CTO definitions: Do we need a new consensus? Gerald S. Werner, Darmstadt, Germany 10th Experts „Live“ CTO Workshop - Day1

1. Do we need new definitions for CTO PCI
Or should we revisit what terms we use
Gerald S. Werner, MD, FESC, FACC, FSCAI
Klinikum Darmstadt GmbH
Darmstadt
gerald.werner@mail.klinikum-darmstadt.de

2. Do we need new definitions for CTO PCI
Or should we revisit what terms we use
Gerald S. Werner, MD, FESC, FACC, FSCAI
Klinikum Darmstadt GmbH
Darmstadt
gerald.werner@mail.klinikum-darmstadt.de

3. Conflict of interest statement
• I, Gerald S. Werner, MD, have no financial
relation to disclose regarding the following
presentation

4. Do we talk the same language in CTO PCI ?
The need for consensus on definitions
• What is a CTO ?
• Which patient benefits from CTO PCI ?
• Ambiguity is an ambiguous term !
• Which technique do we apply ?
• What is a successful CTO PCI ?

5. Do we talk the same language in CTO PCI ?
The need for consensus on definitions
• What is a CTO ?
• Which patient benefits from CTO PCI ?
• Ambiguity is an ambiguous term !
• Which technique do we apply ?
• What is a successful CTO PCI ? Will be discussed by Tony

6. Just one comment
• In a recent study from UK (CONSISTENT) a
repeat intervention within 3 months of the
initial attempt was not considered an event
• This is going beyond a consensus on what is a
procedural success and what is not.
• We should be clear, that a procedure consists
of one date with the patient
• Anything else is a second attempt, which is
not bad in itself

7. Do we talk the same language in CTO PCI ?
The need for consensus on definitions
• What is a CTO ?
• Which patient benefits from CTO PCI ?
• Ambiguity is an ambiguous term !
• Which technique do we apply ?

8. What is a CTO ?
• A complete occlusion of a coronary vessel with
no flow through the occluded segment (TIMI 0)
• ... and an occlusiuon duration of >3 months

9. Do we talk the same language in CTO PCI ?
The need for consensus on definitions
• What is a CTO ?
• Which patient benefits from CTO PCI ?
• Ambiguity is an ambiguous term !
• Which technique do we apply ?

10. Who will benefit ?
 No prior MI
– Evidence of ischemia and/or symptoms
 Prior MI
– Evidence of viability
 In MVD with CTO
– Staged procedure with goal of complete
revascularization

11. 0
10
20
30
40
50
60
70
80
90
100
OMT PCI
Physical
limitation
Anginal
frequency
Anginal
stability
Treatment
satisfaction
Quality of
life
Primary Endpoint: SAQ health status (ITT)
For multiple testing the significance level is 0.01
BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU
P=0.02
P=0.003
P=0.007
P=0.89
P=0.47
Eur Heart J 2018

12. Do we talk the same language in CTO PCI ?
The need for consensus on definitions
• What is a CTO ?
• Which patient benefits from CTO PCI ?
• Ambiguity is an ambiguous term !
• Which technique do we apply ?

13. A B
D E F
C
Figure 12 from EAPCI Textbook on Cardiovascular Intervention; Part III 3.13: CTO 2018 version
What is an ambiguous cap ?
Blunt tapered Tapered
Tapered
No cap, side branches Side branch, notch
No cap, side branch

14. Ambiguity can be resolved by imaging modalities
• Proximal cap at a side branch take-off
– IVUS assessment from the side branch
– MSCT as a preplanning option

15. LAD CTO: Where is the proximal cap ?

16. LAD CTO: Where is the proximal cap ?
• An occluded vessel ostium
is a solid structure
• There is a considerable
step-up in vessel size

17. LAD CTO: Where is the proximal cap ?

18. LAD CTO: Where is the proximal cap ?

19. Do we talk the same language in CTO PCI ? The need
for consensus on definitions
• What is a CTO ?
• Which patient benefits from CTO PCI ?
• Ambiguity is an ambiguous term !
• Which technique do we apply ?

