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Kambis Masheyekhi: Optimal planning of CTO-PCI
- 1. Optimal planning of CTO-PCI Kambis Mashayekhi Heart Center Lahr
- 2. Affiliation/Financial Relationship • Consulting Fees/Honoraria Company • Abboth, Abiomed, Ashai Intecc, Astra Zeneca, Biotronik, Boston, Cardinal Health, Daiichi Sankyo, Medtronic, Schockwave, SIS, Teleflex,Terumo, Disclosures Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
- 4. 1. Indication 2. Communication 3. Angiogram 4. CTA 5. Radiation 6. Complexity 7. Strategy Optimal planning of CTO-PCI
- 5. What is our therapeutic goal in CTOs? Reduce ischemic burden: Improve prognosis Improve symptoms 1 Indication: Did I understand the indication?
- 6. 10years Outcomes: OMT vs. CTO PCI Clinical Outcomes in the Propensity Score–Matched Population (78.9% MVD) Park TK et al. J Am Heart Assoc. 2021 Mar
- 7. • Discuss alternative therapy options (conservative, CABG) • The patient has to feel comfortable during the procedure – sedation and analgesia (f.e. Dexmedetomidin- hydrochlorid) – resting comfort – bladder catheter – good intravenous accesses • The cathlab team has to be alert during the whole procedure Communication 2 Explain your patient and your stuff what is going on today
- 8. Essential angiographic preconditions for planning a CTO PCI: • Understand the proximal cap • Understand the vessel route • Understand the distal cap Occluded segment Proximal fibrous cap (hard) Distal fibrous cap Good Visualization 3
- 10. Visualizing the landing zone Contra-lateral Injection? Ipsi-lateral Injection? Super-selectiv Injection? Conusbranch? common rare
- 11. Visualization of the landing zone Contra-lateral Injection
- 12. Visualization of the landing zone Super selectiv conus branch injection
- 13. CTA for procedural planning 4 • cap ambiguity • calcification: – proximal cap – intra CTO segment – distal cap – potential landing zone • vessel course and live CTA guidance
- 14. LIVE CASE TCT 2021
- 16. Randomized Trial Registry data • CCTA was used in approximately 5% of CTO PCIs (7,034 CTO PCI procedures performed between 2012-2022 in the Progress Registry) • most often useful in resolving proximal cap ambiguity followed by identification calcium not seen by conventional angiography. • CCTA may facilitate risk/benefit calculation and guide intraprocedural strategy, but was not associated with higher success rates in the present study Effect of Coronary CTA on CTO PCI Simsek B. et al., Insights from the PROGRESS-CTO registry. Int J Cardiol. 2022 Aug 11:
- 17. Radiation: • Reduce the frame rates (Fluoroscopy: 6 – (7,5) f/s Cines: 7,5 f/s) • Use low dose programms • Use fluoro store instead of cines (-90%) • Lead shield, lead blanket: reducing scatter radiation • X-ray-detector closer to the patient (-20%) • Avoid strong angulation (-80%) • Avoid LAO cranial, lateral, caudal if possible • Step back while filming 5 Protect yourself!
