Sylvia Otto: Impulse: How to evaluate and adress the risks of CTO PCI

EuroCTO Club 2022
How to evaluate and adress the risks of CTO PCI
Mainz – 03.09.2022 PD Dr. Sylvia Otto
Klinik für Innere Medizin I
Kardiologie, Angiologie & Internistische Intensivmedizin

Disclosure Statement of Financial Interest
I, Sylvia Otto DO NOT have a financial interest/arrangement or
affiliation with one or more organizations that could be
perceived as a real or apparent conflict of interest in the
context of the subject of this presentation

What are the risks of CTO-PCI?
Stroke
Death
emergency CABG
Bleeding
Predictors: ACS, female sex, cardiogenic
shock, ≥85 years, renal dysfunction

PCI-Failure ↔ Complication Rates
Patel VG. JACC 2013;6:128–36; Khan MF. CCI 2015;85:781-794
Relative and Absolute Risk of Adverse Outcomes with Failed and Successful CTO-PCI

Trends in CTO-PCI
Annual Distribution of First-Intention CTO-PCI
Procedures (CL-Study)
Changes of procedural characteristics
2004-2010 20011-2013
Alessandrino et al. J Am Coll Cardiol Intv 2015;8:1540–8; Galassi AR, J Am Coll Cardiol Intv 2016;9:911–22
• Annual CTO volume ↑
• Advanced techniques &
material:
radial access, retrograde
approach, contralateral
injections, …
Retrograde Approach

Temporal trends
Success & Complication Rates
3.1 %
2.5 %
2.9%
3.8%
Patel VG. JACC 2013;6:128–36;
Galassi AR, J Am Coll Cardiol Intv 2016;9:911–22; Tajti P. J Am Coll Cardiol Intv 2018;11:1325–35
Success Rates ↑ (despite lesion complexity↑) ~ 90 %
Lesion complexity
J-CTO Score

Complication rates in retrograde vs. antegrade approach
Peter Tajti et al. J Am Coll Cardiol Intv 2018; 11:1325-1335 ; Galassi AR, J Am Coll Cardiol Intv 2016;9:911–22
5.2
0 0.5
3.8
2005-2014
2010-2014

Abbrevation Full SCORE Name Year / Author Study population Objective Aim
J-CTO Score Japanese chronic total occlusion score 2011 Morino Y et al. N = 494 native CTO lesions To determine successful
(antergrade)
guidewire crossing ≤30 min
CL-Score Clinical and Lesion-related score 2015
Alessandrino B et al.
N = 1.657 patients with first
attempt (antegrade)
To describe independent
predictors of CTO PCI failure
Progress-CTO
Score
Prospective Global Registry for the Study of
Chronic Total Occlusion
Intervention
2016
Christopoulos G et al
N = 781 (registry) prediciting technical success in
CTO PCI performed using the
hybrid approach
ORA Score ostial location, Rentrop grade <2, age ≥75
years
2016 Galassi AR et. Al N = 1.073 lesions to establish a model for
predicting technical failure
Hybrid-Approach Complex definition of the hybrid algorithm 2012 Brilakis ES et al.
2017 Ellis SG. et al
N = 456 lesions a hybrid approach–specific
model to predict CTO PCI
success
RECHARGE Registry of CrossBoss and Hybrid Procedures
in France, the Netherlands, Belgium and UK
2018 Maeremans J et al. N = 1.253 lesions to report achievable results using
the hybrid algorithm
CASTLE Score CASTLE = coronary artery bypass graft history,
≥70 yrs of age, stump anatomy (blunt or
invisible), tortuosity degree (severe or
unseen), length of occlusion (≥ 20 mm), extent
of calcification (severe)
2019 Szijgyarto Z et al. N > 20.000 cases (EuroCTO-
Registry)
contemporary scoring system to
predict the outcome of chronic
total occlusion
Antegrade CTO Score. 2017 Namazi MH et al CT-Rector score. Opolski et al.
Korean Multicenter CTO CT Registry Score. 2017 Yu et al.

