This document summarizes the results of a study analyzing the angiographic and clinical outcomes of patients who underwent successful percutaneous coronary intervention (PCI) to treat a chronic total occlusion (CTO). The study found that the use of everolimus-eluting stents was associated with significantly lower rates of CTO vessel reocclusion compared to first-generation drug-eluting stents. Additionally, the use of the STAR technique for CTO PCI was associated with a very high rate of vessel reocclusion despite initial success. Patients treated with everolimus-eluting stents or conventional antegrade/retrograde approaches had much higher sustained vessel patency linked to improved one-year clinical outcomes.

1. David Antoniucci, MD
Madrid, September 25, 2014
Stenting in CTO

2. Disclosure Statement of Financial Interest
I, David Antoniucci, DO NOT have a
financial interest/arrangement or
affiliation with one or more organizations
that could be perceived as a real or
apparent conflict of interest in the
context of the subject of this
presentation.

3.  Large registries have shown a survival
benefit in patients with successful CTO PCI.
 Intuitively, sustained vessel patency may be
considered as a main variable related to long-
term survival and stent performance plays a
key role in this setting.
 Very few data exist about the angiographic
outcome after successful CTO PCI.

4. Danzi GB et al, Am J Cardiol 2013

5. Florence CTO Registry
Angiographic Outcome
 Design: Prospective
single-center registry of
CTO- PCI treated with DES.
 End points: Angiographic
outcome. Predictors of
reocclusion
 Methods: Forward
stepwise Logistic
Regression Analysis.
Freedom from MACE
assessed by Kaplan-Meier
estimation.
 Successful CTO-PCI
n=802 (77%)
233 Fail CTO-PCI
 6-9 months Angio FU (82%)
n=616
29 Deaths
20 Renal Insufficiency
From 2003 to 2011
1035 pts underwent CTO-PCI
Valenti R et al, JACC 2013;61:545

6. n=802
 Age (yrs) 68 ± 11
> 75 years, n (%) 233 (29)
 Male, n (%) 680 (85)
 Hypertension, n(%) 485 (60)
 Hypercholesterolemia, n (%) 458 (57)
 Diabetes mellitus, n (%) 200 (25)
 Previous myocardial infarction, n (%) 405 (50)
 Previous PCI, n (%) 289 (36)
 Previous coronary surgery, n (%) 91 (11)
 ACS, n (%) 55 (32)
 LVEF, (%) 44 ± 12
LVEF < 40 %, n (%) 298 (37)
Baseline Characteristics
in Successful CTO PCI Patients
Valenti R et al, JACC 2013;61:545

7. n=802
 Multivessel disease, n (%) 660 (82)
 3-vessel disease, n (%) 393 (49)
 CTO vessel, n (%)
LAD 248 (31)
LCx 177 (22)
RCA 329 (41)
Others 48 (6)
 Occlusion length, mm 38 ± 21
 Lenght > 20 mm, n (%) 597 (74)
 Reference CTO vessel diameter, mm 2.63 ± 0.53
 Ref. Diameter ≤ 2.5 mm, (%) 190 (24)
Angiographic Characteristics
Valenti R et al, JACC 2013;61:545

8. n=802
 Adjunctive Rotactional atherectomy, n (%) 37 (4.6)
 STAR technique, n (%) 34 (4.2)
 CTO stent implanted, n 1509
Mean stents / patient 1.88
 First generation DES (PES and SES) 66%
 EES 34%
 CTO stent length, mm 52 ± 30
 Post-PCI minimum lesion diameter, mm 2.74 ± 0.49
 Fluoroscopic time, min Median [IQ range] 24 [15 – 36]
 Contrast, ml Median [IQ range] 300 [200 – 400]
 Multivessel PCI, n (%) 540 (67)
 Completeness of revascularization, n (%) 675 (84)
Procedural Characteristics
Valenti R et al, JACC 2013;61:545

9. 6-9 months Angiographic Outcome
20
12.5
7.5
0
5
10
15
20
25
Rest/Reoccl NonOcclusive Rest Reocclusion
CTO Reocclusion
1st generation DES 10%
EES 3%
STAR 57%
%
p=0.001
CTO Rest./Reoccl.
1st generation DES 25%
EES 13%
STAR 64%
F-U rate 82%
Valenti R et al, JACC 2013;61:545

10. Predictors of Angiographic Outcome
Logistic Regression Analysis
Reocclusion OR 95% CI p value
 STAR technique 29.5 11.9-73.2 < 0.001
 EES 0.22 0.09-0.54 0.001
Nonocclusive Restenosis
 RCA-CTO 1.64 1.02-2.62 0.040
Valenti R et al, JACC 2013;61:545

14. Conclusions
 The use of EES is associated with a 5-fold
decrease in CTO vessel reocclusion rate as
compared to 1st generation sirolimus-eluting stent
and paclitaxel-eluting stent.
The use of the STAR technique, even successful, is
associated with a very high rate of target vessel
reocclusion.
 The use of EES and conventional antegrade or
retrograde approaches to CTO are associated with a
very high sustained patency rate that links with
prognosis.

15. One-year Clinical Outcome
3.2
0.9
0
12.8
16
0.4
0
2
4
6
8
10
12
14
16
18
Death MI CABG CTO re-
PCI
MACE Def. ST
CTO vessel re-PCI
1st generation DES 14.1%
EES 10.5%
STAR 32%
%
MACE
1st generation DES 19%
EES 11.6% p=0.005
Valenti R et al, JACC 2013;61:545

16. Predictors of Clinical Outcome
Multivariate Cox Regression Analysis
Cardiac Death HR CI p value
 Age >75 yrs 4.64 2.19-9.83 < 0.001
 LVEF < 40% 7.25 2.77-19 <0.001
 LAD-CTO 2.39 1.13-4.33 0.020
 Complete Rev. 0.48 0.24-0.95 0.037
MACE
 Age >75 yrs 1.64 1.17-2.31 0.004
 STAR technique 2.26 1.21-4.22 0.010
 LVEF < 40% 1.47 1.06-2.06 0.023
 LAD-CTO 1.42 1.02-2.01 0.046
Valenti R et al, JACC 2013;61:545

17. 60 12 362418 30
1
0.9
0.8
0.7
0.6
0.5
0.4
Time (months)
Event–FreeSurvival
77 ± 2%
55 ± 14%
nonSTAR
STAR
p = 0.014
Kaplan-Meier Analysis
of Freedom from MACE
Valenti R et al, JACC 2013;61:545