16:05 Bufe - Learning to stop and to stage CTO PCI

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1) The document discusses strategies for percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs), including staged procedures and when to stop a procedure. 2) It notes that in cases of failed antegrade PCI, patients should be referred to a CTO specialist center for a second attempt, either immediately with a retrograde approach or in a staged procedure later. 3) Successful CTO recanalization rates have increased in recent years with more use of retrograde approaches, either primarily or after failed antegrade attempts. However, radiation exposure, contrast volume, and complications should be considered in determining when to stop a procedure.

Health & Medicine

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
A. Bufe
HELIOS Heart Center Krefeld
Department of Cardiology
Learning to stop and to stage
CTO PCI

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Experience and
limitations of
the operator
Radiation and
Contrast media
Complications
When to stage
and to stop
the procedure
CTO PCI
Patients and
operators
condition

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
0
10
20
30
40
50
60
70
80
90
100
antegrade operator ante- and retrograde
operator
%
Interventional cardiologies performing CTO PCI
and referring to Krefeld Heart Center after failure
91,6
8,4
n = 24
n=22
n=2

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
LAD lesions

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
RCA-CTO
SYNTAX Score = 21
J-CTO Score = 2

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
RCA CTO antegrade at first
CABG
Complete revascularization is mandatory
if unsuccessful

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
RCA CTO antegrade
CABG
Complete revascularization is mandatory
unsuccessful
1. LAD
2. RCA
1. RCA
2. LAD

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Septal
channels
Epicardial
channels

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Step by Step
Staged procedure

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Xience Pro 2,5/38
Xience Pro 2,75/18

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Septal
channel
Stent

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Epicardial
channels

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Reverse CART

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Experienced operators who
provide all techniques
Less experienced
(antegrade only)
Strategy and
thinking
about staging
a procedure is
very different among
CTO operators

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Even if you are not so experienced
CTO operator your work can give information
for second try and can „prepare the lesion“
two
months
later

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
0
5
10
15
20
25
30
35
40
45
50
primary retro retro in same session
after antegr failure
retro in second session
48,0
23,5
28,5
n =175
EuroCTO Club: retrograde recanalization strategy 2005 - 2007
%
Sianos et al., EuroIntervention 2008;4:84-92

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
0
10
20
30
40
50
60
70
80
90
primary retro retro in same session
after antegr failure
retro in second session
89,3
65,9
88,0
n =175
EuroCTO Club: succes rates according to strategy 2005 - 2007
Erfolgin%
Sianos et al., EuroIntervention 2008;4:84-92

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
0%
10%
20%
30%
40%
50%
60%
70%
80%
primary retrograde retrograde after failed
antegrade
76.2
23.8
Galassi et al., EuroIntervention 2014; in progress
n =1582
EuroCTO Club: retrograde recanalization strategy 2008 - 2012

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
When to stop….
The issue of radiation:
 air kerma should not reach 10 Gy (alert at 5 Gy)
 we can reduce fluoroscopic pulse rate down to 4/sec
 we can reduce radiographic frame rate down to 7.5/sec
The issue of contrast media:
 Volume of contrast should not excced 4 x GFR
 preventive pre-, post-, intraprocedural hydration

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
When to stop….
The issue of
complication:

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
 Try to solve the problem immediately
 Perforation: balloon, covered stent, coil, pericardial drain
 donor artery complication: PCI, ACT measurements
 stop the procedure if it seems to be safer for the patient

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Conclusion
 In complex coronary artery disease with CTO staged
procedure strategy is reasonable
 In case of antegrade failure by operator with limited
experience patient should be referred to CTO specialist
for analysis – transport our achievements to general
cardiologists
 In very complex CTO primary retrograde approach is
favourable
 If complications occur – solve it. Go on with the
intervention only if it is safe for the patient.
Determine limits of contrast medium and radiation

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld
Thank you!
Heart Center Krefeld Germany
We like to
reopen
CTOs

HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru
A. Bufe: HELIOS Heart Center Krefeld Morino J et al, JACC Cardiovasc Interv 2011;4:213-21

