Experts "Live" CTO Workshop 2014 25th Septemper 2014 in Madrid, Spain

1. Treating instent CTO
José Ramón Rumoroso
Interventional cardiology
Hospital Galdakao

2. Mechanisms of restenosis
In POBA era the cause was
Elastic recoil and negative remodeling
In the stent era the cause is
neointimal hyperplasia

3. Mechanisms of DES Restenosis
• Biological factors
– Drug resistance
– Hypersensivity
• Mechanical factors
– Non uniform struts distribution
– Non uniform drug deposition
– Polymer peeling
• Technical factors
– Underexpansion
– Gaps
– Barotrauma to unstented segment

5. Schematic image of 4 patterns of introduced classification of ISR in relation to previous
dichotomous description of focal vs diffuse ISR. Pattern I contains 4 types (A-D).
Mehran R et al. Circulation. 1999;100:1872-1878
Copyright © American Heart Association, Inc. All rights reserved.

6. One year events
Mehran R et al. Circulation. 1999;100:1872-1878

8. The problem itself
• Difficult to know what and how to treat because
these type of CTOs are contraindications in CTO
trials
• It is supposed that the rate of success is lower
than any other setting, why?
– The stent is a landmark but sometimes it is easy to go
outside the stent
– The recurrence of ISR is high
– The need of more stents, DES for the treatment
– Multiple layers of struts may lead to stent thrombosis

12. Sometimes it is a real problem to go
through the stent…
CTOs due to ISR represent challenging
lesions with low success rates using wire-
based strategies

13. The Common problem
• The wire slips through the struts and passes
along outside of the stent, even if it re-enters,
new generation balloons are so good that they
can follow the wire, but we can distort the
stent architecture

14. Sometimes it is a real problem to go
through the stent…

17. Proximal Distal
*
* *

18. EuroIntervention 2014; 9(11):1285-1292

19. True to True Lumen

20. The Efficacy of “Hybrid” PCI in CTOs Caused by
In-Stent Restenosis
Conclusion: A hybrid strategy incorporating antegrade and/or retrograde
approaches increases procedural success of PCI for in-stent CTOs.
PROGRESS CTO registry: 521 patients treated at 5 US high-volume
CTO PCI centers, Jan 2012-Sept 2013.
Christopoulos G, et al. Catheter Cardiovasc Interv.
2014; 84:646–651
Procedural Outcomes
In-Stent CTOs
(n = 57)
De Novo CTOs
(n = 464) P Value
Technical Success 89.4% 92.5% .43
Procedural Success 86.0% 90.3% .31
MACEa 3.5% 2.2% .63
aDeath, Q-wave MI, stroke, TVR, and cardiac tamponade requiring pericardiocentesis

21. Spanish Registry of Chronic TOtal Oclusion
secondary to an Oclusive In-stent Total
RestenOsis
TORO Registry

22. DR. GOICOLEAHOSPITAL PUERTA DE HIERRO
DRA. MARTIN-YUSTEHOSPITAL DE SANTA CREU I SANTA PAU
DR. VINHASHOSPITAL GARCIA DA ORTA
DR. RUMOROSOHOSPITAL GALDAKAO-USANSOLO
DR. PÉREZ DE PRADOHOSPITAL DE LEON
DR. MOREIRASHOSPITAL DE SALAMANCA
DR. HERNÁNDEZHOSPITAL 12 DE OCTUBRE
DR. CASCÓNHOSPITAL DE CARTAGENA
DR. TERUELHOSPITAL DE BELLVITGE
DR. SUÁREZHOSPITAL CENTRAL DE ASTURIAS
DR. MOREUHOSPITAL VIRGEN DE LA SALUD
DR. DE LA TORREHOSPITAL DE VALDECILLA
DR. LOZANOHOSPITAL DE CABUEÑES
DR. CUBEROHOSPITAL VALME
DR. PANHOSPITAL REINA SOFÍA
PIHOSPITAL

23. • All patients undergoing an attempt of percutaneous coronary
intervention due to occlusive ISR were included in our registry
among 15 different hospitals. CTO = coronary obstruction with
TIMI flow grade 0 with an estimated duration of > 3 months.
• A total of 233 interventions in CTOs due to ISR were reported. Our
study sought to evaluate PCI related success rate, procedural
techniques and outcomes on follow up among PCI-Success and
PCI-Failure groups. Ischemia driven target lesion (TLR) and target
vessel (TVR) revascularization, binary restenosis, thrombosis and
MACE rates were also evaluated among both groups.
• Analyses were performed using the software packages SPSS 15.0.
METHOD

24. FOLLOW-UP
• Median follow up: 20,1 months (IQR 9,6-39,8).
• Follow up rate 85,4%.
• No systematic angiographic follow up.
• MACE: TLR or TVR or any cause MI or cardiovascular
death.

