Room: Ballroom CTO in India Surya Prakasa Rao Vithala, India The Experts “Live” Workshop 2017 Saturday, September 16th, 2017

1. IJCTO & IMPACT ON CTO–
PCI IN INDIA
Dr V Suryaprakasa Rao
Head of Cardiology Apollo Hospitals
Hyderguda Hyderabad - India
Course director – IJCTO

3. • To benefit large pool of CTO patients in
India.
• To improve outcomes – short and long
term with use of improvised skills from
world and access to better devices and
stents
• To train fellows across India and Indian
Sub continent.
• To provide cost effective CTO – PCI to
low affordable groups in India.
Objectives:

4. INDIAN FOUNDER MEMBERS :
• Dr V. Surya Prakasa Rao
Apollo Hospitals, Hyderguda, Hyderabad, India.
• Dr A.V.Ganesh Kumar
L.H.Hiranandani Hospital, Mumbai, India.
• Dr P.K.Goel
SGPGI, India
• Dr Pratap Kumar.N.
Meditrina Group of Hospitals, India.
ASSOCIATE MEMBERS :
DRPLNKAPARDHI DRANILDHAL DRRAMANCHAWLA
DRTRAJESH DRDDASH DRP.KANTILALSHAH

5. HONORARY JAPANESE
MEMBERS:
DR E.TSUCHIKANE
Dr M OCHAI
DR KENYA NASU
DR MURAMATSU
DR ASAKURA
DR YAMANANE
DR Y HAMAZAKI.
VISTING EUROPEAN
FACULTY :
DR A GALASSI
DR G SIANOS
DR G WERNER

6. Situation in year
1994 - CTO PCI
Simple mid RCA CTO
Reasons being no
dedicated hardware
and skills of
interventionists
1994

7. PCI Trends in India last 20 years
No of Cath labs in
1994 = 40
 PCI including POBA and
beginning of BMS
procedure time 2 hrs.
 PCI total procedures
25000
 No complex cases
 CTO not known
No of Cath labs in
2017 = app 1000
 PCI load = 3,50,000
procedures
 CTO accounts to approx.
6% of PCI.
 IJCTO group contributed
for this development
 Retrograde trend is
growing

8. 2012-BIRTH OF
2013- MUMBAI
2014-HYDERABAD
2015- LUCKNOW
2016- KOCHI
2017- MUMBAI
CTO FOCUS IN
INDIA STARTED
WITH FIRST
DEDICATED CTO
CONFERENCE IN
INDIA

13. IJCTO Current
scenario

14. GAIA : MADE THE DIFFERENCE

18. CROSS BOSS & STING RAY

19. Attempted
Case of HTN / ACS / 2VD / Normal LV function / Attempted PCI to RCA (11/2016)

20. Attempt 2nd time (01/2017), Rt FA approach, Antegrade approach, 7F, Al1,
RCA proximal segment with multiple dissecting planes,
Wires: Fielder XT R, GAIA series, Conquest Pro, Miracle -3, Pilot series finally
ULTIMATE BROS 3 with Corsair 135 support.
Procedure Abandoned for Air Kerma > 5 Gray
Fluoro Time : 104 Mins
Contrast : 360 ml
J CTO Score: 3
ULTIMATE BROS -3

21. Attempt 3rd time (04/2017),
J CTO Score: 3
Bi femoral approach, 7F, Al1, and EBU 3.5,
RCA proximal segment multiple dissecting planes, retrogradely filling from LCS.
Retrograde approach: Corsair 150 – collateral channels – septals profiled,
Multiple CTO wires escalated finally SUOH 03 crossed via septal connection.
Antegrade approach: Corsair 135 – with Ultimate Bros 03 in sub intimal space,

22. • Reverse cart at CTO Site with 2 & 2.5 NC balloon.
• Wire position checked with rotational Angio and IVUS
• Recapture of wire into guidezilla and externalization

