumen or subintimal
within the body of the CTO
2) the wire is coming from an antegrade or
retrograde direction

36. Chronic Total Occlusion Revascularization
The CrossBoss™ CTO Catheter DesignThe CrossBoss™ CTO Catheter Design
• Multi-wire coiled shaft
• Tracks via FAST Spin Technique
– Highly torqueable coiled-wire
shaft
– FAST Spin reduces push required
to cross CTO
• Atraumatic distal tip advanced
across a CTO ahead of the
guidewire
• OTW 0.014” guidewire compatible
CrossBoss is designed to quickly and safely deliver a guidewire via true lumen or subintimal pathways

37. Chronic Total Occlusion Revascularization
The Stingray™ CTO Re-Entry System Design
Unique self-orienting
balloon has a flat shape for
true lumen targeting
180° opposed and offset
exit ports for selective
guidewire re-entry
Re-entry probe
at Stingray
Guidewire tip
Compatibility:
6Fr. Guide/0.014” Wire
2.9Fr. shaft
profile
Stingray System (catheter and guidewire) is designed to accurately target and re-
enter the true lumen from a subintimal position

38. BridgePoint System

39. Chronic Total Occlusion Revascularization
Advanced Strategies and Techniques: Retrograde

40. Chronic Total Occlusion Revascularization
Advanced Strategies and Techniques: CART
Surmely JF: J Invasive Cardiol. 2006 Jul 18(7):33408

41. Chronic Total Occlusion Revascularization
Advanced Strategies and Techniques: CART

42. Chronic Total Occlusion Revascularization
Advanced Strategies and Techniques: CART

43. Chronic Total Occlusion Revascularization
Advanced Strategies and Techniques: CART

44. Case Presentation: SD
• 42 yo pt WF with FH and Tobacco Abuse
• Admitted 12/12 with NSTEMI
• Angiogram:

45. SD continued

46. SD continued

47. SD continued

48. SD continued
• Discharged to Home on Medical
Therapy
• Try to Quit Smoking

49. SD continued
• Readmitted 3/13 with USA
• ECG with CP: Inferior ST depression
• Angiogram: NO CHANGE
• TIME to FIX THIS THING

50. SD continued

51. SD continued

52. SD continued

54. SD continued

55. SD continued

61. Case Presentation: TL
• 42 yo pt w/Hx PE
• Referred for c/o DOE
• Stress Echocardiogram EF 35% global
•7’35” SOB, worsening inferior wall function
• Angiogram:

62. Case Presentation: TL

63. TL continued
• Cardiac Rehab
– Exercise induced VT

64. TL continued: PCI

65. TL continued: PCI

66. TL contiued: PCI

67. TL continued
• Exercise stress test 2 weeks after PCI:
– 13’30” no VT
• Echo approximately 2 months after PCI:
– EF ~55%