8th Experts Live CTO Workshop 2016, September, 30th - October 1st, 2016 in Krakow, Poland

1. CTO PCI in Post-CABG Patients
Dimitri Karmpaliotis, MD, PhD, FACC
Assistant Professor of Medicine
Columbia University Medical Center
Director of CTO, Complex and High Risk Angioplasty
CIVT/NYPH
Email: dk2787@columbia.edu
EURO CTO
Krakow, Poland, September 30-Oct 1, 2016

2. Disclosures
• As a faculty member for this program,
I disclose the following relationships
with industry:
• Speakers Bureau for Abbott Vascular,
MDT vascular, ASAHI Intel and Boston
Scientific

3. CTO PCI in post CABG Patients
• Despite declining rates of overall re-vascularization in
the U.S, more than 100,00 CABG operations are
performed every year
• 10,000 re-do CABG/year
• Hundreds of thousands of patients with
occluded/degenerated grafts and symptoms/ischemia
are under-treated
• CTO PCI is more technically challenging in post-
CABG patients
• Diffuse disease/Calcified vessels
• Progression of native vessel disease
• Distortion of anatomy due to vessel “tenting”

4. CABG
n=266
Not Bypassed
n=81
ITT, Per Lesion
Bypassed
n=173
CABG
n=254
12 were not treated with CABG
Overall 68.1 % of TO were
successfully bypassed
49.6% overall complete
revascularization in CTO subset
SYNTAX CTO Subset Procedural
Characteristics: Per Lesion Analysis
Serruys P, CRT 2009 [modified]; courtesy Prof Serruys and the SYNTAX investigators
• 26.2% patients with CTO
• CTO accounted for 266
lesions (7.4%)
Reason not bypassed:
Not intended to treat (n=12)
Diseased (n=11)
Inadequate conduit (n=2)
Too small (n=19)
Unable to find (n=1)
Other (n=36)

5. New CTOs After CABG Surgery
338 patients with 1 yr angio in Radial Artery Patency Study (RAPS)
Pereg et al, JACC CV Intv 2014
169 pts (43.6%)
had at least 1 new
native CTO
CTOs were almost
5X more likely to
occur in vessel with
pre CABG visual
stenosis >90% and
bypassed by SVG
or radial graft

6. Drug-Eluting vs. Bare-Metal Stents in
Saphenous Vein Graft (SVG) Lesions
Conclusion: In high-risk SVG lesions, DES cut TLR rates almost in half,
leading to an overall decrease in late outcomes.
ISAR-CABG: Randomized, superiority trial in 610 pts.
Mehilli J, et al. Lancet.
2011. Epub ahead of print.
DES reduced angiographic restenosis at 7 months (15% vs. 29%; P < 0.0001).

7. Author Year
N (CTO
lesions)
Prior
CABG Diabetes Retrograde
Technical
Success
Major
complicati
ons Death
Tampon
ade
Fluoroscopy
time
(minutes)
Contrast use,
(ml)
Rathore 2009 904 12.6 40.0 17 87.5 1.9 0.6 0.6 NR NR
Morino 2010 528 9.6 43.3 26 86.6 NR 0.4 0.4 45
(1-301)*
293
(53-1,097)*
Galassi 2011 1983 14.6 28.8 14 82.9 1.8 0.3 0.5 42.3±47.4 313 ±184
U.S
Registry*
2013 1361 37.0 40.0 34
85.5
1.8
0.22 0.6 42±29 294 ±158
* Median (range)
Summary of Large Contemporary Registry Publications of
Percutaneous Coronary Interventions of Chronic Total Occlusions
* Tesfaldet, Karmpaliotis, Brilakis, Lembo,
Lombardi, Kandzari. Am J Cardiol 2013

8. Author Year n
Prior
CABG
(%)
Septal
collaterals
used (%)
Reverse
CART
(%)
Technical
Success
(%)
Major
complications
(%)
Fluoroscopy
time, min
Contrast
use, mL
Sianos 2008 175 10.9 79.4 NR 83.4 4.6 59 ± 29 421 ± 167
Rathore 2009 157 17.8 67.5 NR 84.7 4.5 NR NR
Kimura 2009 224 17.6 79 14 92.4 1.8 73 ± 42 457 ± 199
Tsuchikane 2010 93 10.8 82.8 60.9 98.9 0 60 ± 26 256 ± 169
Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR*
Karmpaliotis* 2012 462 50.0 71 41 81.4 2.6
61 ± 40 345 ± 177
Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari:
JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.
Retrograde Coronary Chronic Total Occlusion Revascularization:
Procedural and In-Hospital Procedural Outcomes from a Multicenter
Registry in the United States