25. 1,06 ± 0,82Creatinine
28,8 ± 4,5BMI
9,9%Peripheral disease
5,2%Ictus
5,6%CABG
49,5%Multivessel
56,2%Previous MI
66,5%Dyslipemia
56 ± 13LV EF
61,4%Smoker
41,5%DM
69,5%HBP
81,1%Gender ♂
62 ± 12Age
Basal data

26. CLINICAL PRESENTATION AT THE TIME OF DIAGNOSIS
37,8%
32,6%
17,4%
+ stress test
NSTEACS

27. STENTS CHARACTERISTICS
64,7%
35,3% 62,6%
24,7%
8%

28. 47%
35%
19%
LAD
RCA
CX

29. PROCEDURE
Estadísticos descriptivos
116 7 115 35,86 24,268
207 30 300 96,93 43,958
208 70 900 312,44 159,772
223 8 98 28,61 15,560
106
TIEMPO DE ESCOPIA
Duración
Contraste
LONG.
N válido (según lista)
N Mínimo Máximo Media Desv. típ.
TIME OF X RAY
DURATION
DYE

30. 6F
7F
8F
94%
20%
17%
9,9%
90%
63%
6%
78,4%
21,6%

31. WIRE THAT CROSSES THE LESION

32. TYPE OF TREATMENT
85%
13%

33. N=192
N= 41
83%
17%

34. RATE OF SUCCESS BY ARTERY
69,0% 31,0%
84,4% 15,6%
89,6% 10,4%
0% 20% 40% 60% 80% 100%
CX
CD
DA
Tabla de contingencia
31 121 152
79,5% 63,7% 66,4%
8 69 77
20,5% 36,3% 33,6%
39 190 229
100,0% 100,0% 100,0%
Recuento
% de Éxito
Recuento
% de Éxito
Recuento
% de Éxito
No
Si
DA
Total
No Si
Éxito
Total
P=0,057

35. J-SCORE
Tabla de contingencia
13 109 122
10,7% 89,3% 100,0%
22 76 98
22,4% 77,6% 100,0%
35 185 220
15,9% 84,1% 100,0%
Recuento
% de JScore>3
Recuento
% de JScore>3
Recuento
% de JScore>3
No
Si
JScore>3
Total
No Si
Éxito
Total
p = 0,017

36. COMPLICATIONS
85,3% had no complicatios.
14,7%

37. COMPLICATIONS
85,3% had no complicatios.
14,7%
3,5%
J-Score
2.8 ± 1.3

38. Outcome

39. 98,3%84,23%NO-CABG
1,7% (3/177)15,8% (6/38)CABG
SUCCESSFAILURE
p = 0,001
* 18 casos no reportados
RATE OF CABG IN THE FOLLOW UP

40. RATE OF CABG PER ARTERY
Tabla de contingencia CABG * Éxito
5 60 65
62,5% 98,4% 94,2%
3 1 4
37,5% 1,6% 5,8%
8 61 69
100,0% 100,0% 100,0%
Recuento
% de Éxito
Recuento
% de Éxito
Recuento
% de Éxito
No
Si
CABG
Total
No Si
Éxito
Total
Tabla de contingencia CABG * Éxito
14 86 100
87,5% 97,7% 96,2%
2 2 4
12,5% 2,3% 3,8%
16 88 104
100,0% 100,0% 100,0%
Recuento
% de Éxito
Recuento
% de Éxito
Recuento
% de Éxito
No
Si
CABG
Total
No Si
Éxito
Total
Tabla de contingencia CABG * Éxito
12 28 40
92,3% 100,0% 97,6%
1 0 1
7,7% ,0% 2,4%
13 28 41
100,0% 100,0% 100,0%
Recuento
% de Éxito
Recuento
% de Éxito
Recuento
% de Éxito
No
Si
CABG
Total
No Si
Éxito
Total
p = 0,111
p = 0,317
LAD
CD
CX
p = 0,004

41. 5,6%14,7%14,7%14,1%
REOCLUSIONRESTENOSISTVRTLR
212
PosibleProbableDefinitiva
THROMBOSIS ARC
Trombosis: 4 DAs y 1 Cx. En todos los casos se había implantado 1 sólo stent en
la RIS oclusiva. El stent que se trombosa es siempre farmacoactivo
ANGIOGRAPHIC OUTCOMES
Al analizar la Reestenosis+Reoclusión por arteria: 25% en Cx 19,5% en DA/CD. P=NS.

42. Com paraciones globales
,111 1 ,739Log Rank (Mantel-Cox)
Chi-cuadrado gl Sig.
Prueba de igualdad de distribuciones de supervivencia para
diferentes niveles de Éxito.
Resum en del procesamiento de los casos
33 7 26 78,8%
164 38 126 76,8%
197 45 152 77,2%
Éxito
No
Si
Global
Nº total Nº de eventos Nº Porcentaje
Censurado
MACE IN THE FOLLOW UP

43. Com paraciones globales
,680 1 ,409Log Rank (Mantel-Cox)
Chi-cuadrado gl Sig.
Prueba de igualdad de distribuciones de supervivencia para
diferentes niveles de Éxito.
Resum en del procesamiento de los casos
34 4 30 88,2%
165 8 157 95,2%
199 12 187 94,0%
Éxito
No
Si
Global
Nº total Nº de eventos Nº Porcentaje
Censurado
TOTAL MORTALITY IN THE FOLLOW UP

44. Com paraciones globales
1,939 1 ,164Log Rank (Mantel-Cox)
Chi-cuadrado gl Sig.
Prueba de igualdad de distribuciones de supervivencia para
diferentes niveles de Éxito.
Resum en del procesamiento de los casos
34 3 31 91,2%
165 5 160 97,0%
199 8 191 96,0%
Éxito
No
Si
Global
Nº total Nº de eventos Nº Porcentaje
Censurado
CARDIAC MORTALITY

45. Conclusions
• The rate of success of CTO due to ISR is lower than in
native CTO with wire based techniques
• ISR CTO is mainly due to bare metal stents
• LAD ISR CTO has a greater rate of success
• LAD ISR CTO failure has a higher rate of MACE
• There is a very high rate of intraprocedural
complications and thrombosis as compared with the
hybrid approach
• There is no significant differences in terms of MACE
and mortality between both groups, although there
is a trend to a lower MACE and mortality in the
successful group