A 56-year-old male with a history of heart disease presented with ongoing chest pain after an unsuccessful attempt to open a chronic total occlusion of the right coronary artery via percutaneous coronary intervention 6 weeks prior. The patient underwent a second PCI procedure where the CTO was successfully opened using an antegrade approach, resolving his symptoms. At follow-ups 6 months, 12 months and 18 months later, the patient reported continued relief from symptoms and was able to return to exercising and training for triathlons without any chest pain.

1. +
Cath/CT Conference
LT. S.T. Anthony Kaviratne MD
January 20, 2015

2. +
Case Presentation
56 year old male non-smoker with history of HLD and recent
NSTEMI treated medically presented with chief complaint of
ongoing chest pain with exertion.
The patient initially presented 6 weeks ago to a OSH with 2
days of stuttering chest pain after completing Iron man
triathlon. He noted severe chest discomfort at the end of his
run but completed the race. Symptoms resolved with rest but
would occur with exertion over the next 2 days.
Patient was seen by OSH followed by cath which showed total
occlusion of the right coronary artery but otherwise non
obstructive mild disease. Per report attempt was made at
opening the right coronary which was unsuccessful and
medical therapy was pursued.
Current symptoms similar initial which has not improved
over the last 6 weeks.

3. + Past Medical History
 Coronary artery disease
 HLD
 ASA 81mg
 Plavix 75mg
 Lipitor 80mg
 Metoprolol XL 25mg
 Lisinopril 2.5mg PO qday
 Renexa 1000mg PO BID
 Nitro PRN
Medications

4. +
Social and Family History
Tobacco: Denies
Etoh: 6 beers/ week
Recreation drug use: None
Family History:
- No known family members with CAD.

5. +
Physical Exam:
 VS: sinus bradycardia but otherwise unremarkable.
 Male in NAD with normal work of breathing
 Neck: JVD 8 cm, Carotid upstroke was delayed.
 Cardiac: Normal S1 and S2. No murmurs/rubs/gallops
 Pul: CTAB
 Ext: No Edema
 Vascular: 2+biltateral and equal

6. +
Labs
 Labs:WNL
 EKG: sinus with nonspecific T wave abnormalities throughout
the precordium
 Echo: LVEF 55-60% with inferior and lateral wall
hypokinesis. Mild MR. otherwise unremarkable.
 MPS: moderate to severe ischemia inferior and infralateral
wall from mid to apex. SDS of 8
 Previous cath
 LM: no disease
 LAD: mild luminal irregularities with left to right collaterals
 LCX: mild luminal irregularities
 RCA:Total occlusion with small bridging collaterals

7. +

8. +
Approach to this patient?
 Should another attempt made at the CTO?
 Continue medical management?
 Further medical management or referral to CABG?
 How will this change the patient’s course?

9. +
Management of Chronic
Total Occlusion

10. +
Objectives
 Define CTO and epidemiology
 PCI success rates and attempts and barriers to
attempt
 Indications for PCI for CTO (when to consider
CABG)
 Benefits of PCI to CTO
 Strategies for opening CTO with examples

11. +
Chronic Total Occlusion (CTO)
 “True CTOs” are characterized by significant narrowing with lumen
that results in complete interruption of antegrade blood flow (TIMI
0).
 “Functional CTO” which has minimal contrast penetration though
the lesion without distal vessel opacification (TIMI 1)
 Registry data demonstrate that 15–30% of patients undergoing
diagnostic coronary angiography will have at least one occluded
coronary artery
 Retrospective review of >6500 patients reported CTO lesions in up
to 52% of patient
 CABG has historically been the preferred revascularization option
owing to its higher immediate procedural success rate in the CTO
vessel
Christofferson RD, Lehmann KG, Martin GV et al. Effect of chronic total coronary occlusions on treatment strategy. Am. J. Cardiol.
95(9),1088–1091 (2005).

12. +
PCI success rates
 SYNTAX trial reported 50%
success rates
 70% of CTOs were successfully
re-opened with PCI in the
Canadian Multicenter registry
 Angiographic results of the
PRAGUE-4 tria: 1-year patency
after bypass grafting of
collateralized CTO vessels only
23%. LAD CTOs were much
better with 100% patency at 12
month
 Rathore S et al. Procedural and in-hospital outcomes after
percutaneous coronary intervention for chronic total
occlusions of coronary arteries 2002 to 2008: impact of
novel guidewire techniques. JACC Cardiovasc. Interv.
2(6),489–497 (2009).