9. Study
Retrograde PCI,
n (%)
Primary
Retrograde, %*
Previous Failed
CTO PCI in
Retrograde
Group, %
Overall
Technical
Success in
Retrograde
Group, %†
MACE in
Retrograde
Group, %†
Kimura et al22 224 100 65 92 1.8
Galassi et al23 234 (12) 76 U 65 3.0
Karmpaliotis et
al12
462 (34) 46 18 81 2.6
Yamane et al24 378 (25) 75 32 84 0.5
Tsuchikane et
al25
801 (27) 67 29 85 1.6
Galassi et al7 1582 (16) 76 43 75 0.8
Karmpaliotis, et
al
539 (41) 46 21 85 4.3
Circ Cardiovasc Interv. 2016;9:

10. Author Year
N
(CTO
lesions)
Prior
CABG,
(%)
Prior
CABG in
successful
PCI group
(%)
Prior
CABG in
unsuccessf
ul PCI
group (%)
Overall,
retrograde
(%)
Overall,
technical
Success
(%)
Overall,
major
comp-
lications
(%)
Overall,
fluoroscopy
time, min
Overall, contrast
use,
ml
Olivari 2003 376 5.0 4.5 6.9 NR 77.2 5.1 NR NR
Rathore 2009 904 12.6 11.9 17.7 17 87.5 1.9 NR NR
Morino 2010 528 9.6 NR NR 26 86.6 NR 45 (1-301)* 293 (53-1,097)‡
Mehran 2011 1791 15.9 13.6 20.9 NR 68.0 NR NR 448±229
Galassi 2011 1983 14.6 NR NR 14 82.9 1.8 42.3±47.4 313 ±184
Jones 2012 836 10.2 16.5 7.4 NR 69.6 2.3 NR NR
U.S
Registry*
2012 1363 37.0 35.0 50.8 34
85.5
1.8
42±29 294 ±158
Summary of Large Contemporary CTO PCI Registry Publications that
Reported Outcomes for the Subgroup of Patients with Prior CABG
* Tesfaldet, Karmpaliotis, Brilakis, Lembo,
Lombardi, Kandzari. Am J Cardiol 2013

11. 87.2
93.7
78.1
90.0
70
80
90
100
2006-2011 2012-2013
%
No prior CABG
Prior CABG
Pre “Hybrid” era
Michael, Karmpaliotis, Brilakis, Lombardi,
Kandzari et al. Heart 2013;99:1515-8
Δ=9.1%
P<0.001
Christopoulos, Menon, Karmpaliotis, Alaswad, Lombardi,
Grantham, Brilakis et al, AJC 2014;113-1990-4
CTO PCI: success and prior CABG
N= 1,363
3 US sites
Prior CABG: 37%
Complications: 1.5% vs. 2.1%
Retrograde: 27.1% vs. 46.7%
Δ=3.7%
P=0.092
“Hybrid” era
N= 630
6 US sites
Prior CABG: 37%
Complications: 2.5% vs. 0.8%
Retrograde: 34% vs. 39%

12. N= 21 - 4 US centers/14% OF RETROGRADE CASES)
The most common re-entry technique was rCART.
Technical success: 86%
Procedural success: 81%
Retrograde failure due to inability to wire the SVG or collaterals
Major complications: 2 patients (periprocedural MI, tamponade resulting in death)
Nguyen-Trong PKJ, Alaswad K, Karmpaliotis D, Lombardi W, Grantham J, Lembo N, Kandzari D, Karatasakis
A, Rangan B, Ayers CR, Thompson C, Banerjee S, Brilakis ES. J Invasive Cardiol. 2016 Jun;28:218-24
Native CTO PCI through retrograde SVG
PROspective Global REgiStry for the Study of CTO interventions

13. Case 1

23. Case 2

30. Case 3

36. Case 4

44. CTO PCI in post CABG Patients:
Conclusions
• Despite declining rates of overall re-vascularization in
the U.S, more than 100,00 CABG operations are
performed every year
• 10,000 re-do CABG/year
• Hundreds of thousands of patients with
occluded/degenerated grafts and symptoms/ischemia
are under-treated
• Re-Do CABG especially with patent LIMA is ill advised
• Great opportunity exists to benefit public health by
expanding CTO revascularization

47. Thank You

48. Thank You