CTO PCI today – A summary of recent publications Carlo Di Mario, London, Great Britain 11th Experts Live CTO The annual Euro CTO meeting September 13th –14th, 2019 - Berlin, Germany

1. CTO PCI today
A summary of recent publications
Alessio Mattesini, MD
on behalf of
Carlo Di Mario, MD, PhD, FESC, FACC, FSCAI
Careggi University Hospital, Florence, Italy

2. RANDOMIZED CONTROL TRIALS: UPDATES NOT AVAILABLE
Galassi AR, Werner GS et al Eurointervention 2019

4. • Performed by Euro CTO Club
• To promote the widespread applications of state-of-the-art
CTO PCI not only in Europe but also in neighboring
communities

5. The modified hybrid algorithm for CTO PCI using the
contemporary techniques

6. Perforation algorithm for CTO PCI

7. Brilakis E et al Circulation 2019 140:420-433
The seven rules !

8. • New CTO scores
Rapid Review of the Recent CTO Literature

9. CTO scores
J-CTO score
(n=494)
CL-score
(n=1657)
PROGRESS-CTO
score
(n=781)
ORA score
(n=1073)
CT-RECTOR
score
(n=240)
RECHARGE
score
(n=880)
EURO-CTO
CASTLE score
(n=20000)
Proximal
cap blunt
1 Proximal cap
blunt
1 Proximal cap
ambiguity
1 Age  75 years 1 Proximal cap
blunt
1 Proximal cap
blunt
1 Proximal cap
blunt
1
Calcification 1 Severe
calcification
2 Moderate/sever
e tortuosity *
1 Ostial location 1 Severe
calcification
1 Calcification 1 Calcification 1
Tortuosity >
45°
1 Lesion lenght
20 mm
1.
5
Circumflex CTO 1 Collateral filling
Rentrop 0-1
2 Tortuosity
>45°
1 Tortuosity >
45°
1 Severe
tortuosity
1
Lesion
lenght 20
mm
1 Non-LAD
CTO
1 Absence of
interventional
collaterals
1 Multiple
occlusion
1 Lesion lenght
20 mm
1 Lesion lenght
20 mm
1
Previous
CABG
1.
5
Second
attempt
1 Previous CABG
on CTO target
vessel
1 Previous CABG 1
Previous MI 1 CTO duration
>12 months
or unknown
1 Diseased distal
landing zone
1 Age >70 years 1

10. EURO CTO CASTLE score
Szijgyarto Z, Rampat R et al J Am Coll Cardiol Intv 2019
Boudou N, Avran et al EuroIntervention 2019;14:e1814-e181

11. 660 consecutive CTO PCIs: the mean J-CTO score were 1.86 ± 1.2 ; the mean
EuroCTO (CASTLE) score were 1.74 ± 1.2
Kalogeropoulos AS et al , Eurointervention 2019
Equal overall discriminatory capacity between the two scores (AUC: 0.698,
95%CI: 0.653-0.742 p<0.001 for J-CTO vs. AUC: 0.676, 95%: CI 0.627-
0.725, p<0.001 for EuroCTO; AUC difference: 0.022, p=0.5)

12. For more complex procedures (J-CTO > 3 or EuroCTO CASTLE >4), the
predictive capacity of EuroCTO (CASTLE) score appeared superior (AUC: 0.588,
p=0.03 for EuroCTO (CASTLE) score vs. AUC: 0.473 p=NS for the J-CTO score, AUC
difference: 0.115, p=0.04)
Kalogeropoulos AS et al , Eurointervention 2019

13. Nagamatsu W, Tsuchikane E et l, Eurointervention 2019

14. • Hybrid approach: evolution over the years
• New CTO scores
• CTO PCI outcome
Rapid Review of the Recent CTO Literature

15. Konstantinidis NV, …. Sianos et al, Circ Cardiovasc Interv.2018;11:e006229
• CTO PCI outcome

16. Konstantinidis NV, …. Sianos et al, Circ Cardiovasc Interv.2018;11:e006229
• CTO PCI outcome

17. • CARDIO-ARSIF (Agence Régionale de Santé Ile de France) registry from
2012 to 2015
• Among 128,739 included patients, 10,468 (8.1%) had at least 1 CTO
• PCI success rate was 75.9% in the CTO group
• CTO-PCI volume per center did not correlate with CTO-PCI success rate
Boukantar M, Loyeau A et al, Am J Cardiol 2019
• CTO PCI outcome

18. • 17 randomized and
observational studies
• 11,493 participants
Ka Hou Christien Li et el Curr Atheroscler Rep (2019) 21: 42
ALL CAUSE MORTALITY EVENTS
11 observational studies
3 randomized controlled trials

