Published data on CTO complications Nikolaos Konstantinidis, Thessaloniki, Greece 11th Experts Live CTO The annual Euro CTO meeting September 13th –14th, 2019 - Berlin, Germany

1. Nikolaos Konstantinidis MD, MSc, PhD
St Luke’s Hospital of Thessaloniki
AHEPA University Hospital
Thessaloniki, Greece
Published Data on CTO
Complications
Complication Management in
CTOs
September 13th, 2019, Berlin, Germany

2. Potential Conflicts of Interest
I, Nikolaos Konstantinidis MD, MSC, PhD, do not have any potential conflict of
interest to declare

3. Early CTO PCI reports, initial perception
Contemporary series of CTO PCI
Randomized trials of CTO PCI
Revascularization approach and complication rates
Factors associated with CTO PCI complications
Predictive CTO Complication score
Published Data on CTO Complications

4. Procedural Outcomes of Chronic Total Occlusion Percutaneous
Coronary Intervention; A Report From the NCDR (National
Cardiovascular Data Registry)
(22.365 patients with CTO (of 594.510) enrolled between 2009-2013, technical success 59%, in hospital MACE 1.6%)
Brilakis et al, J Am Coll Cardiol Intv 2015;8:245–53

5. In-hospital outcomes of percutaneous coronary intervention in
patients with CTO: insights from the ERCTO registry
(1983 patients enrolled between 2008-2010, procedural success 82.9%, in hospital MACE 1.8%)
Galassi et al, EuroIntervention 2011;7:472-479

6. Patel et al, J Am Coll Cardiol Intv 2013;6:128–36
Angiographic Success and Procedural Complications in Patients
Undergoing Percutaneous Coronary CTO Interventions
A Weighted Meta-Analysis of 18,061 Patients From 65 Studies (published 2000-2011)
Pooled Complication Rates

7. Early CTO PCI reports, initial perception
Contemporary series of CTO PCI
Randomized trials of CTO PCI
Revascularization approach and complication rates
Factors associated with CTO PCI complications
Predictive CTO Complication score
Published Data on CTO Complications

8. Brilakis et al, Circulation. 2019;140:420–433.
Guiding Principles for Chronic Total Occlusion Percutaneous Coronary
Intervention; A Global Expert Consensus Document

9. 5.2
4.7
4.4
4.8
0.7 0.7 0.7
0.5
0.36 0.29
0.07 0.09
0
1
2
3
4
5
6
2008-2009 2010-2011 2012-2013 2014-2015
Complicationrate(%)
Any periprocedural complication MACE In hospital mortality
Any periprocedural complication: p for time 0.793, p for operator <0.001
MACE: p for time 0.034, p for operator 0.003
In hospital mortality: p for time 0.120, p for operator 0.999
Temporal Trends in Chronic Total Occlusion Interventions in Europe
17 626 Procedures From the European Registry of Chronic Total Occlusion
(17626 patients enrolled between 2008-2015, J-CTO score increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015 –
p<0.001, procedural success 79.7% in 2008 - 89.3% in 2015 - p<0.001, MACE 0.6%)
Konstantinidis et al, on behalf of the EuroCTO Club, Circ Cardiovasc Interv. 2018;11:e006229

10. Comparison of PCI for CTO Outcome According to Operator Experience
from the Japanese Retrograde Summit Registry
(3229 patients enrolled between 2012-2013, procedural success 88.4%, in hospital MACCE 0.53%)
Habara et al, Catheterization and Cardiovascular Interventions 87:1027–1035 (2016)

11. Tajti et al, J Am Coll Cardiol Intv 2018;11:1325–35
The Hybrid Approach to Chronic Total Occlusion Percutaneous
Coronary Intervention Update From the PROGRESS CTO Registry
(3055 patients enrolled between 2012-2017, 87% technical success rate, in-hospital MACE was 3.04% (death, 0.85%;
acute MI, 1.08%; stroke, 0.26%; emergency CABG, 0.16%; urgent repeat PCI, 0.36%; pericardial tamponade, 0.85%)
In-Hospital Major Complications Classified According to Final Successful Crossing Strategy
Use of the retrograde approach was associated with higher overall in-hospital MACE and risk for perforation

12. Tajti et al, J Am Coll Cardiol Intv 2018;11:1325–35
Xenogiannis I, 24 September 2018, San Diego, CA, TCT 2018
The Hybrid Approach to Chronic Total Occlusion Percutaneous
Coronary Intervention Update From the PROGRESS CTO Registry
(3055 patients enrolled between 2012-2017, 87% technical success rate, in-hospital MACE was 3.04% (death, 0.85%;
acute MI, 1.08%; stroke, 0.26%; emergency CABG, 0.16%; urgent repeat PCI, 0.36%; pericardial tamponade, 0.85%)
Most common cause of Death is perforation/tamponade
Mortality 0.8%