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2. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Experience and limitations of the operator Radiation and Contrast media Complications When to stage and to stop the procedure CTO PCI Patients and operators condition

3. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld 0 10 20 30 40 50 60 70 80 90 100 antegrade operator ante- and retrograde operator % Interventional cardiologies performing CTO PCI and referring to Krefeld Heart Center after failure 91,6 8,4 n = 24 n=22 n=2

4. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

5. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld LAD lesions

6. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

7. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld RCA-CTO SYNTAX Score = 21 J-CTO Score = 2

8. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

9. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

10. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld RCA CTO antegrade at first CABG Complete revascularization is mandatory if unsuccessful

11. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

12. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

13. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

14. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

15. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

16. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld RCA CTO antegrade CABG Complete revascularization is mandatory unsuccessful 1. LAD 2. RCA 1. RCA 2. LAD

17. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Septal channels Epicardial channels

18. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Step by Step Staged procedure

19. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

20. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Xience Pro 2,5/38 Xience Pro 2,75/18

21. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Septal channel Stent

22. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Epicardial channels

23. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

24. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

25. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Reverse CART

26. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

27. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Experienced operators who provide all techniques Less experienced (antegrade only) Strategy and thinking about staging a procedure is very different among CTO operators

28. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

29. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

30. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Even if you are not so experienced CTO operator your work can give information for second try and can „prepare the lesion“ two months later

31. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

32. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

33. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld 0 5 10 15 20 25 30 35 40 45 50 primary retro retro in same session after antegr failure retro in second session 48,0 23,5 28,5 n =175 EuroCTO Club: retrograde recanalization strategy 2005 - 2007 % Sianos et al., EuroIntervention 2008;4:84-92

34. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld 0 10 20 30 40 50 60 70 80 90 primary retro retro in same session after antegr failure retro in second session 89,3 65,9 88,0 n =175 EuroCTO Club: succes rates according to strategy 2005 - 2007 Erfolgin% Sianos et al., EuroIntervention 2008;4:84-92

35. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld 0% 10% 20% 30% 40% 50% 60% 70% 80% primary retrograde retrograde after failed antegrade 76.2 23.8 Galassi et al., EuroIntervention 2014; in progress n =1582 EuroCTO Club: retrograde recanalization strategy 2008 - 2012

36. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% primary retrograde retrograde after antegrade failure 82 53 Galassi et al., EuroIntervention 2014; in press n =1582 sucess% EuroCTO Club: succes rates according to strategy 2008 – 2012 (overall success: 75.3% in 2012: 79.3%)

37. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld When to stop…. The issue of radiation:  air kerma should not reach 10 Gy (alert at 5 Gy)  we can reduce fluoroscopic pulse rate down to 4/sec  we can reduce radiographic frame rate down to 7.5/sec The issue of contrast media:  Volume of contrast should not excced 4 x GFR  preventive pre-, post-, intraprocedural hydration

38. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld When to stop…. The issue of complication:

39. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld  Try to solve the problem immediately  Perforation: balloon, covered stent, coil, pericardial drain  donor artery complication: PCI, ACT measurements  stop the procedure if it seems to be safer for the patient

40. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Conclusion  In complex coronary artery disease with CTO staged procedure strategy is reasonable  In case of antegrade failure by operator with limited experience patient should be referred to CTO specialist for analysis – transport our achievements to general cardiologists  In very complex CTO primary retrograde approach is favourable  If complications occur – solve it. Go on with the intervention only if it is safe for the patient. Determine limits of contrast medium and radiation

41. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Thank you! Heart Center Krefeld Germany We like to reopen CTOs

42. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

43. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld

44. HELIOS Klinikum Wuppertal - HerzzentrumHELIOS Klinikum Wuppertal - Herzzentru A. Bufe: HELIOS Heart Center Krefeld Morino J et al, JACC Cardiovasc Interv 2011;4:213-21

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16:05 Bufe - Learning to stop and to stage CTO PCI