19. Ka Hou Christien Li et el Curr Atheroscler Rep (2019) 21: 42
MACE EVENTS
MYOCARDIAL INFARCTION

20. Ka Hou Christien Li et el Curr Atheroscler Rep (2019) 21: 42
CARDIAC DEATH

21. • Data from EuroCTO Registry in the period 2015-2017
• Three groups were created based on occlusion age: 3 to 6 months (n= 1415),
7 to 12 months (n= 973), > 12 months (n= 1656)
Bryniarski KL, Werner GS et al, Adv Interv Cardiol 2019; 15, 1 (55): 28–41

22. Bryniarski KL, Werner GS et al, Adv Interv Cardiol 2019; 15, 1 (55): 28–41

23. Coronary artery CTO duration is associated with greater extent of calcification,
lesion length, development of collateral circulation and, most importantly,
with lower procedural success.
Bryniarski KL, Werner GS et al, Adv Interv Cardiol 2019; 15, 1 (55): 28–41

24. • Hybrid approach: evolution over the years
• New CTO scores
• CTO PCI outcome
• CTO PCI subgroups
Rapid Review of the Recent CTO Literature

25. • 943 diabetic patients with RCA-CTO who had clinical
presentations of symptomatic stable angina or silent ischemia
• 46.98% of patients in the CTO-medical therapy group (CTO-MT)
• 53.02% of patients in the CTO-revascularization group (CTO-SR)
• 309 pts PCI; 191 CABG
• mid-term follow-up: CTO-SR: 48 months; CTO-MT: 42 months
Yan et al. Cardiovasc Diabetol (2019) 18:108
• CTO PCI subgroups

26. ALL CAUSE DEATH CV DEATH
Yan et al. Cardiovasc Diabetol (2019) 18:1
• CTO PCI subgroups

27. Yan et al. Cardiovasc Diabetol (2019) 18:1
For stable RCA-CTO patients with diabetes,
successful revascularization offered patients
more clinical benefits than medical therapy
• CTO PCI subgroups

28. Chronic Total Occlusion Represents an Independent Predictor for
Mortality in Malignant Arrhythmia and Sudden Cardiac Death
 1587 pts from retrospective registry including all consecutive patients with VT, VF and
sudden cardiac death undergoing to coronary angiography in the period 2002-2016
 Prevalence of CTO 22%
 CTO group compared with no CTO group
 CTO was associated with higher all-cause mortality at short-term (33% vs25%, p=0.002)
 CTO was associated with higher all-cause mortality at mid-term (46% vs 33%, p=0.001)
 irrespective of the underlying malignant arrhythmia (VT/VF), degree of left ventricular
dysfunction, myocardial infarction
Behnes et al Eurointervention 2019

29. • Hybrid approach: evolution over the years
• New CTO scores
• CTO PCI outcome
• CTO PCI subgroups
• Vascular access
Rapid Review of the Recent CTO Literature

30. Radial Approach:inside PROGRESS-CTO
• 3,790 CTO interventions performed between 2012 and 2018 at 23
centers in the United States, Europe, and Russia
• 747 via radial-only access (RA)
• 844 via radial-femoral access (RFA)
• 2199 femoral-only access (FA)
• Transradial access (RA and RFA) was used in 42% and significantly
increased over time from 11% in 2012 to 67% in 2018 (p < 0.001)
• Patients treated via transradial access were youger, less prior
PTCA and less prior CABG
Tajiti P, Alaswad K et al JACC Cardiovasc Interv. 2019 ;12(4):346-358

31. Technical success, procedural success and in-hospital major
complication were similar in three groups
Tajiti P, Alaswad K et al JACC Cardiovasc Interv. 2019 ;12(4):346-358

32. Konstantinidis NV, …. Sianos et al, Circ Cardiovasc Interv.2018;11:e006229

33. • Hybrid approach: evolution over the years
• New CTO scores
• CTO PCI outcome
• CTO PCI subgroups
• Vascular access
• Coronary physiology in CTO
• CTO-PCI: complications
Rapid Review of the Recent CTO Literature

34. • 1,811 consecutive patients undergoing CTO PCI at five centers
between 2011 and 2018.
• Coronary perforation was observed in n=99 (5.5%)
• In 53% of cases perforations required intervention
• Patients with perforation were older, had higher J-CTO score,
more often required antegrade dissection/re-entry and the
retrograde approach, and had lower success rates.
Azzalini L, Poletti E et al Eurointervention 2019
• CTO-PCI: complications

35. Sites of perforation
Azzalini L, Poletti E et al Eurointervention 2019
• CTO-PCI: complications

36. Azzalini L, Poletti E et al Eurointervention 2019
• CTO-PCI: complications

37. Brilakis et al EuroIntervention. 2019 Jun 20;15(2):137-139
CTO PCI : the road ahead !!!

38. Brilakis et al EuroIntervention. 2019 Jun 20;15(2):137-139
CTO PCI : the road ahead !!!