13. Perforation type
Danek et al, Am J Cardiol 2017;120:1285–1292
Incidence, Treatment, and Outcomes of Coronary Perforation During
Chronic Total Occlusion Percutaneous Coronary Intervention
(2049 patients enrolled between 2012-2017, 88% technical success rate, in-hospital MACE was 2.64%; Coronary
perforation was 4.1%; Ellis class 1, 2, and 3 perforations were 21%, 26%, and 53%, respectively)

14. Outcomes of Percutaneous Coronary Interventions for Chronic Total
Occlusion Performed by Highly Experienced Japanese Specialists
The First Report From the Japanese CTO-PCI Expert Registry
(2847 patients enrolled between 2014-2015, technical success 89.9%, in hospital MACCE <2%)
Suzuki et al, J Am Coll Cardiol Intv 2017;10:2144–54

15. The Hybrid Algorithm for Treating Chronic Total Occlusions in Europe
The RECHARGE Registry
(1253 patients enrolled between 2014-2015, procedural success 86%, in hospital MACE 2.6%)
Maeremans et al, J Am Coll Cardiol 2016;68:1958–70

16. Hybrid approach improves success of chronic total occlusion
angioplasty; The UK HYBRID CTO Registry
(1156 patients enrolled between 2012-2014, procedural success 90%, 30 day MACE 1.6%)
Wilson et al. Heart 2016;102:1486–1493
Complication rates at 30 days according to final strategy

17. Early Procedural and Health Status Outcomes After Chronic Total
Occlusion Angioplasty A Report From the OPEN-CTO Registry
(1000 patients enrolled between 2014-2015, core-lab adjudicated, J-CTO 2.3± 1.3, technical success 86%, in hospital
MACE 7%)
Sapontis et al, J Am Coll Cardiol Intv 2017;10:1523–34

18. Early CTO PCI reports, initial perception
Contemporary series of CTO PCI
Randomized trials of CTO PCI
Revascularization approach and complication rates
Factors associated with CTO PCI complications
Predictive CTO Complication score
Published Data on CTO Complications

19. A randomized multicentre trial to compare revascularization with
optimal medical therapy for the treatment of CTOs; The EUROCTO Trial
(396 patients enrolled between 2012-2015, J-CTO 1.82±1.07 86.6% success rate, 12 month
follow up)
Werner et al, European Heart Journal (2018) 39, 2484–2493

20. Percutaneous Intervention for Concurrent Chronic Total Occlusions
in Patients With STEMI; The EXPLORE Trial
(304 patients enrolled between 2007-2015, J-CTO 2.0±1.0, 73% success rate, 4 month follow up)
Henriques et al, J Am Coll Cardiol 2016;68:1622–32

21. Mashayekhi et al, J Am Coll Cardiol Intv 2018;11:1982–91
A Randomized Trial to Assess Regional Left Ventricular Function After
Stent Implantation in Chronic Total Occlusion; The REVASC Trial
(205 patients enrolled between 2007-2015, J-CTO 2.0±1.0, 86% success rate (97% after 2nd attempt), 6&12 month follow up)

22. Obedinskiy et al, J Am Coll Cardiol Intv 2018;11;Issue 13:1309–11
The IMPACTOR CTO Trial
(94 patients with CTO RCA enrolled between 2010-2014, 83% success rate, 12 month follow up)
 Among patients who underwent CTO PCI attempts, 4 of 47 (8.5%) experienced
periprocedural complications: 2 vascular complications and 2 tamponades.
 No death was observed in either group.
 In the PCI group, 2 patients underwent target vessel revascularization 5 and 6 months
following the index procedure.
 No significant difference was found in MACE-free survival between the PCI and OMT
groups at 12 months (94.9% vs. 100%; p . 0.19).

23. Randomized Trial Evaluating Percutaneous Coronary Intervention for
the treatment of CTO; The DECISION-CTO trial
(834 patients enrolled between 2010-2016, J-CTO 2.2± 1.2, 90.6% success rate, 4-year follow up)
Lee et al, Circulation; 2019 Apr 2;139(14):1674-1683.

