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

1. In Stent CTO PCI
Jarosław Wójcik
Dept of Cardiology
Medical University of Lublin / Poland

2. R. Mehran

3. • Prevalence
• Pathophysiology
• Angiographic apperance
• Treatment Algorithm

4. PREVALENCE
1. Christopoulos G, Karmpaliotis D, Alaswad K, et al. The efficacy of
“hybrid” percutaneous coronary intervention in chronic total occlusions
caused by in-stent restenosis: insights from a US multicenter
registry. Catheter Cardiovasc Interv. 2014;84:646–51. 10,9%
2. Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’Neill
WW. Success, safety, and mechanisms of failure of percutaneous
coronary intervention for occlusive non-drug-eluting in-stent restenosis
versus native artery total occlusion. Am J Cardiol. 2005;95:1462–6. 25%
3. Werner GS, Moehlis H, Tischer K. Management of total restenotic
occlusions. EuroIntervention. 2009;5 Suppl D:D79–83. 5-10%
4. Wilson WM, Walsh S, Hanratty C, et al. A novel approach to the
management of occlusive in-stent restenosis (ISR). EuroIntervention.
2014;9:1285–93. 14,9%

5. PREVALENCE
5 - 25%

6. 0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
2008 2009 2010 2011 2012 2013 2014 2015 2016 All
1264
1619
2029
2389 2369
2660 2475 2374
1549
18728
39 105 156 225 199 247 219 191 114
1495
In stent CTO (count)
de novo CTO
in stent CTO
PREVALENCE
7,39%

7. siology
In-Stent CTOIn-Stent CTO
In-stent restenosis - ISR
Stent thrombosis - ST
The Proportion ?

8. PATHOPHYSIOLOGY
STENT RECOIL, UNDERDEPLOYMENT,
FRACTURE 
smooth muscle cells ingrowth (neointima
proliferation)

10. Christopoulos et al.
DM: 56,1% vs 39,6% (in-stent CTO vs de
novo CTO (p=0,02)
Occlusion length: 35mm vs 30 mm
(p=0,04)
Christopoulos G, Karmpaliotis D, Alaswad K, et al. The efficacy of
“hybrid” percutaneous coronary intervention in chronic total occlusions
caused by in-stent restenosis: insights from a US multicenter
registry. Catheter Cardiovasc Interv. 2014;84:646–51.

11. - Less calcifications
- Composed of a hypocellular matrix
made up of hard and resistant
collagenous material – relative
absense of microchannels
- Less calcifications
- Composed of a hypocellular matrix
made up of hard and resistant
collagenous material – relative
absense of microchannels

12. Different angio appereance depending
on the restenosis or thrombotic
phenomenon and time of occlusion
Different angio appereance depending
on the restenosis or thrombotic
phenomenon and time of occlusion
Angiographic Appereance

13. Restenosis - Proximal cap tends to be more frequently tapered

14. Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’Neill
WW. Success, safety, and mechanisms of failure of percutaneous
coronary intervention for occlusive non-drug-eluting in-stent
restenosis versus native artery total occlusion.
Am J Cardiol. 2005;95:1462–6
„ in-stent occlusions are more frequently blunt at the
proximal cap compared with de novo CTOs ”
Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’Neill
WW. Success, safety, and mechanisms of failure of percutaneous
coronary intervention for occlusive non-drug-eluting in-stent
restenosis versus native artery total occlusion.
Am J Cardiol. 2005;95:1462–6
„ in-stent occlusions are more frequently blunt at the
proximal cap compared with de novo CTOs ”

15. Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’Neill
WW.Am J Cardiol. 2005;95:1462–6. 63%
Werner GS, Moehlis H, Tischer K. EuroIntervention. 2009;5 Suppl
D:D79–83. 70 vs 85% (ISR vs de novo CTOs)
Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’Neill
WW.Am J Cardiol. 2005;95:1462–6. 63%
Werner GS, Moehlis H, Tischer K. EuroIntervention. 2009;5 Suppl
D:D79–83. 70 vs 85% (ISR vs de novo CTOs)
Treatment Algorithm
- The Succes Rate

16. 87,81%
0
200
400
600
800
1000
1200
1400
2008 2009 2010 2011 2012 2013 2014 2015 2016 All
35
91
136
187 175
213 200
169
106
1312
4
14 20
38
24 33 19 22
8
182
Successful
Not successful
Operation success (in stent CTO)

17. Failure:
 the inability to cross the lesion with a
guidewire
 sub-stent wire tracking
 stent-fractures, undersized stents,
deformed &malapposed stents
Failure:
 the inability to cross the lesion with a
guidewire
 sub-stent wire tracking
 stent-fractures, undersized stents,
deformed &malapposed stents
Treatment Algorithm

18. The efficacy of “hybrid” percutaneous coronary
intervention in chronic total occlusions caused by in-
stent restenosis: insights from a US multicenter
registry
Georgios Christopoulos et al, Catheter Cardiovasc Interv. 2014 1;
84(4): 646–651. doi:10.1002/ccd.25465.

19. Antegrade wire escalation:
 Soft tip tapered polymer-jacketed
(Fielder XT)
 Stiffer polymer jacked Pilot 200
 Hard tip wires Miracle 12
 Confianza Pro 12
 Gaia Family (3rd)
Antegrade wire escalation:
 Soft tip tapered polymer-jacketed
(Fielder XT)
 Stiffer polymer jacked Pilot 200
 Hard tip wires Miracle 12
 Confianza Pro 12
 Gaia Family (3rd)

20. Knuckled wires - avoided as a first
strategy: can track under the stent struts
or in the subintimal sub-stent space
Knuckled wires - avoided as a first
strategy: can track under the stent struts
or in the subintimal sub-stent space

21. EuroIntervention 2014;9:1285-1293
A novel approach to the management of occlusive in-stent restenosis (ISR)

22. CrossBoss alone:
 Papayannins et al. 83%
 Wilson et al. 90%
 Christopoulos et al. 89,4%
CrossBoss alone:
 Papayannins et al. 83%
 Wilson et al. 90%
 Christopoulos et al. 89,4%

23. Conclusions:
 IS CTOs carry their own predictors of
success and mechanism of failure that differ
from de novo CTOs. PCI of IS CTO is (was?)
traditionally associated with lower success
rate
 The hybrid strategy, especially including the
CrossBoss catheter seems to be associated
with similarly high procedural success and
low major complication rates as for pts with
de novo CTOs.
Conclusions:
 IS CTOs carry their own predictors of
success and mechanism of failure that differ
from de novo CTOs. PCI of IS CTO is (was?)
traditionally associated with lower success
rate
 The hybrid strategy, especially including the
CrossBoss catheter seems to be associated
with similarly high procedural success and
low major complication rates as for pts with
de novo CTOs.
44

24. • Female 67 yo.
• CCS II / III
• PCI RCA / 2x BMS in 1998
• Angio in 2011 – total in stent occlusion
• 2011 & 2012 – unseccsesful attempts of antegrade
recanalization
• EF 50%
• SPECT +
• Risk factors: HT, DM (oral)

33. BVS implantation
1 st - 3.0/28 mm
2nd - 3.0/28
3rd - 3.5/28

34. The final shot

36. 8 months f-up:
Patient – is very happy, CCS I
Doctor – is very happy, too

37. CONCLUSIONS:
• Retrograde approach for in-stent CTO could
be succsesfull option
• Implantation of BVS in such clinical setting is
very promising solution, we need the long
term angio f-up