J-CTO Score
Morino Y. J Am Coll Cardiol Intv 2011;4:213–21

J-CTO Score
Morino Y. J Am Coll Cardiol Intv 2011;4:213–21
Relationship between Difficulty and GW-crossing < 30 min
ROC Curves for Probability of
GW Success <30 Min
AUC
0.82 (derivation set)
and
0.76 (validation set)
Difficulty Group and Final Procedural Success Rates
N = 494 native CTO lesions

Validation of J-CTO Score
Technical success rates for antegrade/retrograde
approach
 good discriminatory & calibration capacity for GW crossing ≤ 30 minutes in antegrade & retrograde approaches
 no prediction of final success rate using hybrid antegrade, retrograde, and reentry techniques
Nombela-Franco L. Circ Cardiovasc Interv. 2013;6:635-643.)
N = 209, 41.1 % with J-CTO Score 3, 53.1 % involving a retrograde approach

CL-Score
Independent Predictive Variables Scored According to
Odds Ratio
Procedural Success Rate According to CL-Score Value in the
Derivation and Validation Groups
• 6 variables (2 clinical variables, 4 lesion-related variables)
• 4 risk groups
• first-attempt CTO-PCI procedures performed with antegrade
approach (90.6 %)
ROC Curve for Probability of Successful CTO-PCI
0.68
0.60
Alessandrino et al. J Am Coll Cardiol Intv 2015;8:1540–8

J-CTO vs. CL-Score
3
69 y o female, s/p anterior STEMI

J-CTO vs. CL-Score

“Hybrid” Algorithm
Algorithm for Crossing CTOs
Brilakis ES, J Am Coll Cardiol Intv 2012;5:367–79, Maeremans, J. et al. J Am Coll Cardiol. 2016;68(18):1958–70.
Assessment of 4 angiographic parameters:
1) clear understanding of location of the proximal cap
(angiography or IVUS)
2) lesion length
3) presence of branches, as well as size and quality of the
target vessel at the distal cap – distal target
4) suitability of collaterals for retrograde techniques
→ to provide a consistent framework to evaluate
patients, reproduceabile and teachable method

“Hybrid” Algorithm world-wide
Ellis SG.; Harding SA. J Am Coll Cardiol Intv 2017;10:2135–43; Galassi AR. EuroIntervention 2019;15:198-208;

Outcome with „Hybrid“ Approach
Recharge-Registry (N = 1.253 lesions) In-Hospital MACCE and Complications
→ hybrid algorithm is effective (success rates of ~90%), safe (low rates of complications) and efficient
(favourable procedural metrics)
Procedural Parameters

Progress-CTO Score
(Prospective Global Registry for the Study of Chronic
Total Occlusion Intervention) Score
Christopoulos G. J Am Coll Cardiol Intv 2016;9:1–9
4 baseline angiographic characteristics - Hybrid Approach
Comparison of the Performance of PROGRESS
CTO Score in the Derivation and Validation Sets
COMPARISON WITH J-CTO SCORE TO
PREDICT TECHNICAL SUCCESS.
Similar predicting accuracy was noted
for each stratum of both scores
→ good calibration & discriminatory capacity and similar performance to J-CTO score in predicting technical success
Success
rate
inability to unequivocally
determine the proximal
entry point into the CTO

ORA-Score (ostial location, Rentrop grade <2, age ≥75)
Galassi AR, J Am Coll Cardiol Intv 2016;9:911–22
N = 1.073 CTO procedures, 2005-2014, single-operator,
antegrade and retrograde approach
Derivation set
Validation set
95.9% 90.6%
87.6%
57.1%
ORA score ≥ 3
↑ contrast-induced nephropathy (12.1% vs. 5.4%; p = 0.031)
↑ in-hospital MACE (6.1% vs. 3.6%; p = 0.228).

Collateral vessel classification
Werner GS et al..Circulation 2003;107:1972–7., Rentrop KP et al. J Am Coll Cardiol 1985;5:587–92., Gestrich C. Thorac Cardiovasc Surg 2020;68:660–668.
No filling of
collateral vessels
filling of collateral
vessels without any
epicardal filling of
the target artery
Partial epicardial
filling by
collateral vessels
of the target
artery
Complete
epicardial filling
by collateral
vessels of the
target artery
Werner classification (collateral connection)
≥ 0.4 mm
Rentrop (collateral connection)

