The document summarizes findings from the Euro CTO Club registry regarding chronic total occlusion (CTO) percutaneous coronary intervention (PCI) from 2008-2015. Key points include: - The number of CTO PCI procedures increased annually in the registry from about 1000 to 2500. - Overall success rates have remained stable around 85-90% for the past 5 years. - Retrograde procedures increased significantly after 2011, accounting for up to 35% of cases. - Complication rates remained below 1.5-2%. - Higher scores on the J-CTO scale predict need for hybrid/retrograde approaches and dissection re-entry techniques to successfully treat more complex C

1. EURO CTO CLUB
Krakow 2016
8th Experts "Live"
CTO Workshop 2016
Sept 30th – Oct 01st, 2016
Alfredo R. Galassi MD, FESC, FACC, FSCAI
Department of Clinical and Experimental Medicine
University of Catania, Italy
The Euro CTO Club:
The Registry

2. EURO CTO CLUB
Krakow 2016
Club
Membership
0
20
40
60
80
100
120
140
160
13
21
29 33 38 43
52 55 61
124
143
0
10
20
30
40
50
60
70
80
90
100
Full Associated Affiliated
48
92
3

3. EURO CTO CLUB
Krakow 2016
Club
Membership

4. 0
500
1000
1500
2000
2500
3000
2008 2009 2010 2011 2012 2013 2014 2015
1303
1724
2189
2634 2603 2660 2615
2404
Online Registry 2008-2015

5. 0%
20%
40%
60%
80%
100%
2008 2009 2010 2011 2012 2013 2014 2015
50
31 28.6
20.5 18.8 14.6 16.6
5.5
50
69 71.4
79.5 81.2 85.4 83.4
94.5
Antegrade only Retrograde + Antegrade
Antegrade/Retrograde
Operators

6. 0%
20%
40%
60%
80%
100%
2008 2009 2010 2011 2012 2013 2014 2015
90 88.5 89.5 86
77
71 72.4
64.9
10 11.5 10.5 14
23
29 27.6
35.1
Antegrade Retrograde± Antegrade
Antegrade/Retrograde
Procedures

7. 0
20
40
60
80
100
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
75 77
80 82
85.3 85 85.3 87 85.8 87.1
Angiographic Success
%

8. 0
20
40
60
80
100
2008 2009 2010 2011 2012 2013 2014 2015
85.5 86.5 88.1 87.6 87.8 90.3
87 89
73.6
64.2
77.1 76.5 77.8
79.5 82.2 83.3
Antegrade Retrograde
Angiographic Success
%

9. 0
10
20
30
40
50
60
2011
2012
2013
2014
2015
Wires to start
%

10. Wires to start
(Fielder XT Family)
0
10
20
30
40
50
60
2014 2015
Fielder XT R
Fielder XT A
Fielder XT
%

11. Wires to start
(Gaia Family)
0
5
10
15
20
2014 2015
Gaia 3rd
Gaia 2nd
Gaia 1st
%

12. 0
5
10
15
20
25
30
2011
2012
2013
2014
2015
Final wires to cross
%

13. Final wires to cross
(Fielder XT Family)
0
5
10
15
20
25
30
2014 2015
Fielder XT R
Fielder XT A
Fielder XT
%

14. Final wires to cross
(Gaia Family)
0
5
10
15
20
25
2014 2015
Gaia 3rd
Gaia 2nd
Gaia 1st
%

15. Guiding Catheter Selection in the ERCTO
No trend differences were observed between antegrade
and retrograde approach during years
0
10
20
30
40
50
60
2008 2009 2010 2011 2012 2013 2014 2015
6 Fr 7 Fr 8 Fr

16. Procedural Details
0
10
20
30
40
50
60
70
80
2008 2009 2010 2011 2012 2013 2014 2015
Contralateral injection Radial approach

17. 0
5
10
15
20
25
30
2009 2010 2011 2012 2013 2014 2015
3
2
5
7,9 7,3 6,7
12
1 1
6
17,6
22,8 22,7
27,2
2,4 2,1
5
10,3
11,8 11,1
17,3
Antegrade Retrograde Overall
IVUS
%

18. 0
0,5
1
1,5
2
2,5
3
3,5
2008 2009 2010 2011 2012 2013 2014 2015
Death
Myocardial infarction Vascular complication
Donor vessel dissection
Cardiac tamponade
Coronary perforation
Procedural Complications

19. Revascularization strategies 2014-2015
2014
2615 CTO PCI attempts
Antegrade only
1892 CTO PCI (72.3%)
Hybrid
410 CTO PCI (15.7%)
Retrograde only
313 CTO PCI (12%)
2015
2404 CTO PCI attempts
Antegrade only
1559 CTO PCI (64.9%)
Hybrid
413 CTO PCI (17.4%)
Retrograde only
426 CTO PCI (17.7%)

20. 2014
2615 CTO PCI attempts
Antegrade only
1892 CTO PCI (72.3%)
Hybrid
410 CTO PCI (15.7%)
Retrograde only
313 CTO PCI (12%)
Unsuccessful
242 CTO PCI (9.2%)
Successful
1650 CTO PCI (90.8%)
1222
(74.1%)
185
(11.2%)
169
(10.2%)
74
(4.5%)
Single wire
Parallel wire
Step up/Step down
ADR

21. 2015
2404 CTO PCI attempts
Antegrade only
1559 CTO PCI (64.9%)
Hybrid
413 CTO PCI (17.4%)
Retrograde only
426 CTO PCI (17.7%)
Unsuccessful
172 CTO PCI (11%)
Successful
1387 CTO PCI (89%)
906
(65.3%)
185
(13.3%)
208
(15%)
88
(6.4%)
Single wire
Parallel wire
Step up/Step down
ADR

