Which CTO should be treated by PCI or CABG & The specific problems of PCI for post CABG patients Gerald S. Werner, Darmstadt, Germany 11th Experts Live CTO The annual Euro CTO meeting September 13th –14th, 2019 - Berlin, Germany

1. Which CTO should be treated by PCI or
CABG
&
The specific problems of PCI for post
CABG patients
Gerald S. Werner FESC, FACC, FSCAI
Medizinische Klinik I
Klinikum Darmstadt GmbH

2. Coronary artery chronic total occlusions (CTOs) are an
exacerbation of stable coronary artery disease (CAD) with
advanced calcification. CTOs are defined as 100% coronary
occlusions with Thrombolysis in Myocardial Infarction grade
0 flow persisting for >3 months.1
National database registries
and large single-center series suggest that in patients with
CAD the overall incidence of CTOs may vary from 16% to
19% in Japan2
and 29% to 33% in North America,3
making
this a common problem globally. Treatment of CTOs should
be considered if associated with symptoms or viable/ischemic
myocardial territories. Historically, treatments have been via
coronary artery bypass grafting (CABG) or medical therapy.3–9
suggests widespread use of CTO-PCI in patients with multi-
vessel CAD. This is likely to be at the expense of more estab-
lished treatments such as CABG. The difference in CTO-PCI
practice observed between Japan and North America is not
easily explained. Contributing factors may be differences in
study period, unclear guidelines, misrepresentation of safety/
efficacy evidence supporting the use of CTO-PCI, neglect of
the evidence supporting more established treatments, gate-
keeper effect, and lack of policies by health authorities.
In this article, we provide evidence to support the view
that CABG surgery remains the gold standard for the treat-
ment of CTOs in patients with isolated left main stem (LMS)
CTOs, left anterior descending (LAD) CTOs, or CTOs in the
Should Chronic Total Occlusion Be Treated
With Coronary Artery Bypass Grafting?
Chronic Total Occlusion Should Be Treated With Coronary
Artery Bypass Grafting
Mustafa Zakkar, PhD, MRCS; Sarah J. George, PhD;
Raimondo Ascione, FRCS, FRCS-CTh equiv, MD, ChM
CONTROVERSIES IN
CARDIOVASCULAR MEDICINE
Downloadedfromhttp://ah
Should chronic total occlusions (CTOs) of coronary arteries
be revascularized by coronary artery bypass graft (CABG)
surgery? It would seem that this is not a question that is often
Of patients with significant coronary artery disease, a CTO
was present in 1612 patients (52%), of whom 375 (12%) had
>1 CTO. Among patients with significant coronary artery
Should Chronic Total Occlusion Be Treated
With Coronary Artery Bypass Grafting?
Chronic Total Occlusion Should Not Routinely Be Treated
With Coronary Artery Bypass Grafting
William S. Weintraub, MD; Kirk N. Garratt, MD
CONTROVERSIES IN
CARDIOVASCULAR MEDICINE

3. CTO-PCI and CABG
• What are the results of CABG for CTOs ?
• Thesis: Should we not prefer CTO PCI over
CABG and use CABG as the final resort ?
• The specific problem of CTO PCI in post CABG
patients

4. SYNTAX Study: The only randomized study to
compare PCI and CABG for CAD including CTOs
The presence of a CTO was the main reason not to
be randomized -> CABG Registry
Patrick Serruys, MD PhD
CRT 2009, March 4, 2009

5. SYNTAX and CTO revascularization
Farooq et al. JACC 2013; 61: 282-94
PCI
No revasc.
51%
CABG
No revasc.
32%

6. 47 years, male: PCI or CABG ?

7. What is the actual patency rate post CABG ?
PREVENT IV JAMA. 2005;294(19):2446-2454
About 30% of all venous grafts were occluded after 1 year
In 45% of patients at least 1 graft was occluded
8% of all LIMA(LITA) were occluded after 1 year

8. Venous graft patency for occluded vessels
PRAGUE IV. Circulation 2004;110:3418-3423
Study goal: compare on-pump with off-pump surgery

9. Venous graft patency for occluded vessels
PRAGUE IV. Circulation 2004;110:3418-3423
More than 50% of
CTOs are located
in the RCA, 20%
in the LCX

10. Higher Mortality with longer CTOs post CABG
Banerjee SR et al. J Cardiac Surg 2012; 27: 662-7
605 CABG patients
42% with CTO, 48% in RCA
Bypass to CTO in
LAD LCX RCA
100% 92% 85%

11. The problem of the anstomoses to occluded vessels
Werner et al. Circulation 2003;107:1972-7

12. The distal epicardial territory acute and at follow-up
6 months later
Epicardial diameter depends on
shear stress, which is increasing
with increasing perfusion pressure
and flow

13. Lumen increase 6 months after PCI of CTO
Park JJ et al. JACC Interv, 2012; 5:1827-36
However:
Total occlusion defined
with <1 month duration
and TIMI 0 and I