20. Strategic options for recanalization of a CTO
Bilateral
Maximal Guide
backup
Antegrade
Fielder XT -> Gaia 2
or -> Progress
200T/Conf.Pro 12
Penetration, then
step down
Distal good target
Parallel with stiff
wire
Reentrysystem
BridgePoint
Antegrade
no Stump
IVUS for guided
Penetration ?
Retrograde
With feasible collateral
pathways

21. A misconseption about parallel wire approach
• Citation from a UK hybridologist: “My way of
parallel wiring is to take a second, stronger
wire to replace the first”
• This is misunderstanding the change of game
by the presence of the first wire

22. Parallel wiring still a valid and quick option
Gaia 2 in parallel

23. Why parallel wiring works well in the RCA:
the wire straightens the vessel architecture

24. Why parallel wiring works well in the RCA:
the wire straightens the vessel architecture

25. Strategic options for recanalization of a CTO
Bilateral
Maximal Guide
backup
Antegrade
Fielder XT -> Gaia 2
or -> Progress
200T/Conf.Pro 12
Penetration, then
step down
Distal good target
Parallel with stiff
wire
Reentrysystem
BridgePoint
Antegrade
no Stump
IVUS for guided
Penetration ?
Retrograde
With feasible collateral
pathways

26. Copyright © The American College of Cardiology.
All rights reserved.
From: Fundamental Wire Technique and Current Standard Strategy of Percutaneous Intervention for Chronic
Total Occlusion With Histopathological Insights
J Am Coll Cardiol Intv. 2011;4(9):941-951. doi:10.1016/j.jcin.2011.06.011
What is CART and what is RDR ?
• If we connect the antegrade and
retrograde wires within the
occlusive plaque, there is a high
likelihood of staying intimal
• Separation within the plaque
between wires is not
constituting a subintimal
position
Reverse CART = Controlled
Antegrade and Retrograde
Tracking

27. IVUS detection of subintimal wire positionIVUS Image
Intimal vs. Sub-Intimal Tracking
a = IVUS catheter , b = the intimal-medial layer, c = the occluded true lumen,
d = false lumen in the adventitia
Intimal Tracking Sub-intimal Tracking

28. Results
Acute IVUS classification
CTO Cases
Antegrade
( 59 )
Retrograde
( 104 )
Intimal
Tracking
87.7%(50)
Intimal
Tracking
75.3%(73)
Sub-Intimal
Tracking
12.3%(7)
Sub-Intimal
Tracking
24.7%(24)
P= P=p=0.10
Analysis impossible: 2 Analysis impossible: 7
87.7%
12%
75%
25%
0%
20%
40%
60%
80%
100%
Intimal Tracking Subintimal Tracking
Antegrade
Retrogarade
P=0.10
P=0.16

29. The hybrid approach
The big misunderstanding of definitions
The Hybrid Algorithm for CTO PCI
provisional approaches
Dual Catheter Angiography
1. Clear proximal cap
2. Good Distal Target
3. Length < 20mm
Antegrade Retrograde
yes no
Wire
escalation
Dissection Reentry
(crossboss-stingray)
Wire
escalation
Dissection Reentry
(reverse CART)
yes yes nono
Dissection Reentry
(reverse CART)
Dissection Reentry
(crossboss-stingray)
fail
fail
fail
fail

30. Higher rate of subintimal tracking in US !
Song L, Maehara A et al. JACC Int 2017; 10:1011

31. The CART Terminology

32. The hybrid approach
Do not use the term CART when you do RDR
The Hybrid Algorithm for CTO PCI
provisional approaches
Dual Catheter Angiography
1. Clear proximal cap
2. Good Distal Target
3. Length < 20mm
Antegrade Retrograde
yes no
Wire
escalation
Dissection Reentry
(crossboss-stingray)
Wire
escalation
Dissection Reentry
(reverse CART)
yes yes nono
Dissection Reentry
(reverse CART)
Dissection Reentry
(crossboss-stingray)
fail
fail
fail
fail

33. Do we need new definitions ?
• The terminology we have is pretty clear and
defined
• The problem is more that terms are misused
and mixed-up
• One of the most obvious misunderstandings
are related to the description and application
of the retrograde approach