24. Early CTO PCI reports, initial perception
Contemporary series of CTO PCI
Randomized trials of CTO PCI
Revascularization approach and complication rates
Factors associated with CTO PCI complications
Predictive CTO Complication score
Published Data on CTO Complications

25. Any periprocedural complication: p <0.001
MACE: p 0.217
Temporal Trends in Chronic Total Occlusion Interventions in Europe
17 626 Procedures From the European Registry of Chronic Total Occlusion
(17626 patients enrolled between 2008-2015, J-CTO score increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015 –
p<0.001, procedural success 79.7% in 2008 - 89.3% in 2015 - p<0.001, MACE 0.6%)
Konstantinidis et al, on behalf of the EuroCTO Club, Circ Cardiovasc Interv. 2018;11:e006229
3.7
5.7
8.2
0.6 0.6 0.8
0
2
4
6
8
10
Antegrade wire escalation Antegrade Dissection Reentry Retrograde
Complicationrate(%)
Any periprocedural compication MACE

26. Periprocedural complication trend according to the recanalization approach (AWE, ADR, retrograde);
p for adopted strategy <0.001, p for operator <0.001, p for time >0.05.
Temporal Trends in Chronic Total Occlusion Interventions in Europe
17 626 Procedures From the European Registry of Chronic Total Occlusion
(17626 patients enrolled between 2008-2015, J-CTO score increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015 –
p<0.001, procedural success 79.7% in 2008 - 89.3% in 2015 - p<0.001, MACE 0.6%)
Konstantinidis et al, on behalf of the EuroCTO Club, Circ Cardiovasc Interv. 2018;11:e006229
4.9
4
3.5
2.3
4.8
8.6
4.1
6.7
7.8
8.1
7
9.7
0
1
2
3
4
5
6
7
8
9
10
2008-2009 2010-2011 2012-2013 2014-2015
Complicationrate(%)
Years
Antegrade wire escalation Antegrade Dissection Reentry Retrograde Approach

27. Tajti et al, J Am Coll Cardiol Intv 2018;11:1325–35
The Hybrid Approach to Chronic Total Occlusion Percutaneous
Coronary Intervention Update From the PROGRESS CTO Registry
(3055 patients enrolled between 2012-2017, 87% technical success rate, in-hospital MACE was 3.04% (death, 0.85%;
acute MI, 1.08%; stroke, 0.26%; emergency CABG, 0.16%; urgent repeat PCI, 0.36%; pericardial tamponade, 0.85%)
In-Hospital Major Complications Classified According to Final Successful Crossing Strategy
Use of the retrograde approach was associated with higher overall in-hospital MACE and risk for perforation

28. IVUS Analysis of Intraplaque Versus Subintimal Tracking in CTO PCI and
Association With Procedural Outcomes
(219 patients enrolled between 2014-2016, subintimal tracking in 52.1% of cases (86.7% dissection re-entry, 27.9% wire
escalation, success 89.5%, in hospital outcomes)
Song et al, J Am Coll Cardiol Intv 2017;10:1011–21

29. IVUS Analysis of Intraplaque Versus Subintimal Tracking in CTO PCI and
Association With Procedural Outcomes
(219 patients enrolled between 2014-2016, subintimal tracking in 52.1% of cases (86.7% dissection re-entry, 27.9% wire
escalation, success 89.5%, in hospital outcomes)
Song et al, J Am Coll Cardiol Intv 2017;10:1011–21

30. Procedural and longer-term outcomes of wire- versus device-based
antegrade dissection and re-entry techniques for the percutaneous
revascularization of coronary chronic total occlusions
(223 patient, J-CTO 2.3 ± 1.2, technical success 86%, procedural complications 2.7%)
Azzalini et al, Int J Cardiol 231 (2017)78-83
24-month MACE rates were higher in STAR (15.4%) and LAST (17.5%), as compared with
device-based ADR with CrossBoss/Stingray (4.3%, p = 0.02)

31. Tajti et al, J Am Coll Cardiol Intv 2019;12:346–58
Procedural Outcomes of Percutaneous Coronary Interventions for
Chronic Total Occlusions Via the Radial Approach
Insights From an International Chronic Total Occlusion Registry
(3790 patients enrolled between 2012-2018, 89% technical success rate, in-hospital major complication (2.47% vs. 3.40% vs.
2.18%; p . 0.830) were similar in all 3 groups, major bleeding was lower in the RA group (0.55% vs. 1.94% and 0.88%; p .0.013).
P:0.641 & P:0.009

32. One-Year Clinical Outcomes of the Hybrid CTO Revascularization
Strategy After Hospital Discharge: A Subanalysis of the Multicenter
RECHARGE Registry
(1253 patients enrolled between 2014-2015, 1067 analyzed post 1 year - MACE 8.7%)
Maeremans et al, J Invasive Cardiol 2018;30(2):62-70
Procedural parameters according to MACE events