22. 2014
2615 CTO PCI attempts
Antegrade only
1892 CTO PCI (72.3%)
Hybrid
410 CTO PCI (15.7%)
Retrograde only
313 CTO PCI (12%)
Unsuccessful
26 CTO PCI (8.3%)
Successful
287 CTO PCI (91.7%)
116
(40.4%)
23
(8%)3
(1.1%)
145
(50.5%)
Wire Crossing
Touching wire
CART
Reverse CART

23. 2015
2404 CTO PCI attempts
Antegrade only
1559 CTO PCI (64.9%)
Hybrid
413 CTO PCI (17.4%)
Retrograde only
426 CTO PCI (17.7%)
Unsuccessful
30 CTO PCI (7%)
Successful
396 CTO PCI (93%)
125
(31.5%)
47
(11.8%)
3
(0.7%)
221
(55.8%)
Wire Crossing
Touching wire
CART
Reverse CART

24. 2014
2615 CTO PCI attempts
Antegrade only
1892 CTO PCI (72.3%)
Hybrid
410 CTO PCI (15.7%)
Retrograde only
313 CTO PCI (12%)
37
(40.2%)
22
(23.9%)
15
(16.3%)
18
(19.6%)
Single wire
Parallel wire
Step up/Step down
ADR
Unsuccessful
103 CTO PCI (25.1%)
Successful Antegrade
92 CTO PCI (22.4%)

25. 2015
2404 CTO PCI attempts
Antegrade only
1559 CTO PCI (64.9%)
Hybrid
413 CTO PCI (17.4%)
Retrograde only
426 CTO PCI (17.7%)
33
(30%)
26
(23.6%)
21
(19.1%)
30
(27.3%)
Single wire
Parallele wire
Step up/Step down
ADR
Unsuccessful
116 CTO PCI (27.7%)
Successful Antegrade
110 CTO PCI (26.6%)

26. Antegrade only
1892 CTO PCI (72.3%)
Hybrid
410 CTO PCI (15.7%)
Retrograde only
313 CTO PCI (12%)
Unsuccessful
103 CTO PCI (25.1%)
Successful Antegrade
92 CTO PCI (22.4%)
2014
2615 CTO PCI attempts
Successful Retrograde
215 CTO PCI (52.5%)
78
(36.3%)
26
(12.1%)2
(0.9%)
109
(50.7%)
Wire Crossing
Touching wire
CART
Reverse CART

27. Antegrade only
1559 CTO PCI (64.9%)
Hybrid
413 CTO PCI (17.4%)
Retrograde only
426 CTO PCI (17.7%)
Unsuccessful
116 CTO PCI (27.7%)
Successful Antegrade
110 CTO PCI (26.6%)
2015
2404 CTO PCI attempts
Successful Retrograde
396 CTO PCI (89%)
48
(24.9%)
19
(9.8%)
5
(2.6%)
121
(62.7%)
Wire Crossing
Touching wire
CART
Reverse CART

28. J-CTO score
283
(11.8%)
477
(19.8%)
652
(27.1%)
599
(24.9%)
321
(13.4%)
71
(3%)
0 1 2 3 4 5
121
(4.6%)
529
(20.2%)
946
(36.2%)
718
(27.5%)
254
(9.7%)
47
(1.8%)
0 1 2 3 4 5
2014 2015

29. Revascularization strategies
according to J-CTO score 2014
93.4 86.4
73.5
64.9
52
36.2
2.5
7.5
14.6
21.5
28.7
29.8
4.1
6.1
11.9 13.6
19.3
34
0
20
40
60
80
100
0 1 2 3 4 5
Antegrade only Hybrid Retrograde only
%
P<0.05

30. 89.2
82.6
65.8
54.1
43.3
26.8
5.1
8.6
17
23.7
28
29.6
5.7 8.8
17.2 22.2
28.7
43.6
0
20
40
60
80
100
0 1 2 3 4 5
Antegrade only Hybrid Retrograde only
Revascularization strategies
according to J-CTO score 2015
%

31. Revascularization strategies
according to J-CTO score
2014
95.9 92.3 88.8
82
76
70.2
4.1 7.7 11.2
18
24
29.8
0
20
40
60
80
100
0 1 2 3 4 5
Conventional wire escalation Dissection re-entry
P<0.05
%

32. Revascularization strategies
according to J-CTO score
2015
95.7 92.5
79.3
71.2
65.7
53.5
4.3 7.5
20.7
28.8
34.3
46.5
0
20
40
60
80
100
0 1 2 3 4 5
Conventional wire escalation Dissection re-entry
P<0.05
%

33. 94.2 94.9
83.7 85.5
74.4
70.2
79.9
93.9
90.5 86.6
81.6
73.2
0
20
40
60
80
100
0 1 2 3 4 5
2014 2015
Success according to J-CTO score
2014 p<0.05
2015 p=NS
%

34. Conclusions from the Euro CTO club
 Number of CTO recanalization increased from 2008 till 2015 from
~1000 to ~2.500 per/year
 Overall success stable around ~85-90% in the last 5 years
 Retrograde procedures increased significantly from 2011 onwards
(up to ~35%)
 Severe complications <1.5-2.0%
 Predictive scores could be applied to select the appropriate
candidates for PCI among CTO patients and the appropriate
strategy to use
 The higher the J-CTO score, the greater the need for hybrid and
retrograde approaches, and the greater the use of dissection re-
entry techniques

35. Thank You
For Your Attention
www.alfredogalassi.com