14. LIMA graft patency for occluded vessels
PRAGUE IV. Circulation 2004;110:3418-3423

15. CTO-PCI or CABG
• We need to accept that a LIMA to LAD-CTO
will still be superior to PCI especially for the
long-term benefit
• We need to establish the long-term benefit of
CTO PCI for our patients in the range beyond a
few years
• To do CTO PCI for a LAD we should respect a
future LIMA anastomoses option

16. CTOs are frequent in chronic CAD
0
2000
4000
6000
8000
10000
12000
14000
16000
Post-CABG STEMI Coronary angio
CTO
No CTO
Fefer P et al. J Am Coll Cardiol. 2012;59(11):991-997
Number of patients
54%
10%
18%

17. Post CABG prevalence in the literature
Muramatsu T et al. EuroIntervention 2014
Alessandrino G et al. JACC CI 2015
Alaswad K et al. CCI 2015
CABG prevalence in CTO
patients ranged from 7.5%
to 36%

18. CTO Scores and CABG ?
J-CTO score PROGRESS score
Morino Y et al. JACC Interv 2011; 4: 213 Christopoulos G et al. JACC Interv 2016; 9: 1

19. Post CABG CTO PCI success
Michael TT et al. Heart 2013;99:1515-18

20. Post CABG CTO PCI success (RECHARGE)
Maeremans J et al. JACC 2016; 68: 1958-70

21. CTO Scores and CABG ?
Alessandrino G et al. JACC CI 2015; 8: 1540

22. RECHARGE score
(based on 880 lesions)
Maeremans et al CCI 2018; 91: 192-202

23. The EURO CTO “CASTLE” Score
Previous CABG
No 1.00
Yes 1.42 (1.25 – 1.61) <0.0001
Based on 17238 procedures
CASTLE:
CABG
Age>70
Stump (non-tapered)
Tortuosity (proximal to CTO)
Length>20
Calcification severe
Risk groups
Risk scores 0-1 2 3 4-6
0.0
0.1
0.2
0.3
0.4
ProbabilityoffailureofPCI
1 2 3 4
observed
predicted
Failure rate
Szijgyarto et al JACCInterv 2019

24. Post CABG CTOs are unpredictable ?
A personal experience
• If CTO developed post CABG the CTO is often
functional, and can be easily passed
• If it is a prior CTO it often is also compromised
by long-term calcification
• Remember that an occluded venous graft may
still be a viable option for a retrograde access

25. Disease progression after CABG
Pereg et al JACC Interv. 2014;7:761-7

26. Pre-op lesion severity and post op CTO
Pereg et al JACC Interv. 2014;7:761-7

30. 20 years Post CABG: Ostial RCA CTO
What is the best strategy ?
Retrograde options are challenging

31. Moderate calcification -> medium-strengh wire

32. OPEN CTO Registry – High prevalence of CABG

33. Considerable Mortality
Safety
In Hospital Frequency
Death 0.9%*
MI 2.4%
Emergent surgery 0.6%
Perforation 6.0%
Clinical perforation 4.9% (82%)
Bleeding Access 4.0%
Radiation injury 0.1%
30 Day Frequency
Death 1.3%
Rehospitalization 14.7%
Unplanned 12.1% (82%)
Revascularization 2.6%
Planned 2.6%
PCI 2.3%
CABG 0.3%
Skin change 3.1%
6 Month Frequency
Death 2.8%
Rehospitalization 32.65%
Skin change 3.4%
*STS risk estimate for OPEN patients 1.67%
Not Adjudicated

34. Be aware of perforations in post CABG patients
Deaths and Adverse Events
Patient In Hosp Perforation Periproc MI Post CABG
1 Yes Yes Yes Yes
2 Yes Yes Yes No
3 Yes Yes No No
4 Yes Yes No Yes
5 Yes Yes No No
6 Yes Yes No No
7 Yes Yes No Yes
8 Yes Yes No Yes
9 Yes Yes No Yes
5/9 deaths associated with perforation were in post CABG patients
similar mortality of perforation with and without prior CABG
(1.1% vs. 0.8%, p=0.62)
All 9 deaths were associated with a perforation
Sapontis et al. JACC CI. 2017;10(15):1523.

35. Conclusion: The post CABG patient with a CTO
• Post CABG patients with CTO are found in
about 10-15% in Europe, >30% in US
• A post CABG patient is often more difficult to
treat, especially if the CTO was preexistent
• The complication from a perforation during
CTO PCI may be even higher than with non-
CABG patients due to the restriction of the
pericardium and difficulty to drain

36. Final thoughts
• Should we not stop referring non-proximal
LAD CTOs to surgery ?
• We would minimize the problem of post CABG
CTO PCI after graft failure
• And we could reserve non-LAD bypass surgery
to failed CTO PCI cases with then an urge for
an arterial revascularization

37. Final thoughts
• Should we not stop referring non-proximal
LAD CTOs to surgery ?
• We would minimize the problem of post CABG
CTO PCI after graft failure
• And we could reserve non-LAD bypass surgery
to failed CTO PCI cases with then an urge for
an arterial revascularization