CTO PCI in secondary revascularisation after CABG can be challenging due to worse lesion characteristics like heavy calcium. Bypass grafts, whether patent or occluded, can be used as conduits for retrograde guidewires using techniques like CART. Achieving complete revascularization after PCI late post-CABG is associated with better long-term outcomes and mortality compared to incomplete revascularization of one or more regions.

1. CTO PCI in secondary
revascularisation after CABG
Achim Büttner
EUROCTOCLUB - Madrid, September 26th, 2014
Klinik für Kardiologie und Angiologie II
Universitäts-Herzzentrum Freiburg – Bad Krozingen

2. Cumulative patency rates for graft types
in symptomatic patients
Khot UN et al. Circulation 2004;109:2086-2091

3. Prevalence of CTO in PCI patients
Fefer P et al, (Canadian PCI Registry) JACC 2012;59:991-7
18%
54%
No CABG Previous CABG

4. LIMA-graft on LAD patent CTO of proximal RCA
♂ 59 yrs. * 6 yrs. post CABG * Angina CCS 2
LVEF 62% * SVGs on LCX and RCA 100%
#192996

5. Left coronary artery (RAO)

12. • Registry data
• Technical aspects
◦ Calcification
◦ Bypass grafts as guidewire conduit
◦ CART
◦ Recanalisation of grafts
• Prognosis after PCI

13. Complex CTOs: Patients after CABG
Registry 3 US centres, 2006 – 2011 (n=1363 CTO patients)
P<0.001 P<0.001 P<0.001
(n=855) (n=508)
63.3
27%
38
88%
67.7
47% 49
80%
Age (years) Retrograde
approach
Fluoroscopy time
(min)
Success rate
No CABG Previous CABG
P=0.015
Michael TT et al. Heart 2013

14. Complex CTOs: Patients after CABG
CTOs single operator Bad Krozingen 01/2011 – 09/2013 (n=583)
P<0.001 P<0.001 P<0.001
(n=434) (n=145)
62.7
19%
34%
51
95%
69.3
37% 41%
66
82%
Age (years) Angina CCS
3+4
Retrograde
approach
Fluoroscopy
time (min)
Success rate
No CABG Previous CABG
P<0.001P=0.118

15. Complex CTOs: Patients after CABG
CTOs single operator Bad Krozingen 01/2011 – 09/2013 (n=583)
P<0.001 P<0.001
(n=434) (n=145)
P<0.001
27%
23mm
18%
1.4%
10%
32mm
43%
4.1%
LAD-CTO CTO length Calcium °3 Rotablation
No CABG Previous CABG
P=0.053

16. • Registry data
• Technical aspects
◦ Calcification
◦ Bypass grafts as guidewire conduit
◦ CART
◦ Recanalisation of grafts
• Prognosis after PCI

17. ♂ 69 yrs. * 11 yrs. post CABG * Angina CCS 2
LVEF 40% * SVG on LCX 100%
#208470

23. ♂ 60 yrs. * 14 yrs. post CABG * Angina CCS 4
LVEF 62% * SVGs on LCX and RCA 100%
#207523

30. #179311-1
CTO of LCX 11yrs post CABG
Ostial LCX occlusion Patent SVG on LCX-OM1
Recanalisation target: OM2
RAO caudal RAO caudal

31. ConfianzaPro12
in SVG
1.5mm Rotablator
ConfianzaPro12 in OM2
Stents not expanded
3.0mm balloon
50atm Final result (88mm DES)
#179311-2

32. • Registry data
• Technical aspects
◦ Calcification
◦ Bypass grafts as guidewire conduit
◦ CART
◦ Recanalisation of grafts
• Prognosis after PCI

34. ♂ 74 yrs * 9 yrs post CABG * Angina CCS 2 * LVEF 25%
* SVG on LCX 100%

40. • Registry data
• Technical aspects
◦ Calcification
◦ Bypass grafts as guidewire conduit
◦ CART
◦ Recanalisation of grafts
• Prognosis after PCI

41. CTO of LCX: Modified CART via occluded SVG
Antegrade wire
subintimal
RAO caudal
Balloon dilatation over
„SVG-wire“ at anastomosis

42. • Registry data
• Technical aspects
◦ Calcification
◦ Bypass grafts as guidewire conduit
◦ CART
◦ Recanalisation of grafts
• Prognosis after PCI

43. CABG + Aortic valve replacement 07/2011
RAO caudal RAO cranial
♂ 72 yrs. * 3 VD (left dominance) * Aortic valve stenosis
SVG an LCX-OM LIMA on Diag / LAD

44. SYNTAX Trial + Registries: Independent predictors for
incomplete revascularisation after CABG
Farooq V et al. JACC 2013;61(3):282-94

45. ♂ 73 yrs. * Angina CCS 3 * 1 yr. post AVR and CABG
LIMA on Diag/LAD open, SVG on LCX 100%

46. LAO
LM occluded with bioprosthesis

47. Recanalisation attempt of SVG on LCX-OM

48. Dilatation proximal SVG with 2.5mm balloon 28atm

49. Second floppy wire and distal blocking with 2.5mm balloon
Balloon dilatation and aspiration …..

50. Introduction of FilterWire EX for stenting (from proximal to distal)
Aspiration …

51. 3.0/38mm
3.0/38mm
3.0/32mm
Positioning of 3rd Everolimus-stent

52. Final result

53. • Unstable angina CCS 4, dyspnea NYHA IV
• 04/2014 Angiography: LM 100%, LIMA-Graft patent, SVG 100%
• → Referral to our center for ????
18 months later …..
#194649+194723+210642

74. • Registry data
• Technical aspects
◦ Calcification
◦ Bypass grafts as guidewire conduit
◦ CART
◦ Recanalisation of grafts
• Prognosis after PCI

75. Outcome after incomplete versus complete revascularisation
in multivessel coronary artery disease (Meta-analysis)
0.2 0.5 1 2 5 10
Risk Ratio (95% CI)
CABG patients (n=25,938)
Risk Ratios for long-term mortality
All patients (n=89,883)
PCI patients (n=63,945)
0.71 (0.65-0.77), p<0.001
0.72 (0.64-0.81), p<0.001
Favours incomplete
revascularisation
Favours complete
revascularisation
0.70 (0.61-0.80), p<0.001
Garcia S et al, JACC 2013;62(16):1421 –31

76. Prognosis after PCI late post CABG
Löffelhardt N, Büttner HJ et al. Abstract DGK 2013
Degree of revascularisation post PCI
54%
32%
14%
0
10
20
30
40
50
60
Complete Incomplete
1 region
Incomplete
≥ 2 regions
N=750 N=444 N=191
(N=1385 pts. 2003 - 2008; PCI 8.7±6.1 years after CABG)

77. Complete* (n=750)
Incomplete 1 region (n=444)
Incomplete ≥ 2 regions*(n=191)
Prognosis after PCI late post CABG
*HR 1.94 (1.36 – 2.77); p<0.001
Adjusted cumulative mortality and degree of revascularisation
0 1 2 3 4 5
Years

78. • CTOs after CABG have worse lesion characteristics (calcium!!)
and are technically demanding.
• Patent or occluded bypass grafts can be used as conduits for
retrograde guidewires (-> CART, retrograde stent implantation).
• Secondary revascularisation with PCI in patients with bypass graft
failure has a marked influence on quality of life and may eventually
also affect prognosis.
Conclusions