Is Bypass Operation Still The Only Option For Left Main Disease And...

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LEFT MAIN AND
CHRONIC TOTAL
OCCLUSIONS –
FORGET BYPASS!
DR. TAN CHONG HIOK

2 VERY SPECIAL
SUBSETS IN CORONARY
ARTERY DISEASE
•Unprotected Left Main disease
•Chronic Total Occlustion (CTO)

UNPROTECTED LEFT MAIN
DISEASE
•Significant disease of Left Main in a person
who has not under gone CABG of the LAD
&/0r LCx

OVER THE YEARS
•Has be battle ground for Surgeons and
Interventionists
•The argument has always been CABG is
better
•But ‘...

GUIDELINES HAVE EVOLVED
OVER THE YEARS
•From a firm Class III
•Now a Class IIa/IIb depending on the
situation
•Not based o...

EXCEL - EVALUATION OF XIENCE
VERSUS CORONARY ARTERY BYPASS
SURGERY FOR EFFECTIVENESS OF
LEFT MAIN REVASCULARIZATION
•1900 ...

PRIMARY AND SECONDARY END POINTS

Time to
Event
• K-M Time to first
event analysis
PCI
CABG

PCI CABG
Event (No.) Rate (%) Event Rate Hazard ratio
p
PCI = 12.6% CABG =
7.5%
PCI = 0.7% CABG =
5.4%!
It is not ZERO! Th...

OVER A 3 YEAR PERIOD - PCI VS
CABG
•There is no significant difference in hard end point
of death, stroke of MI
•As expect...

GUESS WHAT IS THE METHOD OF
REVASCULARISATION FOR GRAFT
OCCLUSION?

THINGS TO NOTE
•The PCI were done in experience centres
•The use of IVUS was high at 77%
•Total procedure time was 83min f...

PCI CABG
CABG ends up with more AF
May take 1 less anti-platelet
BUT end up taking additional anti-
arrhythmic AND anti-co...

•Let me share my data
•Presented in PCR SingLive
2016

METHOD
•A retrospective analysis of 68 unprotected Left Main
PCI cases that were performed from 2007 to 2013
•Mean follow ...

RESULTS
68 patients
45
electiv
e
11
acute
12
urgen
t
Check angiogram
was performed in
52.9% of cases

RESULTS
•Overall MACE rates: 11.8% (8 out of 68 cases)
•Death: 10.3%
•Target lesion revascularisation: 1.5%
•Elective PCI:...

RESULTS
•Acute STEMI PCI: 42.5%
•5 deaths
•Acute LM occlusion cases (5 out of 11, 42.5%)
•Presented with cardiogenic shock

LET’S SEE SOME EXAMPLE
•87 year old gentleman
•Angina
•Not good condition for CABG

VERY CALCIFIED DISTAL
LM

TEAR IN LEFT MAIN

PROTECT LCX WITH
STENT

ROTABLATE LM THEN STENT

FINALLY

CONCLUSION
•LM stenting in the non-urgent setting is safe
and has low MACE rate at 3 years
•Needs to be done in experience...

CHRONIC TOTAL
OCCLUSION-
THE FINAL FRONTIER OF
PCI
DR. TAN CHONG HIOK
ASIA HEART AND VASCULAR CENTRE

CHRONIC TOTAL OCCLUSION

15-30%
85%
CTO Non-CTO
Success
50%
Failur
e50%
Not tried
70%
WHAT’S THE BIG
DEAL?
Of those sent for
Angiogram
15-30% have ...

SO WHAT?...
•Although at present there is no randomised control
trial on treatment of CTO
•But…
•There are 3 possible bene...

IMPROVEMENT IN SYMPTOMSCollateral coming LCx

WHEN 1 ROAD IS BLOCKED, ANOTHER
OPENS
Collateral
“Self
Bypass”
Self bypass
enters the
RCA
RCA filling
‘backwards’

SYMPTOM IMPROVEMENT
•If collaterals are insufficient to provide
adequate blood flow
•During physical stress
•Symptoms will...