23. DES deployed
Good result.
Procedure Time : 124 min
Fluoro Time : 64 min
Air Kerma : 3.4 Gray
Contrast : 180 ml

24. N = 1683
Age Range : 29-78
Males : 86.47%
Females : 13.53%
IJCTO DATA
1683 CTO's – Jul 2012-June 2017

25. DISTRIBUTION
26% of Routine CAGs are CTOs
69%
20% 6%
2%
3% Old MI with Class II Anginal
Symptoms
Class II angina/Unstable Angina
Asymptomatic with Provokable
Ischemia
ACS/Ac on Ch
Acute MI with Non Culprit
Vessel CTO

26. Assessment of viability /
inducible ischemia prior to CTO
PCI:
Tread Mill Test : 3.2%
Stress Echo: 2%
Sestamibi Perfussion scan : 1.7%
CMR : 2%

27. in selective cases:
 64 - MSCT: 10.7%
to study the length, tortuosity, calcium, caliber of vessel
and collaterals.
A gap of 3 weeks is given between MSCT and PCI.

28. LAD; 42,00%
RCA; 48%
LCX; 10%
1683 CASES JUL 2012 TO JUN 2017

29. J – CTO Score
 31% - Score 0
 37% - Score 1
 24% - Score 2
 8% - Score >3

30. CTO APPROACH
Antegrade: (63%)(escalation) wire entry with support catheter/parallel wire (22%) / dissection
and re entry – wire based: ( star tech 7%/ knuckle wire(8%) / cross boss/ ( 8 cases)
Retrograde :
Kissing Wires Land(11.90%) Wire Recross(24.30%) Reverse Cart(50.70%)Knuckle Wire(5.47%)
Guidezilla / Guideliner Capture(7.46%)
Hybrid approach ( antegrade dissection and re entry / retrograde dissection and re entry / cross
boss sting ray / )
88%
12%
CTO APPROACH
Antegrade Approach
Retrograde Approach
94% Septal
Collaterals

31. ROUTE
8%
92%
ROUTE
Radial Sheathless -5

32. AMPLATZ WITH
SH
VODA,EBU,XB JUDKINS
Guidezilla/Guide
liner
CATHETER USE 48% 35% 17% 4,50%
48%
35%
17%
4,50%
CATHETER USE
CATHETER USE

33. 21%
6%
61%
1%
11%
0%
10%
20%
30%
40%
50%
60%
70%
FINECROSS TORNUS CORSAIR CARAVEL CRUSADE
MICROCATHETERS
MICROCATHETERS

34. GUIDE WIRES
1%
27%
6% 6%
14%
8%
1%
37%
0%
5%
10%
15%
20%
25%
30%
35%
40%
GWS
GWS

35. Balloons
 1 mm Saphire / 1.1 mm Acrostak/ 1.25 mm Rejuvin
plus, and Mini Trek / 1.5 and 2.00 mm Rejuvin plus,
Tazuna and Maverik,
 NC High Pressure dilatation : 2.5 mm , 3.0, 3.5, 4.0 mm
: Hiruyu, Spinter, Trek and Saphire.

36. UNCROSSABLE LESSION
 Anchor Balloon : 1.4%
 Tornus : 2%
 Rotablator : 1.6%
 Guideliner / Guidezilla : 0.9%

37. Plaque modification:
 Cutting/Scoring balloon used: 2.6%
 Rotablation: with 1.25 and 1.5 burr : 1.6%

38. Stents:
 All pts received DES : 2819 stents deployed
 18-28 mm :1190/28-38 mm:1210/38-48 mm: 419.
 Overlapping stenting done in 410 cases.
 Deployed at Nominal atm:10 and High Pressure
dilatation 18 to 24 atm
 EES – 68%
 PES – 14%
 SES- 8%
 BVS- 0.6%
 ZES: 9.4%