- 18. Pelvic shield Protection systems Operators exposure reduction Rampart ic
- 19. Comparison of the contribution of fluoroscopy and cineangiography to total Air Kerma between original set up (group 1) and modified radiation protocols (group 2 and 3) Werner GS et al. Cardiovasc Revasc Med. 2022 Mar
- 20. Complexity • Did I understand the complexity of the case? • Anatomic complexity: J-CTO Score, Castle Score • Clinical complexity: • Low Ejection fraction • Retrograde over last remaining vessel • Severe renal impairment 6 Skills – Complexity Rationality Balance between risk and benefit based on your experience level
- 21. THE EUROCTO (CASTLE) SCORE PROCEDURAL SUCCESS SCORE FROM THE 20,000-PATIENT • CABG (previous) • Age (>70) • Stump (Blunt or none) • Tortuosity (severe or unseen) • Length (>20mm) • Extent of Calcification CASTLE Szijgyarto et al., unpublished data 2018
- 22. THE EUROCTO (CASTLE) SCORE • 0-1 92% success • 2 85% success • 3 80% success • 4+ 70% success Comparison of the observed and predicted probabilities of failure of CTO PCI • CABG (previous) • Age (>70) • Stump (Blunt or none) • Tortuosity (severe or unseen) • Length (>20mm) • Extent of Calcification Szijgyarto et al., unpublished data 2018
- 23. Strategy: “anatomy dictates strategy“ Update From the PROGRESS CTO Registry Tajti P. et al, JACC Cardiovasc Interv. 2018 7
- 24. JACC 2021 Eugene B. Wu, Emmanouil S. Brilakis, Kambis Mashayekhi et al
- 25. 1. Indication 2. Communication 3. Angiogram 4. CTA 5. Radiation 6. Complexity 7. Strategy Optimal planning of CTO-PCI
Editor's Notes
- BACKGROUND: As an initial treatment strategy, percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) did not show midterm survival benefits compared with optimal medical therapy (OMT). We sought to evaluate the ben- efit of PCI compared with OMT in patients with CTO over extended long-term follow-up. METHODS AND RESULTS: Between March 2003 and February 2012, 2024 patients with CTO were enrolled in a single-center registry and followed for ≈10 years. We excluded patients with CTO who underwent coronary artery bypass graft (n=477) and classified patients into the CTO-PCI group (n=883) or OMT group (n=664) according to initial treatment strategy. Patients with multivessel disease received PCI for obstructive non-CTO lesions in both groups. In the CTO-PCI group, 699 patients (79.2%) underwent successful revascularization. The CTO-PCI group had a lower 10-year rate of cardiac death (10.4% versus 22.3%; hazard ratio [HR], 0.44 [95% CI, 0.32–0.59]; P<0.001) than the OMT group. After propensity score matching analyses, the CTO-PCI group had a lower 10-year rate of cardiac death (13.6% versus 20.8%; HR, 0.64 [95% CI, 0.45–0.91]; P=0.01) than the OMT group. The relative reduction in cardiac death at 10 years was mainly driven by a relative reduction between 3 and 10 years (8.3% versus 16.6%; HR, 0.43 [95% CI, 0.27–0.71]; P<0.001) but not at 3 years (5.7% versus 5.0%; HR, 1.12 [95% CI, 0.63–2.00]; P=0.71). The beneficial effects of CTO-PCI were consistent among subgroups. CONCLUSIONS: As an initial treatment strategy, CTO-PCI might reduce late cardiac death compared with OMT in patients with CTO. Extended follow-up of randomized trials may confirm the findings of the present study.
- Reducing Fluoroscopic and Cineangiographic Contribution to Radiation Exposure for Chronic Total Coronary Occlusion Interventions Gerald S Werner 1, Kenji Yaginuma 2, Matthias Koch 3, Karlheinz Tischer 3, Martin Silber 4, Juliane Werner 3, Thomas Keuser 3, Hiller Moehlis 3 Affiliations expand PMID: 33931375 DOI: 10.1016/j.carrev.2021.04.020 Abstract Background: The treatment of chronic total coronary occlusions (CTO) carries the highest radiation exposure among percutaneous coronary interventions (PCI). In order to minimize radiation damage, we need to understand and optimize the contribution of all components of radiation exposure. Methods: A total of 1000 CTO procedures performed between 2011 and 2020 were compared according to implemented radiation modifications. Group 1 used the original set-up of the X-ray equipment (Artis Zee, Siemens). In group 2 a modified protocol aimed at reducing the fluoroscopy exposure, in group 3 further modifications aimed at reducing cineangiographic exposure. Results: Despite an increased lesion complexity, Air Kerma (AK) was reduced from 2619 mGy (1653-4574) in group 1 to 2178 mGy (1332-3500; p < 0.001) in group 2 by mainly reducing fluoroscopic contribution by 54.1%, the cineangiographic contribution was lowered by only 6.6%. In group 3 AK dropped drastically to 746 mGy (480-1225; p < 0.001) mainly by reducing the cineangiographic contribution by 53.4%, still there was a further reduction of fluoroscopy contribution of 8.2%. This also led to a reduction of the skin entry dose from 1038 mGy (690-1589) in group 2 to 359 mGy (204-591; p < 0.001) in group 3. This was achieved both in normal weight and obese patients, and both in antegrade and retrograde procedures. Conclusions: The present study demonstrates that by modifying both the fluoroscopic and cineangiographic contribution to radiation exposure a drastic reduction of radiation risk can be achieved, even in obese patients. Currently accepted radiation thresholds may no longer be a limit for CTO PCI. Keywords: Chronic total coronary occlusion; Percutaneous coronary intervention; Procedural complications; Radiation exposure.