Nicolaus Reifart (Frankfurt - D) 13th Experts "Live" CTO Workshop 17th–18th September 2021 - Florence, Italy

1. History of CTO
What are the lessons ?
Nicolaus Reifart
Frankfurt – Bad Soden - Wuppertal
PCI 1982-2019 CTO-PCI 1985-2019

2. Interventionelle Kardiologie bei MK 1979 - 1985
Martin Kaltenbach 1979-1985
NR

3. 1977 the first PCI interventions
were performed
alternating between
Zürich and Frankfurt
1978 followed by San Francisko
and New York
History of PTCA

4. Diagnostic Angiogram
Four weeks before PCI
80 % RCA LV normal
Angio before PCI
RCA occlusion
Inferior wall infarction
After reopening RCA
LV contraction normal
Three months follow up
Recurrence RCA stenosis
LV normal
Frankfurt 1978

5. My first experience 1986-90
in 509 consecutive patients
•Success 284/509 patients 55.8 %
•Occl length < 10 mm 75.8%
•Kinked occlusion: 28.5 %
•Occlusion age < 4 weeks 68.5 %
•Occlusion age > 6 mos 9.5 %
DMW 1994 Dec 23;119(51-52):1766-70
Wires: ACS Intermediate, Standard, Magnum

6. Active participating in meetings of Japanese
CTO Club
1991 complex PTCA live course
1992-’94
the Mid-Japan Interventional Cardiology
Conference
1994-’99
the Complex Coronary Intervention Conference
(CCIC)
1999-present the annual Japanese CTO club meeting
2000-present the Complex Catheter Therapeutics (CCT)
NR invited speaker

7. Lesson § 1 CTO Definition
•TIMI 0 within vessel lumen
•subacute: < 1 month
•recent: 1-3 months
•chronic (organised thrombus): > 3 months
JCTO Club 1994 €CTO Club 2006

8. Do you remember 1991
when we first met and I
tried to explain the
Magnum wire ?
2001
1991 : The Magnum-
Ramboplasty

9. §2 Dedicated Wires, curves
& Manipulation via OTW
O. Katoh
Shorter distal tip
Stiffer, tapered,
more lubricious,
better torque-
controll
a b

10. Athlete Plus 1995
Wires were later called
Miracle

11. OTW to begin with €CTO 2006
0
10
20
30
40
50
60
70
80
90
100

12. § 3 Distal visualisation
Second arterial sheath for
contralateral injection
required in > 70% of the
cases

13. Contralateral injection € CTO 2006
0
10
20
30
40
50
60
70
80

14. § 4 Planning - Persistance - Patience
• Thorough planning including discussion with peers
• Dont rush
• Allways consider the next step
• Dont give up before you considered all reasonable
options

15. 1995/96 Osamu Katoh in Frankfurt teaching me the japanese
way

16. The parrallel
wire
technique
N.Reifart /O.Katoh
1995/96
Crossit
200-400 or
Conquest
3g-6g
O.Katoh

17. § 5 (Antegrade) success in unselected pts:
very much Op-dependent and up to 85% in 1996
• 1995/96 6400 PCI (9 % CTO)
• O.Katoh (> 120) 85% (about 30% 2nd try)
• N.R. (> 200) 73%
• Op 3 (80) 62%
• Op.4 (60) 51%
• Op.5 (<50) 37%

18. § 6 Retrograde Aproach (O. Katoh) promising
alternative since 2003
2003-2008 n = 118
Success retrograde 65,6 % MACCE 6%
Circulation (2009)

19. § 8 DES by default
Restenosis/intervention
•Balloon 50-70 / 25 %
•BMS 30-50 / 10 %
•DES <15 / <5 %*
* Trials: Prison II Coracto

20. EuroCto Club
Founding Meeting
Paris 14.12.2006
Joachim Büttner
Carlo Di Mario
Gerald Werner
Dariusz Dudek
George Sianos
Nicolaus Reifart
Alfredo Galassi
Jaques Koolen
Hans Bonnier
Success 70-80%

21. Hamburg 2007 analysing the cases
H.Tamai
A.Büttner C.DiMario
O.Katoh
Y.Asakura
2nd attempt:Succeeded in 9/10
CTO cases of €CTO
Breakthrough for the Club

22. § 9 Guidance bei strong Mentors
The optimal way to learn how to prevail
is watching and working with top
instructors
M. Yamane: „They have to stand beside
me and see how I struggle“

23. § 10 not all CTOs are equal
Technical failure was seen to increase from 8% with a CASTLE score of 0 to 1, to 35% with a score >=4.
JACC 2019

24. Be allways aware of your
Limits: progress step by step

25. Success 71,2% MACCE 0.8% (i.e. 40% more than
following antegrade)
JACC 2015

26. § 11 Keep it simple and safe:
- Allways consider antegrade first,
- recheck indication during the procedure
Antegrade success in unselected patients >
80%
Complications 40% less
Reconsider indication if the procedure
complexity increases

27. Balance complexity and patients benefit
during the procedure
1. Intolerable symptoms + viability – no other option
2. Intolerable symptoms + viability - CABG possible
3. Severe symptoms + viability
4. Markedly reduced physical capacity + viability
5. Symptoms NYHA II + viability
6. Silent ischemia, large territory
Complexity

28. § 12 Supplementals by Experts
O. Katoh: Do not harm the patient (allways reconsider wether the procedure is
beneficial), dont stent incompletely recanalised vessels
Kambis Mashayekhi: Imaging (IVUS), ACT measurements, Networking
Manos Brilakis: Proven ischemia, Expertise & Equipment, be humbbyle,
learn from your mistakes, ask for help
Gerald Werner: Only experienced operators, established Indication,
antegrade first, limit amount of Stents
A. Galassi: Be aware to handle complications, Take time and be Zen
A. Büttner: Beginners should start step by step, 70% are doable from antegrade (single wire
parallel wires); ADR is easy when not necessary and risky when unavoidable
Th. Lefevre: Learn how to do a good angiogram, prove that your wire is in distal lumen
before proceeding, Failure wo. complication is not an issue

29. Last word: Stop when…
• you start to shut off collaterals by
(uncontrolled) opening of a false lumen (worth
a 2nd try)
•You learn that the complexity is going to
outweigh the benefits for the patient (O.K &
N.R)
•Excessive dye consumption (GFR)
• Excessive radiation
• AND: Be always aware of delayed tamponade