Tortuosity + ++ +++
Perforation
risk
+ ++ +++
Wiring
difficulty
+ ++/+++ +++
Able to
dilate
yes yes no
Retrograde Approach: Collateral vessel selection
Rathore S. Circ Cardiovasc Intervent. 2009;2:124-132
SVG Septal Epicardial Predictors of failure
 epicardial channel use (p=0.01)
 corkscrew tortuosity of the channel (p=0.011)
 angle of vessel with collateral > 90° (p=0.024)
Predictors of failure are primarily related
to collateral vessel characteristics, rather
than CTO morphology / anatomy

 Rentrop 2
Partial epicardial filling by collateral vessels
of the target artery
 Werner CC1
Sidebranch connection < 0.4 mm
 Epicardial collateral
corkscrew tortuosity
Example – collateral vessel classification

CASTLE Score
2 clinical factors and 4 angiographic factors:
(1 point for each factor)
CABG
AGE, ≥ 70
Stump
Tortuosity, severe
Length ≥ 20 mm
Extent of calcification, severe
Score: 0 – 6
4 Risk Categories
Szijgyarto Z et al. J Am Coll Cardiol Intv 2019;12:335–42
Euro-CTO Registry
> 20,000 cases (2008-2014)
derivation (n = 14,882) &validation (n = 5,745) datasets

CASTLE Score
PCI-Failure
Szijgyarto Z et al. J Am Coll Cardiol Intv 2019;12:335–42
AUC CASTLE: 0.68
AUC J-CTO: 0.64
Decreasing trend of annual failure rate
CASTLE model was adjusted for the effect of time on failure
rate before computing the predicted failure rate of
percutaneous coronary intervention (PCI).
Risk Groups
Risk Scores
The discriminating ability of the CASTLE model was reasonable to distinguish
patients at low and high risk. Multicenter-derived scoring system!
Euro-CTO Registry
> 20,000 cases (2008-2014)
8 %
35 %

Comparison of Scores
A. Karatasakis et al. Internat J Cardiol 224 (2016) 50–56; Salinars P. et al. 2021. Plos One.
N = 1,342 CTO procedures - REBECO Registry
→ good calibration of all scores
→ moderate discriminatory performance
(predicting technical outcome), better for
antegrade-only procedures
→ significant correlation with procedure
time, fluoroscopy dose & contrast
volume (CL)
→ CASTLE score had slightly better
overall performance along with CL score
N = 664 CTO procedures – Progress-CTO Registry

Impact of operator experience
Harding SA. J Am Coll Cardiol Intv 2017;10:2135–43; Brilakis ES. JACC Cardiovasc. Interv. 8 (2015) 245–253; Michael TT et al. Am. J. Cardiol. 112 (2013) 488–492; Michael TT. Catheter Cardiovasc Interv. 2015 Feb
15; 85(3): 393–399.
Operator CTO PCI Volume
 no upper limit in CTO
PCI success rates with
increased CTO PCI
volume
Continuous improvement
is possible, even among
high-volume CTO PCI
operators
Years since Initiation of CTO Programm
Fluorscopy time and contrast volume

Recommendations for CTO operators
 a minimum of 75 CTO-PCIs per operator has
been considered a reasonable threshold to
identify a skilled operator
 appropriate training and continued practice
(courses and proctoring)
 100 CTO PCIs/year must be performed by an
operator to reach a success rate >90%*
 referal of CTO patients to a more experience
operator if < 30 CTO procedures/year
 use of hybrid approach
Center / operator selection
Harding SA. J Am Coll Cardiol Intv 2017;10:2135–43; ; Galassi AR. EuroIntervention 2019;15:198
 Retrograde techniques should be reserved for
experienced operators (performing>50 per
year)
 50 retrograde procedures (25 as second
operator and 25 as first under supervision)
before becoming an independent retrograde
operator

Knowledge of complication management
Perforation Management Algorithm
 Being prepared to deal with
complications! especially in the
retrograde setting (e.g., perforation,
tamponade, donor vessel ischaemia)
 Availability of dedicated material
(covered stents, pericardiocentesis
kit, MCS)
 Trained nurses and technicians
 Cooperation with heart surgery