13. +

14. +
Barriers to CTO attempt
 PCI technical complexity: Difficulty crossing CTO with wires,
Operator skill
 Unique complications
 Vessel perforation
 Contrast nephropathy
 Radiation injury: Av floro time 46 min+/- 25 (3.2Gy +/- 2.1)
 Possible loss of collaterals
 Economic disincentive: labor and resources
 Physician skepticism
 Higher short term MACE rate (in hospital elective 0.9-6.5%
vs. 1.2% non CTO)
 Higher mortality (in house 0.5% with failed CTO 1-2.6%). 30
day high as 1.1%

15. +
Indications for PCI for CTO
 PCI is warranted when all three of the following conditions
are met:
 The occluded vessel is responsible for the patient's symptoms or
in selected patients with silent ischemia in whom there is a large
amount of myocardium at risk.
 The myocardial territory of the occluded artery is viable
 The likelihood of success is >60 percent with estimated rate of
death <1% and MI < 5%.
 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary
Intervention
 Class IIa: PCI of a chronic total occlusion in patients with appropriate
clinical indications and suitable anatomy is reasonable when performed
by operators with appropriate expertise. (Level of Evidence: B)
Stone et al. “Percutaneous Recanalization of Chronically Occluded Coronary Arteries: A Consensus Document”.
Circulation. 2005;112:2364-2372

16. +
CABG over PCI for CTO
 Left main disease
 Complex three-vessel disease, particularly in patients with
insulin-requiring diabetes, severe left ventricular
dysfunction, or chronic kidney disease.
 An occluded proximal left anterior descending coronary
artery that supplies a viable anterior wall that is not
favorable for PCI.
 Multiple CTOs with a low anticipated rate of success
Multivessel disease

17. +
What are the benefits?

18. +
Long term survival with CTO
 Hannan EL, Racz M, Holmes DR, et al. Impact of completeness of percutaneous coronary intervention
revascularization on long-term outcomes in the stent era. Circulation 2006;113:2406–12

19. +
Long Term outcome of
Recanalization of CTO: Survival
Jones et al JACC:CV intervention April 2012 Muhammad et al, Cath and CV intervention 3/2013

20. +
Impact on angina
 TOAST-GISE (Total Occlusion An- gioplasty Study–Società
Italiana di Cardiologia Invasiva) trial, CTO-PCI success was
associated with 86% angina-free survival, whereas CTO-PCI
failure was associated with 70% angina-free survival (p
=0.008)
 The COURAGE nuclear substudy reported reduction in
ischemic myocardium measured by MPS showed PCI plus
OMT (-2.7%) vs. OMT (-0.5%)
 PRISON II trial, the proportion of patients with CCS angina
class ≥3 was reduced from 62% at baseline to 25% at 6
month
 Other trials, 85–90% of patients with CTO lesions are
reported as symptomatic of 'typical angina

21. +
Improved Tolerability of Acute
Coronary Syndrome Events
 In a STEMI CTO of a nonculprit vessel is a independent
predictor of early mortality and cardiogenic shock.
 Van der Schaaf et al showed CTO is increased twofold
compared with STEMI patients with single-vessel disease (1-
year mortality 63 vs 31%)
 The presence of CTO in a non-IRA has a comparable effect
on the outcome of non-STEMI (NSTEMI) patients
 Bataille Y, Dery JP, Larose E et al. Deadly association of cardiogenic shock and chronic total occlusion in acute
ST-elevation myocardial infarction. Am. Heart J. 164(4),509–515 (201
 van der Schaaf RJ, Timmer JR, Ottervanger JP et al. Long-term impact of multivessel disease on cause-specific
mortality after ST elevation myocardial infarction treated with reperfusion therapy. Heart 92(12),1760–1763 (2006

22. +

23. +
Other possible benefits
 Reduction in ICD therapy
 In patient’s with LVEF >35% CTOs have a greater risk of sudden
cardiac death or appropriate ICD therapy compared with non-
CTO patients (VACTO trial 21% CTO vs. 7% non CTO)
 Benefit on LV function and geometry
 Using CMR demonstrated wall thickening improved in
successful PCI

24. +
Factors influencing procedural
outcomes
 More experienced operators leads to be more success rates
(FAST-CTO study report 67% first 75 cases rising to 87% in
second 75 cases)
 Geometry of the lesion (shorter length, tapered cap,
microchannels, duration of CTO, calcium, tortuosity)
 Bridging collateral, cap continuation with minor branches
 Using specific guidewires for CTO (from expert-CTO trial)
 greater stiffness at the tip
 tapered tip to engage in microchannels (nl 0.014, CTO 0.009)
 hydrophilic or very lubricious coating to traverse
 Low profile balloon for pre-dilatation

25. +
PCI strategies
 Antegrade approach
 Parallel wire technique
 Retrograde technique
 IVUS guided
 “knuckle wire” technique
 Controlled Antegrade Retrograde Tracking (CART)

32. + Control antegrade retrograde
tracking (CART)

33. +
Questions?

34. +
Summery
 CTO are common angiographic finding and a common
reason for referral to CABG
 PCI to CTO are complex requiring a lot of resources with
unique risk/complications associated with it.
 PCI to CTO technically challenging and financial
disincentives prevent more attempts.
 PCI to CTO should be considered in patients who are
symptomatic despite OMT, CABG but now with failed grafts,
and in patients with large area of myocardium in jeopardy
(specially if they are unwilling to undergo CABG).

35. +
Patient outcome
 PCI of the CTO attempted with antegrade approach and was
successful. Procedure took 4 hours with 65 min of fluoro
time.
 His symptoms resolved and returned to exercising 1 month
later without any symptoms.
 6 month follow up: Patient started training for “fun”
 12 month outcome: Patient had atypical symptoms was re
cathed with patent RCA stent with no other significant
lesions.
 18 months: Patient completed his 2 half marathon and 1 full.
Planning on attempting Iron man again.