39. PROCEDURE CHARACTERISTICS
• Fluro Time - varies : 54 - 128 Min
• Volume of Contrast varies : 170 -380 ML
• Procedure Time varies : 85 -262 Min
• Success Rate : 89.9%

40. Complications
 2.9%
 11 septal hematoma
 4 case of them had hemodynamic compromise – RV outflow
obstruction.
 7 cases of donor artery thrombosis – managed with stenting and
thrombosuction.
 5 case of LM ( donor artery ) dissection – needed bailout stenting.
 3 case of Intra cavity – type IV perforation – managed
conservatively.
 3 case coronary perforation – needing covered stent.
 4 case of cardiac tamponade – pericardiocentesis done.
 2 case having diagonal closure needed IABP support.
 No case required emergency CABGs / no in hospital mortality /
 Contrast nephropathy – not leading to dialysis – 9 cases.

41. IVUS : 42% OF CASES (Volcano eagle
eye gold and eagle eye platinum 5F)
 FOR THE PROXIMAL CAP PUNTURE
 BALLOON SIZING IN REVERSE CART
 VESSEL DIAMETER
 STENT APPOSITION
 DISSECTION

42. Follow up: 3 days /30 days/ 90 days /180 days/ 1 year / >
5 years.
 Clinical questionnaire - all cases on follow up
 ECG on all cases of follow up
 2 D Echo – all cases on follow up
 Tread Mill Test – 6months and yearly
 MSCT – in selected cases.
 Perfusion scan in selected cases
 Coronary Angiography – in symptomatic and inducible ischemia pts:
12.8%
 Lost follow up: 136pts

43. Follow Up
 Quality of life : Improved in 84% ( by clinical questionnaire)
 Angina Relief : More than 90%
 SAT: 0
 Improvement of LV function(11%) Seen more in LAD CTO
 ISR : 12%
 DEB 1.36% (Paclitaxal / Sirolimus)
 TVR Redo PCI 59.7% / CABGs 27.8%
 MI – enzymatic MI - rise noted in 14%( two fold increase in
CPK MB ) in hospital.
 SCD :5 On Follow up
 Death – 21 ( non cardiac )

44. Medication:
 DAPT: (>>>Clopidogrel />> Prasugrel / >Ticagrelor) +
Entric coated Aspirin : 1 year
 Subsequently – Enteric coated Aspirin
 Through out Statins: Atorvastatin 40mg and Rosuvastatin
40mg (monitored liver function and muscle enzymes)

45. Future:
 To Structure Current CTO registry in the Indian continent and
expand network by increasing permanent members of IJCTO.
 R&D for cost effective CTO devices so More Patients can avail
the CTO PCI.
 Slender systems to decrease vascular problems.
 To Bring down Radiation hazards for Physician and Patients
 Collaboration of IJCTO with major CTO bodies around Globe.

46. Partners

47.  6th Live summit of
IJCTO 2018
 Dates: 1st, 2nd & 3rd
June 2018
 Venue: Hyderabad,
India
Save your
dates

49. CACTO 2006 facts
• 1st live workshop @ Hyderabad
dedicated to complex cases
• More than 400 delegates
attended two day program
• 6 live transmission cases
• Didactive Lectures of CTO PCI
approach
• Course Directors of CACTO
Dr Suryaprakasa Rao
Dr PLN Kapardhi
CACTO (Complex Angioplasty and Chronic Total Occlusion) a charitable trust is started by
like minded Cardiologists from Hyderabad with a thought and vision for Discussing,
Exchanging and Sharing the experiences and also to Improve the skills in Interventional field
and manyCACTO started its program in the year of 2006
and the Live workshops were coordinated by Dr.S.Saito Dr.M.Ochia, Dr.E.Kyo, Dr.
M.Yammane, Dr.Kenya Nasu all from Japan

50. SAACI 2009 - Trivandrum
SACCI - First Dedicated complex coronary intervention meeting in Kerala started in Apr 2009 with 23
international faculty like Dr Asakura(Japan), Dr Y Louvard(France) Dr Imad Sheban(Italy),
Dr J Scanned (spain) Dr T Ischinger(germany)....etc along with Many Indian Faculty. Live case transmissions
and Focused Lectures.