Prevention of AKIN
Pavlidis AN. Am J Cardiol 2015;115:844e851; Galassi AR. EuroIntervention 2019;15:198
Risk factors for development of acute kidney injury in
CTO PCI
CI-AKI risk prediction model
→ i.v. hydration with isotonic saline one day prior to and 12 hours after the procedure for CTO patients irrespective of their eGFR
Proposed algorithm for prevention of contrast-induced acute
kidney injury in CTO interventions

Know your limits - When to stop?
Harding SA. J Am Coll Cardiol Intv 2017;10:2135–43; Laskey et al. JACC Vol. 50, No. 7, 2007
cutoff value for ratio of the volume of
contrast media to the creatinine
clearance (V/CrCl) of 3.7 • the sensitivity and specificity for detection of an early, abnormal post-
PCI creatinine increase were 65% and 75%, AUC 0.69
• V/CrCl is a useful and independent predictor of an early increase in
postprocedural serum creatinine in unselected patients undergoing PCI
• to calculate prospectively the maximum volume of contrast media
that can be given without significantly increasing the risk of acute renal
injury

When to stop?
Chambers C.E. Catheterization and Cardiovascular Interventions 77:546–556 (2011); Harding SA. J Am Coll Cardiol Intv 2017;10:2135–43
Severity of Tissue Reactions From Single-Delivery Radiation Dose
11 Gy 18 Gy
Strategies to Reduce Radiation Exposure
→ radiation monitoring
→ active management of radiation and safety
→ monitor patient for radiation skin injury if > 4- 5-Gy
→ > 7- or 8-Gy air stop!

When to stop?
Definition:
• having the antegrade wire in the distal true lumen,
• having the stingray catheter in position in the reentry zone, or
• having crossed the collateral channel with the retrograde wire and microcatheter
Harding SA. J Am Coll Cardiol Intv 2017;10:2135–43; Laskey et al. JACC Vol. 50, No. 7, 2007

CTO-Bifurcation lesions (BFL)
Galassi AR et al. Artery Disease26(2):142-149, March 2015. doi: 10.1097/MCA.0000000000000194
• incidence of CTO bifurcation lesions
during PCI varies based on definition
from 25% to 50%
CTO periprocedural complications
Multivariate predictors of bifurcation technical success

CTO - Bifurcation lesions
A: Non CTO-bifurcation vs CTO-bifurcation lesions. B: Bifurcation technical
success vs no technical success.
MACE-free survival
Ojeda S. et al. International J Cardiol 230 (2017) 432–438
• CTO-BFL are associated with lower
procedural success and higher
complication rates
• CTO-BFL are associated with higher
MACE-rate (losing SB > 1mm !) at 12
months

Mechanisms of Side-branch
occlusion
The retrograde
wire followed a short subintimal course,
Reentering into true lumen at bifurcation
The stent was adjusted to the ostium, thus not
covering the entry (i.e., proximal)
point to the subintimal space
stent expansion resulted in proximal extension
of the subintimal space, occluding the LCx
ostium
→ use intracoronary imaging (OCT / IVUS) to understand side branch
anatomy and wire position (in true lumen?)

Success ↔ Indication
Tajti P. JACC 2018; 11(7):615-25; Grantham JA. Circ Cardiovasc Qual Outcomes 2010;3:284 –90; Finci L. Am J Cardiol 1990;66:660 –2; Baks T. J Am Coll Cardiol 2006;47:721–5; Claessen BE. J Am Coll Cardiol Intv
2009;2:1128 –34; Safley DM. J Am Coll Cardiol Intv 2008;1:295–302. Joyal D. Am Heart J 2010;160:179–87.
RISK-BENEFIT RATIO:
 Individualized decision
 Indication:
• angina relief
• ↑ exercise tolerance
• ↑ left ventricular function
• ↑ tolerance for future acute coronary syndrome
• reduce the need for coronary artery bypass graft
surgery
• (↑) improve survival if successful (especially for
LAD CTOs)
→ Do not perform CTO-PCI without indication! No procedure = no complication

PROGRESS-CTO Complication Score
• 11 centers
• 1.569 lesion
• In-hospital MACE: 2.8 %
(MACE = MI, stroke, urgent Re-PCI or CABG, tamponade requiring
pericardiocentesis, death)
simple score:
1 clinical characteristic (age >65 years)
1 angiographic characteristic (CTO length ≥23 mm)
1 procedural characteristic (use of the retrograde
approach)
Danek BA. J Am Heart Assoc. 2016;5:e004272 doi: 10.1161/JAHA.116.004272
AUC: 0.793 (95% CI 0.682-0.905)
In-hospital complications