33. In-hospital Outcomes of Attempting More Than One CTO Through
Percutaneous Intervention During the Same Procedure
(2955 patients enrolled between 2012-2017, 2% had more than one CTO lesions attempted during the same procedure -
70% in different major epicardial arteries, technical success was similar (86% vs 87%, p = 0.633), in-hospital major
complication rate was higher (10.3% vs 2.7%, p = 0.005))
Tajti et al, Am J Cardiol 2018;122:381 387

34. Early CTO PCI reports, initial perception
Contemporary series of CTO PCI
Randomized trials of CTO PCI
Revascularization approach and complication rates
Factors associated with CTO PCI complications
Predictive CTO Complication score
Published Data on CTO Complications

35. Procedural Outcomes of Chronic Total Occlusion Percutaneous
Coronary Intervention; A Report From the NCDR (National
Cardiovascular Data Registry)
(22.365 patients with CTO (of 594.510) enrolled between 2009-2013, technical success 59%, in hospital MACE 1.6%)
Brilakis et al, J Am Coll Cardiol Intv 2015;8:245–53
Operator CTO PCI Volume Association With Procedural Success and Complications

36. Patel et al, J Am Coll Cardiol Intv 2013;6:128–36
Angiographic Success and Procedural Complications in Patients
Undergoing Percutaneous Coronary CTO Interventions
A Weighted Meta-Analysis of 18,061 Patients From 65 Studies (published 2000-2011)
Temporal Trends in Cumulative Angiographic Success Rates and
Major Procedural Complication Rates

37. OPEN-CTO Registry
(1000 patients enrolled between 2014-2015, core-lab adjudicated, technical success 86%, in hospital MACE 7%)
Salisbury AC et al, 24 October 2017, Denver, Colorado, TCT 2017
Predictors of CTO PCI Complications
 Age
 Retrograde approach
 High J-CTO score

38. Danek et al, Am J Cardiol 2017;120:1285–1292
Incidence, Treatment, and Outcomes of Coronary Perforation During
Chronic Total Occlusion Percutaneous Coronary Intervention
(2049 patients enrolled between 2012-2017, 88% technical success rate, in-hospital MACE was 2.64%; Coronary
perforation was 4.1%; Ellis class 1, 2, and 3 perforations were 21%, 26%, and 52%, respectively.

39. Tajti et al, Circ Cardiovasc Interv. 2019;12:e007338.
In-Hospital Outcomes of CTO PCI in Patients With Prior CABG Surgery
Insights From an International Multicenter Chronic Total Occlusion Registry
(3486 patients enrolled between 2012-2018, Prior CABG patients had lower technical (84% versus 89%; P<0.001) success,
but similar incidence of in-hospital major complications (3.1% versus 2.5%; P=0.287).

40. One-Year Clinical Outcomes of the Hybrid CTO Revascularization
Strategy After Hospital Discharge: A Subanalysis of the Multicenter
RECHARGE Registry
(1253 patients enrolled between 2014-2015, 1067 analyzed post 1 year - MACE 8.7%)
Maeremans et al, J Invasive Cardiol 2018;30(2):62-70
Demographic characteristics according to MACE events

41. Early CTO PCI reports, initial perception
Contemporary series of CTO PCI
Randomized trials of CTO PCI
Revascularization approach and complication rates
Factors associated with CTO PCI complications
Predictive CTO Complication score
Published Data on CTO Complications

42. Danek et al, J Am Heart Assoc. 2016;5: e004272
Development and Validation of a Scoring System for Predicting
Periprocedural Complications During PCI of CTOs
The PROGRESS CTO Complications Score
(1569 patients enrolled between 2012-2016, 90% success rate, In hospital MACE 2.8%)

43. Take home message
 Contemporary well controlled series and RCTs report higher complication and MACE rates
compared to early CTO PCI reports
 Expert operators consistently achieve success rates >90% and address lesions of increasing
complexity over time, while complication and MACE rates seem to remain unchanged
 In-hospital MACE in CTO PCI is in the range of 3%
 Perforation is the most common periprocedural complication (4%), responsible for the
majority of deaths (18% with Ellis III perforation)
 Retrograde approach and ADR are associated with higher complication rate
 Radial approach is associated with lower major bleeding and MACE rate (12 month FU)
 PROGRESS-CTO complications score is a useful tool for estimating in-hospital complication
risk

44. Thank you very much..

45. Thank you very much..