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Ct omin

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Ct omin

  1. 1. Nicolaus Reifart Bad Soden imMain Taunus Kliniken TaunusBad Soden, GermanyCTO PCICurrent Concepts & TechniqueRole of DES
  2. 2. 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 ?
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 2010
  8. 8. Changes of Strategy and Results
  9. 9. Euro CTO Club membership45 4340 3835 33 293025 212015 1310 5 0 2006 2007 2008 2009 2010 2011
  10. 10. 11481 CTO Procedures40003500 3591 Online3000 3090 Registry25002000 19771500 16081000 1215500 0 2006 2007 2008 2009 2010
  11. 11. EuroIntervention 2011
  12. 12. Evidence of viable myocardium 100% 90 80 70 60 50 40 30 68 64 20 50 10 0 2008 2009 2010
  13. 13. Previous STEMI (%)1900n1900ral1900n1900ral1900n1900ral 17 17 181900n1900ral1900n1900ral1900n1900ral1900n1900ral 1905n1905ral 1905n1905ral 1905n1905ral
  14. 14. Unlike OAT:• > 80% of CTO patients had no Q-Infarction 2008/10)
  15. 15. Success of CTO 11481 CTO Procedures100 90 82 86 77 80 80 75 70 60 50 40 30 20 10 0 2006 (3591) 2007 (3090) 2008 (1215) 2009 (1608) 2010 (1977) 06/07: all members - since 2008 online registry
  16. 16. Success related to Volume 2008-10 <100/>150/>200>300 CTO100 95 93 90 89 88 89 83 84 83 85 79 81 81 83 80 75 70 67 65 60 55 50 2008 2009 2010 Remember: Syntax < 50%
  17. 17. Success Second Attempt (%)100 90 80 70 60 50 85 40 69 30 20 10 0 Referral 636 2nd try 260 EuroCTO registry 2011
  18. 18. Dont start with level 3 or4 !!! Stepwise increase indifficulty important
  19. 19. Fluoroscopy & Procedure (min)200180160140120100 89 91 92 94 80 60 40 35 38 47 20 33 0 2007 2008 2009 2010
  20. 20. Dye Consumption (ml)500450400350 278 284 279300250200150100 50 0 1905n1905ral 1905n1905ral 1905n1905ral
  21. 21. CIN (GFR > – 25%) 54.5 43.5 32.5 21.5 0.7 1 1 0.40.5 0 2008 2009 2010
  22. 22. Complications (%) 54.5 AMI: QMI < 0.5 % 43.5 3 Bleeding AMI2.5 Em-CABG 2 Tamponade1.5 Death 10.5 0.3 0.4 0.4 0.3 0 2007 2008 2009 2010
  23. 23. There are different strategies to success…The goal should be : Most simple aproach withoptimal outcome for the patient ….
  24. 24. 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%)
  25. 25. Use of hydrophylic wires (%) (polimer & non-polimer)100 90 80 70 60 50 49 55 40 46 30 35 20 25 10 0 2006 2007 2008 2009 2010
  26. 26. Successful wire504540 * 39 < 1g35 1-3g 32 31 28 6-9g30 27 24 25 > 9g25 22 20 1920 16 171510 5 0 2008 2009 2010 * mostly Fielder XT
  27. 27. Use of IVUS and MSCT (%)10 9 8 7 6 6 5 4 3 4 MSCT 3 2.6 2 1 2 1.5 IVUS 0 2008 2009 2010
  28. 28. Use of Tornus and Corsair20181614 131210 Tornus 8 8 Corsair 6 5 5 4 2 0.08 0.08 0 2008 0.08 2010
  29. 29. Retrograde Aproach % of all CTO2018161412 10.6 9.8 10.810 8 6 4 2 0 2008 2009 2010
  30. 30. Ante - versus Retrograde450400 383350300 268250 ante (4299)200 154 retro (501)150100 81 87 50 36 0 Fluoro (min) Procedure (min) Dye (ml)
  31. 31. Success Antegrade vs Retrograde100 90 84 87 81 79 80 70 65 70 60 50 Antegrde 40 Retrograde 30 20 10 0 2008 2009 2010
  32. 32. 5075265CTO CX 26months2nd tryCorcescreworthogradeepicardialcollateral
  33. 33. 2Confianza 9
  34. 34. Externalisationwith RG3 andantegradedilation
  35. 35. Nobori3.0 x 282.5 x 18
  36. 36. Conclusion• Antegrade should be turned into retrograde before the distal vessel is ruined• Retrograde with Corsair feasable via orthograde corc-screw like collaterals of the same vessel
  37. 37. 50753698 years oldvery calcifyedCTO of LAD
  38. 38. PCI failure5 years agoCCS 2
  39. 39. Confianza12Corsair
  40. 40. Allwayscheck 2ndview
  41. 41. Antegradeno chance
  42. 42. Retrogradetry viaseptalcollaterals
  43. 43. Wire inguiding butimpossible tofollow withCorsair(severecalcification)
  44. 44. Againantegrade„Kissingwires“
  45. 45. Failed withCorsair insituCorsairpulled back
  46. 46. Then wirecould beplaced throughexisting lumen
  47. 47. Andsuccessfullyfinished
  48. 48. Conclusion• Severe calcification easier to penetrate retrogradely• If retrograde fails, why not complete antegradely….• Ante- and retrograde procedures are often complimentary
  49. 49. Use of DES EuroCTO Club 95 97100 85 90 80 72 66 70 60 50 40 30 20 10 0 2006 2007 2008 2009 2010
  50. 50. 14 comparative studies, 4394 patients
  51. 51. 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
  52. 52. There are only 2 randomised trials with DES for CTO Prison II Coracto
  53. 53. 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
  54. 54. 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
  55. 55. 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%
  56. 56. PRISON II vs CORACTO 6m relative risk reduction TVR (%)100 90 80 70 60 50 64 79 CYPHER CORACTO 40 30 20 10 0
  57. 57. 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
  58. 58. 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

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