The New PROGRESS-CTO Complication Scores
CTO risk scores for
• In-hospital MACE
• Mortality
• Pericardiocentesis
• Acute myocardial infarction
Simsek B et al. J Am Cardiol Interv 2022;15(14):1413-1422
Progress-CTO In-hospital MACE Risk Score

Conclusion
Most frequent predictors for unsuccesful
CTO-PCI:
Lembo NJ. JACC 2017;10(11) and Tajti P. JACC 2018; 11(7):615-25
Validated Risk Scores useful for:
• Guidance of interventionalists in their learning phase (case selection) or for operator / center selection
• Heart Team discussions regarding the likelihood of complete revascularization with PCI or CABG
• Comprehensive informed consent for patients regarding the likelihood of CTO PCI success &
Complication
CTO PCI:
1) is performed with increasing success rates
2) overall, carries low risk of major complications
3) compared to successful CTO PCI, unsuccessful CTO
PCI is associated with significantly higher MACE rates
(coronary perforation and tamponade)

Preparation - Key to Success
Neal Sawlani. Circulation: Cardiovascular Imaging. Chronic Total Occlusion Percutaneous Coronary Intervention, Volume: 10, Issue: 4, DOI: (10.1161/CIRCIMAGING.117.006372)
 No Ad-hoc CTO-PCI
 Pre-procedural planning and
review of angiogramm
 Hybrid Approach (dual injection,
careful angio review, initial
crossing strategy selection,
change)
 Consideration of local expertise:
→ operator / center selection
 Know your limits and when to
stop

Online Tool
https://www.progresscto.org/cto-scores

Side-branch occlusion and
myocardial infarction
The retrograde
wire followed a short subintimal course,
Reentering into true lumen at bifurcation
The stent was adjusted to the ostium, thus not
covering the entry (i.e., proximal)
point to the subintimal space
stent expansion resulted in proximal extension
of the subintimal space, occluding the LCx
ostium

Side-branch occlusion and
myocardial infarction
Subintimal shift in OCT imaging
→ use intracoronary imaging (OCT / IVUS) to understand side branch
anatomy and wire position (in true lumen?)
Gutiérrez-Chico JL et al., Cardiol J. 2021. DOI: 10.5603/CJ.a2021.0079

Conclusion
CTO PCI:
1) is performed with increasing success rates;
2) carries low risk of major complications
3) compared to successful CTO PCI, unsuccessful CTO PCI is associated with
significantly higher rates of death, stroke, coronary perforation, and
tamponade;
4) retrograde CTO PCI is associated with low procedural
complication risk.

Algorithm for Crossing CTOs
Assessment of 4 angiographic
parameters:
1) clear understanding of location of the
proximal cap (angiography or IVUS)
2) lesion length
3) presence of branches, as well as size
and quality of the target vessel at the
distal cap – distal target
4) suitability of collaterals for retrograde
techniques
→to provide a consistent framework to evaluate patients, reproduceabile and teachable method

complex definition for the fourth variable
of the hybrid algorithm (interventional collateral
vessels).
4-step grading system:
1) the Werner classification;
2) the number of septal vessels fulfilling at least
Werner criterion 1B;
3) tortuosity classification;
4) the presenceor absence of a 90° turn into or
out of the best interventional collateral vessel.
-> difficult to apply this complex definition in daily
clinical practice.
“hybrid” algorithm
Ellis SG. J Am Coll Cardiol Intv 2017;10:1089–98

J-CTO vs CL-Score
RCA-CTO; J-CTO Score: 2 (difficult); CL-Score: 5.5 (very difficult).
Gielker et al 2017

Comparison of Scores
Salinars P. Choice of CTO scores to predict proceduralsuccess in clinical practice. A comparison of 4 different CTO PCI scores in a comprehensive national registry including expert and learning
CTO operators. 2021. Plos One.; Karatasakis A et al. 2016
N = 1,342 CTO procedures - REBECO Registry
→ Calibration was good for CASTLE & CL, but not for J-CTO or PROGRESS scores.
→ Discrimination: AUC of CASTLE (0.633) was significantly higher than PROGRESS
(0.557) and similar to J-CTO (0.628) and CL (0.652).
→ CASTLE score had slightly better overall performance along with CL score
Table: Simple vs. complex CT-Cutoffs

