1) Stent type, crossing technique, and patient factors influence stent patency after CTO PCI. Drug-eluting stents are superior to bare metal stents in reducing restenosis and reocclusion. 2) Techniques involving extensive subintimal dissection and re-entry are associated with higher restenosis rates, especially if outflow and final TIMI flow are poor. 3) Patient factors like diabetes are also important determinants of stent patency, with diabetics having higher restenosis risks. 4) The role of routine angiographic follow-up after CTO PCI remains controversial.

1. STENT Patency Post-CTO PCI
Dimitri Karmpaliotis, MD, PhD, FACC
Assistant Professor of Medicine
Columbia University Medical Center
Director of CTO, Complex and High Risk Angioplasty
CIVT/NYPH
Email: dk2787@columbia.edu
EURO CTO
Istanbul, Turkey, September 18-19, 2015

2. Disclosures
• As a faculty member for this program,
I disclose the following relationships
with industry:
• Speakers Bureau for Abbott Vascular,
MDT vascular, ASAHI Intel and Boston
Scientific

3. CTO PCI: stent patency
• Stent type
• CTO crossing technique
• Patient factors

4. CTO PCI: stent patency
• Stent type
• CTO crossing technique
• Patient factors

5. BMS vs PTCA: Total Occlusion Study of
Canada (TOSCA-1)
• 40% of lesions <6 weeks old
• BMS revascularization
– 50% restenosis vs. 70%
– 10% re-occlusion
– Clinically Driven TVR 15.4% vs. 8.4%
Buller et al. Circulation 1999
15.4%
8.4%
TVR

6. BMS reduced restenosis comparing
to balloon angioplasty in CTOs
Agostoni et al. Am Heart J 2006
Revascularization
MACE

7. Prison II: 6 month angio FU
Circulation 2006;114-921-928

8. Prison II: 12 month clinical FU
Circulation 2006;114-921-928

9. GISSOC II-GISE trial
• BMS vs. SES
• 6 month binary angiographic restenosis 68% vs. 8%
and reocclusion 17% vs. 0%
• 24 month 45% vs. 15% need for TVR
• No difference in stent thrombosis
Rubartelli, Eur Heart J 2010

10. CORACTO trial
• SES with bioabsorbable polymer vs.
BMS
• True CTOs
• 6-months follow-up angiography:
• lower binary restenosis 17% vs. 60%
• Lower vessel reocclusion 0% vs. 16%
• 24 months clinical follow-up:
• Lower TVR 11% vs. 60%
• No difference in death, MI,stent
thrombosis
Reinfart, Eurointervention 2010

11. 55.2
22.6
12.4
9.5
0
10
20
30
40
50
60
TOSCA I - BMS
Restenosis
In-Treated
Segment
Restenosis
In-Segment
Restenosis
In-Stent
Restenosis
TOSCA-I BMS (n=202)
SES (n=200)
ACROSS - CYPHER
33% absolute
reduction
85% adjusted relative
reduction
In treated-segment refers to length of contiguous target segment exposed to balloon
inflation
In-segment includes stented area plus 5 mm proximal and distal to stent
6 Month Angiographic Restenosis
Kandzari et al. JACC Interventions 2009

12. 126 publications
retrieved
104 publications excluded
Review: 10
Editorial/letter: 4
Case report: 13
Unrelated topic: 61
Other: 16
17 studies
included
Non-randomized
comparative
studies (n= 7)
Randomized
controlled
trials (n=2)
DES vs. BMS
(n=7)
Uncontrolled
DES in CTO
studies (n= 8)
DES only
(n=7)
SES vs. PES
(n=1)
Subgroup
analysis of
trial
(n=1)
Duplicate
publications : 5
Total
occlusion
trial (n=1)
Saeed, CCI 2010
Meta-analysis
of DES vs
BMS in CTOs

