Experts "Live" CTO Workshop 2014 26th Septemper 2014 in Madrid, Spain

1. David Antoniucci, MD
Madrid, September 25, 2014
Stenting in CTO

2. Disclosure Statement of Financial Interest
I, David Antoniucci, DO NOT have a
financial interest/arrangement or
affiliation with one or more organizations
that could be perceived as a real or
apparent conflict of interest in the
context of the subject of this
presentation.

3.  Large registries have shown a survival
benefit in patients with successful CTO PCI.
 Intuitively, sustained vessel patency may be
considered as a main variable related to long-
term survival and stent performance plays a
key role in this setting.
 Very few data exist about the angiographic
outcome after successful CTO PCI.

4. Danzi GB et al, Am J Cardiol 2013

5. Florence CTO Registry
Angiographic Outcome
 Design: Prospective
single-center registry of
CTO- PCI treated with DES.
 End points: Angiographic
outcome. Predictors of
reocclusion
 Methods: Forward
stepwise Logistic
Regression Analysis.
Freedom from MACE
assessed by Kaplan-Meier
estimation.
 Successful CTO-PCI
n=802 (77%)
233 Fail CTO-PCI
 6-9 months Angio FU (82%)
n=616
29 Deaths
20 Renal Insufficiency
From 2003 to 2011
1035 pts underwent CTO-PCI
Valenti R et al, JACC 2013;61:545

6. n=802
 Age (yrs) 68 ± 11
> 75 years, n (%) 233 (29)
 Male, n (%) 680 (85)
 Hypertension, n(%) 485 (60)
 Hypercholesterolemia, n (%) 458 (57)
 Diabetes mellitus, n (%) 200 (25)
 Previous myocardial infarction, n (%) 405 (50)
 Previous PCI, n (%) 289 (36)
 Previous coronary surgery, n (%) 91 (11)
 ACS, n (%) 55 (32)
 LVEF, (%) 44 ± 12
LVEF < 40 %, n (%) 298 (37)
Baseline Characteristics
in Successful CTO PCI Patients
Valenti R et al, JACC 2013;61:545

7. n=802
 Multivessel disease, n (%) 660 (82)
 3-vessel disease, n (%) 393 (49)
 CTO vessel, n (%)
LAD 248 (31)
LCx 177 (22)
RCA 329 (41)
Others 48 (6)
 Occlusion length, mm 38 ± 21
 Lenght > 20 mm, n (%) 597 (74)
 Reference CTO vessel diameter, mm 2.63 ± 0.53
 Ref. Diameter ≤ 2.5 mm, (%) 190 (24)
Angiographic Characteristics
Valenti R et al, JACC 2013;61:545

8. n=802
 Adjunctive Rotactional atherectomy, n (%) 37 (4.6)
 STAR technique, n (%) 34 (4.2)
 CTO stent implanted, n 1509
Mean stents / patient 1.88
 First generation DES (PES and SES) 66%
 EES 34%
 CTO stent length, mm 52 ± 30
 Post-PCI minimum lesion diameter, mm 2.74 ± 0.49
 Fluoroscopic time, min Median [IQ range] 24 [15 – 36]
 Contrast, ml Median [IQ range] 300 [200 – 400]
 Multivessel PCI, n (%) 540 (67)
 Completeness of revascularization, n (%) 675 (84)
Procedural Characteristics
Valenti R et al, JACC 2013;61:545

9. 6-9 months Angiographic Outcome
20
12.5
7.5
0
5
10
15
20
25
Rest/Reoccl NonOcclusive Rest Reocclusion
CTO Reocclusion
1st generation DES 10%
EES 3%
STAR 57%
%
p=0.001
CTO Rest./Reoccl.
1st generation DES 25%
EES 13%
STAR 64%
F-U rate 82%
Valenti R et al, JACC 2013;61:545

10. Predictors of Angiographic Outcome
Logistic Regression Analysis
Reocclusion OR 95% CI p value
 STAR technique 29.5 11.9-73.2 < 0.001
 EES 0.22 0.09-0.54 0.001
Nonocclusive Restenosis
 RCA-CTO 1.64 1.02-2.62 0.040
Valenti R et al, JACC 2013;61:545

14. Conclusions
 The use of EES is associated with a 5-fold
decrease in CTO vessel reocclusion rate as
compared to 1st generation sirolimus-eluting stent
and paclitaxel-eluting stent.
The use of the STAR technique, even successful, is
associated with a very high rate of target vessel
reocclusion.
 The use of EES and conventional antegrade or
retrograde approaches to CTO are associated with a
very high sustained patency rate that links with
prognosis.

15. One-year Clinical Outcome
3.2
0.9
0
12.8
16
0.4
0
2
4
6
8
10
12
14
16
18
Death MI CABG CTO re-
PCI
MACE Def. ST
CTO vessel re-PCI
1st generation DES 14.1%
EES 10.5%
STAR 32%
%
MACE
1st generation DES 19%
EES 11.6% p=0.005
Valenti R et al, JACC 2013;61:545

16. Predictors of Clinical Outcome
Multivariate Cox Regression Analysis
Cardiac Death HR CI p value
 Age >75 yrs 4.64 2.19-9.83 < 0.001
 LVEF < 40% 7.25 2.77-19 <0.001
 LAD-CTO 2.39 1.13-4.33 0.020
 Complete Rev. 0.48 0.24-0.95 0.037
MACE
 Age >75 yrs 1.64 1.17-2.31 0.004
 STAR technique 2.26 1.21-4.22 0.010
 LVEF < 40% 1.47 1.06-2.06 0.023
 LAD-CTO 1.42 1.02-2.01 0.046
Valenti R et al, JACC 2013;61:545

17. 60 12 362418 30
1
0.9
0.8
0.7
0.6
0.5
0.4
Time (months)
Event–FreeSurvival
77 ± 2%
55 ± 14%
nonSTAR
STAR
p = 0.014
Kaplan-Meier Analysis
of Freedom from MACE
Valenti R et al, JACC 2013;61:545