IMPROVE LV FUNCTION
•MRI studies have demonstrated improved
LV function 5 months after successful
opening of a CTO vessel
...

IMPROVED SURVIVAL An MI in RCA would have
resulted in 2 huge territories
being infarcted
RCA collateral suppling a
huge LA...

IMPROVED SURVIVAL
•Observational studies found that mortality
was significantly reduced in the successful
PCI group during...

IF THERE IS BENEFIT IN
REVASCULARISING CTO
•Why is it that not all doctors treat CTO?
•Technically very demanding
•It is c...

WHAT’S SO DIFFICULT ABOUT CTO
PCI?
Left Circumflex
CTO
Start of the
occlusion
Path of occluded
vessel

UNABLE TO SEE THE PATH OF THE
WIRE
The wire can come out of
the vessel completely!
Approximate path
of vessel
Vessel downs...

WHAT HAPPENED TO THE WIRE?
CTO
Fortunately in the CTO segment, there
is no blood flow

FORTUNATELY NOT EVERY CTO IS
SO HARDENED – DEPENDS ON
CHRONICITY
Hard
(Proteogylyca
n-collagen)
Not so
hard
Softer

SUCCESS RATE DEPENDS ON CHRONICITY
OF CTO
•The longer the CTO remains, the higher the content of
fully organised proteogly...

WHAT ELSE CAN GO WRONG
WITH INEXPERIENCE DOCTOR?When the CTO segment is
not correctly crossed by wire

NOT KNOW WHAT TO DO
SO PLACED A STENT

THERE IS A SMALL PERFORATION
ARTERY STILL COMPLETELY
BLOCKED

PUTTING A STENT IN SUB-INTIMAL SPACE
WILL COMPLETELY BLOCK UP THE LUMEN!
Lumen
occluded!
Game Over!

CTO INTERVENTION REQUIRES
GOOD UNDERSTANDING OF
ANATOMY
Wire is not in LAD. Will never go
in correct direction! Failed aft...

MUST REALLY KNOW THE
ANATOMY
Take the small path
Success after 30min!

WHAT IF THE WIRE JUST WON’T
GO?

RETROGRADE APPROACH!
Find the collateral that is
supplying occluded vessel
Bring a wire down

WIRE COMES UP FROM BELOW

ROUND THE WORLD TRIP

HUH? HOW DOES THAT WORK?
ONE long
wire!

WHEN THE SMOKE CLEARS

COMPARE THE BEFORE AND
AFTER

CAN ALL DOCTORS DO THIS?
•No

WORLD WIDE
•Limited number of people have good
experience in this technique
•Many cardiologists know and seen
•Few have tr...

SINGAPORE
•Over the last 15 years I have done more than
100 fully documented retro-grade cases –
highest case load locally...

CASES HAVE BEEN PRESENTED IN
PRESTIGIOUS INTERNATIONAL CTO
CONFERENCES

PROCEDURAL SUCCESS RATE
• High dependent on volume
https://doi.org/10.1016/j.jcin.2014.08.014

CTO SUCCESS
RATE
50%50%
Success rate of General
Interventionist
Success
Failure
95%
5%
Success rate of world
Masters
Succe...

CONCLUSIONS
•Limited number of CTO operators
•Patients are not offered the option of PCI
•If PCI is attempted the failure ...

SOME PEOPLE WOULD SAY
•Go for By-Pass operation
•Just go for one procedure
•Can have full revscularisation
•It’s a once-fo...

•6 Days after discharged for By-Pass
•LIMA to LAD
•SVG to RCA
•SVG to OM
•Presented with Inferior Myocardial Infarction
•A...

SVG TO OM OCCLUDED! - HERE IS LAD AND LIMA

OM GRAFT COMPLETELY BLOCKED!
RCA GRAFT OCCLUDED AT
ANASTAMOSIS

CTO JUST BEYOND
ANASTOMOSIS SITE!
After crossing the CTO and
ballooning
The Lesion can be seen
Finally after Stenting
Wast...

CONCLUSION
• CTO’s are reasonably common
• Patients are often inadequately treated
• Failure rate for PCI is high
• Patien...

THANK YOU

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