13. In-segment binary angiographic restenosis
ReocclusionB
A
Saeed, CCI 2010

14. Death
Myocardial Infarction
A
B
Saeed, CCI 2010

15. Target lesion revascularization
Target vessel revascularization
A
B
Saeed, CCI 2010

16. Colmenarez, H. J. et al. J Am Coll Cardiol 2010;55:1854-1866
RR of ST Associated With DES and BMS Use

17. SCANDSTENT Trial
MACE within 3 years after stent implantation
Kelbaek, JACC 2008
Not a CTO Trial

18. Need for 2nd generation stents in CTOs
• Cobalt-chrome or platinum-chrome
platforms
• Thinner struts
• More biocompatible
• Less stent thrombosis

19. Studies for 2nd generation DES in CTOs
• EES had lower reocclusion rates
comparing to 1st generation DES
• One Randomized study similar re-
stenosis rates but trend for less stent
thrombosis with EES
Valenti, JACC 2013
Worhle, Clin Res Card 2012
Moreno, Circ Cardiovac Interv 2013

20. CIBELES trial
(EES vs. SES)
MACE Stent Thrombosis
Moreno, Circ Cardiovsc Interv 2013
Follow-up angio showed similar late loss

21. CATOS trial (ZES vs. SES)
Park, Circ J 2012
Similar angio and clinical outcomes

22. PRISON III trial
• Randomized Trial in 2 Phases
• SES vs. ZES (Endeavor or Resolute)
• 8 month angiographic follow-up:
 Late lumen loss higher with Endeavor
similar with Resolute
• Similar clinical events between SES and
EES, Numerically higher TLR with
Endeavor
• Low incedence of Clinical Events between
one- and three-year f/u
Suttorp, Am Heart J 2007
Teeuwen, EuroIntervention, 2014

23. CTO PCI patency rates
Author Year Stent n
FU
angio
time
Prior
CABG
Total
stent
length
(mm)
In-stent
restenosi
s (%)
In-
segment
restenosi
s (%)
TLR
(%)
TVR
(%)
PRISON II 2006 SES 100
6
months 3 32±15 7 11 4 8
ACROSS-
TOSCA 4 2009 SES 200
6
months 8.5
45.9
(30.2,
62.1) 9.5 12.4 9.8 11.4
GISSOC II 2010 SES 78
8
months 6.7 41+18 8.2 9.8 8.1 14.9
CIBELES 2012 SES 101
9
months 4 47±24 10.5 11.6
EES 106
9
months 4.7 50±23 9.1 7.9
ACE-CTO 2012 EES 100
8
months 27 85 ±34 45 45 40 43
J-PROCTOR 2012 EES 163
9
months 10 41-60 -
6.8 –
13.5

24. 1st vs 2nd generation DES
Lanka et al. J Invasive Cardiol 2014;26:304-10
Target Vessel Revascularization
Target Lesion Revascularization

25. Kandzari, Kini, Karmpaliotis et al – JACC Intv 2015

26. CTO PCI: stent patency
• Stent type
• CTO crossing technique
• Patient factors

27. Godino et al. CCI 2012
355 successful CTO PCI 2005-2008
Conventional
79%
DES: 94%
Guided STAR
21%
DES: 89%
Median FU: 2.1 years
Angio FU: 78-85%
TLR:
Angiographic
restenosis:
Reocclusion
16% 30% P=0.006
30% 54% P<0.0001
12% 22% P=0.04

28. STAR technique: long-term outcomes
• Florence CTO PCI
registry
• 802 successful CTO
PCI between 2003-2010
• 82% angiographic FU
• EES less reocclusion
than 1st generation DES
• STAR: 57% reocclusion
rate (16/28)
Valenti et al. JACC Intv 2013
Compare to 16-24% in
Colombo/Carlino
series

29. CTO PCI: stent patency
• Stent type
• CTO crossing technique
• Patient factors

30. Total occlusion study of coronary arteries-4
(ACROSS/TOSCA-4)
Kandzari, JACC Cardiovasc Interv 2009

31. 1. DES current standard of care for CTO
PCI
2. Extensive subintimal dissection/re-
entry techniques, especially if
outflow and Final TIMI Flow are poor,
have high restenosis rates
3. Patient factors (diabetes) important
4. The role of routine angiographic FU
remains controversial in CTO PCI
5. BVS ????
Conclusions