rkshop 2016, September, 30th - October 1st, 2016 in Krakow, Poland

1. Ostial CTO Lesions
Valeri Gelev
Tokuda Hospital Sofia

2. Ostial Lesions
Definition
Ostial disease is defined as a lesion
arising within 3 mm of the vessel origin
Classification
– Aorto-ostial – involving the ostia of the
RCA, LMS, and ACB grafts.
– Non-aorto-ostial – involving the ostia
of the major coronary arteries
not arising directly from the aorta; i.e.,
the LAD, Cx and RIM.
– Branch ostial – involving the ostia of
branches of the major coronary vessels;
(diagonals, marginals, PL and PD)
Percy Eurointerverntion 2009

3. Ostial Lesions - Incidence
33%
12%
32%
18%
Overall Incidence around 3%
Patel CCI 2016

4. CTO - Ostial Lesions Incidence
Limited data
Galassi Coron Artery Dis 2015

5. CTO - Ostial Lesions Incidence
Limited data
Euro CTO Registry 2012-07.2015
Mayer-Gessner EuroCTO meeting 2015
RCA Ostial Other Lesions
n 378 (4%) 9030 (96%)
lesion length(mm) 43,4 30,7
J CTO score (men) 3,2 2,3
antegrade only (%) 38 73
retrograde only (%) 37 11
antegradea and
retrograde (%)
25 16
stent length (mm) 78,4 62,3
procedural time 140,1 106,2
fluoro time 62,5 41,2
Contrast (ml) 317,5 292,2
Success rate (%) 78 87

6. CTO - Ostial Lesions Incidence
Limited data
Chun Luo JACC – Cardiovascula Imaging 2015
Independent predictor of Failure

7. CTO - Ostial Lesions Incidence
Non Aorto-
ostial Lesions
Side Branch
at Proximal
Cap
=
Increasing the Proximal Cap
Ambiguity

8. Angiographic Predictors of Unsuccesful CTO
CUMC experience
Odds Ratio 95% CI p-value
CTO length 1.06 per 1mm
increase
1.03-1.09 <0.01
Blunt stump 1.35 0.68-2.66 0.39
Side Branches 2.81 1.45-4.96 <0.01
Bridging collaterals 0.60 0.32-1.15 0.12
>1 CTO in vessel 3.22 1.13-9.19 0.03
Vessel calcification 4.54 2.40-8.56 <0.01
Diffuse disease 0.85 0.34-2.12 0.73
Prior CABG 1.03 0.53-2.03 0.93
Obunal K: ACC 2008

9. 1 1,5 2 2,5 3 3,5
Proximal v distal vessel
Length <15, 16-30, >30
Absent proximal tortuosity
Less calcification
Unambiguous proximal cap
No previous CABG
BMI < 30
Adjusted OR for success
Predictors of success – UK HYBRID
Multivariate analysis: C statistic = 0.72
All p<0.01
Wilson CTO summit 2016

10. PROspective Global REgiStry for the Study of CTO interventions
Proximal cap ambiguity
Brilakis CTO summit 2016

11. CTO - Ostial Lesions - Management
– Microchannels
– Bridging Collaterals
– Calcium in the vessel course
– Additional imaging modalities
• IVUS
• CT angio of CTO
– Utility of Retrograde Approach
Non Ao-ostial Ao - ostial
+ +/-
++ +/-
++ ++
+++ -
+/- +/-
++ +++
Meticulous attention should be paid to prevent retrograde wire
going subintimally in the proximal vessel, LM respectively.
How to predict the vessel origin in the absence of stump

12. CTO - Ostial Lesions Case presentation

13. CTO - Ostial Lesions Case presentation

14. CTO - Ostial Lesions Case presentation

15. CTO - Ostial Lesions Case presentation

16. CTO - Ostial Lesions Case presentation

17. CTO - Ostial Lesions Case presentation
Final Result

19. CTO – Ao-Ostial Lesions - Case presentation

20. CTO – Ao-Ostial Lesions - Case presentation

21. CTO – Ao - Ostial Lesions - Case presentation

22. CTO – Ao - Ostial Lesions - Case presentation
Final Result

23. CTO - Ostial Lesions
• Ostial CTO lesions represent an inhomogeneous subset
of chronically occluded coronaries.
• There is a paucity of data about their incidence,
treatment options and longstanding results.
• PCIs in Ao-ostila CTOs are complex, procedures,
demanding high expertise of the operator and a lot of
resources.
• Reported success rates are lower compared with the
conventional CTO PCI.