Nicolaus Reifart Bad Soden imMain Taunus Kliniken TaunusBad Soden, GermanyCTO PCICurrent Concepts & TechniqueRole of DES
Important to know before:• Will patient benefit from CTO recanalisation ?• Are patient and operator the right candidate for CTO-PCI ?• Familiar with various procedural techniques and their outcomes ?
Whom should we open a CTO?• Limiting symptoms most likely due to CTO• Or objective evidence of relevant viability/ischemia in the territory of the occluded artery
Whom should we open a CTO?• Limiting symptoms most likely due to CTO• Or objective evidence of relevant viability/ischemia (> 10% of LV) in the territory of the occluded artery
How are CTOs treated today?• 27% of CAD patients have at least 1 CTO of these CTO Patients• 7 % PCI (success about 50 %) *• 19 % CABG (grafted about 68 %) *• 74% Medical Treatment• * SYNTAX G. Werner 2009; EuroCTO 2010
Total Occlusion Procedural characteristics Per lesion analysis CABG n=266 12 were not treated with CABG CABG n=254 Not Bypassed Bypassed n=81 n=173 Reason not bypassed: Not intended to treat (n=12) Overall 68.1 % of TO Diseased (n=11) were bypassed Inadequate conduit (n=2) Too small (n=19) Unable to find (n=1) Early Patency ??? Other (n=36) ITT, Per LesionSYNTAX: Total Occlusions • Serruys CRT 2009 • March 2009 • Slide 8
There are different strategies to success…The goal should be : Most simple aproach withoptimal outcome for the patient ….
No Discussion:• Referral is not a shame – go and watch the expert• View of distal vessel 100% (contralateral injection required in 70%)• Start with OTW• Limit dye to 4-6 x GFR• Failures are worth a 2nd try (success > 70%)
Conclusion• DES definitely reduce TVR and Reocclusion and should be 1st choice• Suspiscion of more Late stent thrombosis at least with 1st generation DES• DES with bioabsorbable coating likely to be superior – but not yet proven
There are only 2 randomised trials with DES for CTO Prison II Coracto
The DES Coracto ®• Rapamycin as an anti-restenotic drug and a poly(lactic co-glycolic acid) (PLGA) biodegradable polymer (3-4 µm)• Stent struts 80 µm• Crimped on semi-compliant balloon catheter
CORACTO Randomised trial• Constant Stent with Rapamycine in chronic total occlusions (> 3 mos) or long (> 20 mm) functional occlusions• Bad Soden/Trier- trial 95 pts randomised• PE: 6 mos late loss and restenosis• SE: 6 mos TLR clinically driven• Clinical Fu 12 mos - 24 mos – 78 mos EuroIntervention 2010
6m Restenosis Reocclusion and TVR* (n= 91 pts; 249 stents)% 75 <0.0001 p<0.0001 Constant 65 60 CORACTO 53.3 55 45 35 25 17.4 15.5 15 10.8 5 0 -5 in segment iS Reocclusion TVR Restenosis TVR if Restenosis + angina/ischemia or Stenosis > 70%
6.5 Years Follow-up (20% lost) Death and TVR N= 95 N = 91 N = 7880 68.870 6060 Death 53.3 TVR ***5040 *** ***3020 17.8 17.4 15.2 10.8 10.810 2.5 4.5 0 00 1 year 2 years 6,5 years
Conclusion Coracto• Superbe early and late results of Coracto ® versus similar BMS for CTO-PCI namely:• Sustained rel. reduction of TVR of 75%• No Stent-Thrombosis despite only 6 mos dual antiplatelet therapy• No late catch-up• The only available DES with evidence for CTO-PCI