51. CACTO 2009 facts
• 2ndt live workshop @
Hyderabad dedicated
to complex cases
• More than 400
delegates attended
two day program
• 8 live transmission
cases
• Focused talk on
Retrograde techniques
Image guided PCI
• Course Directors of
CACTO
Dr Suryaprakasa
Rao
Dr PLN Kapardhi

52. CACTO 2012 facts
• 3rd live workshop @ Taj Vivanta,
Hyderabad
• More than 500 delegates attended two
day program
• 12 live transmission cases
• Lectures of CTO PCI approach
• Both Trans Radial and femoral PCI cases
of CTO done.
• Course Directors of CACTO
Dr Suryaprakasa Rao
Dr PLN Kapardhi
Dr. M.Yamane
Dr.E.Tuschikane
Dr.A.Gallasi.
Dr.Kenya Nasu.
Live cases Tx from
Toyohashi Heart Centre, Japan and
C3,Orlando, USA

53. 1st live summit of IJCTO Mumbai, 2013
• 1st Live Congress @ Renaissance Mumbai Convention
Centre Hotel
• More than 600 delegates attended two day program
• 14 live transmission cases
• Peripheral CTO and BVS in CTO demonstrated.
• Sting Ray and Crossboss Live from USA.
• Didactive Lectures of CTO PCI approach
• Course Directors
• Dr M.Yamane
• Dr Muramatsu
• Dr E.Tsuchikane
• Dr. Y.Asakura.
• Dr Kenya Nasu
• Dr Y.Oikawa
• Dr Suryaprakasa Rao
• Dr Prahtap Kumar
• Dr Ganesh Kumar
• Dr PLN Kapardhi
• Dr Abhaichand Rajpal
• Dr.Raman Chawala
• Dr.Anil Dhal.

54. 2nd live summit of IJCTO
Hyderabad,2014.
• 2nd live workshop @ Novotel, HICC, Hyderabad
• More than 620 delegates attended three day program
• 14 live transmission cases
• Fellows Course, Simulators from Ashahi- Etos , Teurmo - TRI and
Crossroads village from Abbott, Peripheral CTO sessions, CD presentations
• Lectures of CTO PCI approach
• Course Directors:
• Dr M.Yamane
• Dr Muramatsu
• Dr E.Tsuchikane
• Dr. Y.Asakura.
• Dr Kenya Nasu
• Dr Y.Oikawa
• Dr. George Sainos
• Dr. Imad Sheiban
• Dr. Van Der Schaff
• Dr. Ashish Pershad
• Dr Suryaprakasa Rao
• Dr Prahtap Kumar
• Dr Ganesh Kumar
• Dr PLN Kapardhi
• Dr Abhaichand Rajpal
• Dr.Raman Chawala
• Dr.Anil Dhal.
• Dr P.K.Ashokan

55. 3rd live summit of IJCTO
Lucknow,2015
• 3rd live workshop @ Lucknow
• More than 680 delegates attended two day
program
• 14 live transmission cases
• Fellows Course, Simulators from Ashahi-
Etos , Teurmo - TRI and Crossroads village
from Abbott, Peripheral CTO sessions, CD
presentations
• Lectures of CTO PCI approach
• Course Directors:
• Dr M.Yamane
• Dr Muramatsu
• Dr E.Tsuchikane
• Dr. Y.Asakura.
• Dr Kenya Nasu
• Dr Y.Oikawa
• Dr. George Sainos
• Dr. G. Werner.
• Dr. E. Lombardi
• Dr Suryaprakasa Rao
• Dr Prahtap Kumar
• Dr Ganesh Kumar

56. CTO club 2015

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