THE CONCEPT OF THE “HYBRID APPROACH”
After dual coronary
angiography, four angiographic parameters are assessed:
1) proximal cap location and (non-) ambiguity; 2) occlusion length;
3) quality of the distal vessel; 4) presence of collaterals suitable
for retrograde techniques (“interventional collaterals”). Based on
these four features, an initial strategy and hierarchy for subsequent
approaches are established. The hybrid algorithm has been shown to be effective (success rates of ~90%), safe
(low rates of complications:
tamponade 1.3%, periprocedural myocardial infarction
1.0%, death 0.4%), and efficient (favourable procedural metrics)50.
Additionally, the mantra of this algorithm is its reproducibility and
the fact that it can be easily taught/learned, resulting in high success
rates obtained by new operators63.
Recently, the Asia Pacific Chronic Total
Brilakis ES, Grantham JA, Rinfret S, Wyman RM, Burke MN, Karmpaliotis D, Lembo N, Pershad A, Kandzari DE, Buller CE, DeMartini T, Lombardi WL, Thompson CA. A
percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5:367-79.

Temporal trends of complication rates
Dash D. Indian Heart J (2016): 68. 737-746,

Impact of operator experience
T.T. Michael, D. Karmpaliotis, E.S. Brilakis, E. Fuh, V.G. Patel, O. Mogabgab,M. Alomar,
B.L. Kirkland, N. Lembo, A. Kalynych, H. Carlson, S. Banerjee, W. Lombardi, D.E.
Kandzari, Procedural outcomes of revascularization of chronic total occlusion of native
coronary arteries (fromamulticenter United States registry), Am. J. Cardiol. 112
(2013) 488–492.
Harding SA. J Am Coll Cardiol Intv 2017;10:2135–43; Brilakis ES. JACC Cardiovasc. Interv. 8 (2015) 245–253; Michael TT et al. Am. J. Cardiol. 112 (2013) 488–492.
Technical success rate

Complication rates in retrograde vs. antegrade approach
Peter Tajti et al. J Am Coll Cardiol Intv 2018; 11:1325-1335 ; Galassi AR, J Am Coll Cardiol Intv 2016;9:911–22
→ Retrograde CTO PCI is associated with low procedural complication risk

Further Validation of J-CTO and CL-Scores
J.E. Guelker et al. Int J of Cardiol 230 (2017) 228–231
• N = 379 consecutive patients
• Procedural success: 84 %
• Retrograde approach: 39 %
→ CL score is superior to the J-CTO score in identifying CTO lesions for successful recanalization
• Mean J-CTO score: 2.9 ± 1.3
• Mean CL score: 4.3 ± 1.7

PCI-Failure ↔ Complication Rates
Patel VG. JACC 2013;6:128–36; Khan MF. CCI 2015;85:781-794
Procedural Complications in Successful Versus Unsuccessful CTO PCI
Relative and Absolute Risk of Adverse Outcomes with Failed and Successful CTO-PCI

Complication rates
Pooled Complication Rates
CABG coronary artery bypass graft; CN contrast nephropathy; MACE major adverse cardiac events; MI
myocardial infarction; QWMI Q-wave myocardial infarction.
3.1 %
2.5 %
2.9%
Patel VG. JACC 2013;6:128–36;
Galassi AR, J Am Coll Cardiol Intv 2016;9:911–22
Complication rates and (in-hospital) MACE ↓
Periprocedural Complications

Assessment of 4 angiographic parameters:
1) clear understanding of location of the proximal cap
(angiography or IVUS)
2) lesion length
3) presence of branches, as well as size and quality of the
target vessel at the distal cap – distal target
4) suitability of collaterals for retrograde techniques
Recharge-Registry (N = 1.253 lesions)
→ previously mentioned angiographic characteristics with negative prognostic outcomes were significantly
more frequent in the failure group.

Sylvia Otto: Impulse: How to evaluate and adress the risks of CTO PCI

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