Sudhir Rathore (London - UK) 13th Experts "Live" CTO Workshop 17th–18th September 2021 - Florence, Italy

1. Optimal Planning for a successful CTO
recanalization: New Algorithms
Dr Sudhir Rathore
MD, FRCP, FACC, FESC
Consultant Interventional Cardiologist
Frimley Health NHS Foundation Trust

2. Aims of Angioplasty: CTO
• Successfully recannalize the vessel and no major complication.
• Try to track and cross with the wire intimally and ensure no major
branch is lost.
• In the event of failed intimal tracking, minimise the length of sub-
intimal passage of wire.
• Durability of the procedure: Stents, length and imaging guided
optimization.
• Efficient use of resources and skills.

3. Success of CTO PCI
If you know the enemy and know yourself, you need
not fear the result of hundred battles.

5. Careful Evaluation of CTO Anatomy: Bilateral
angiogram/ CTCA etc.
• Proximal cap: Blunt vs tapered
• Side branch at the proximal cap
• True Length of the occlusion
• Calcification, Tortuosity
• Angle of the CTO
• Distal vessel size, disease & length
• Retrograde collateral: Ipsilateral/ Contralateral:
Interventional collateral

12. Proximal Cap: Blunt/SB
Distal Vessel Normal
Proximal Cap: Tapered
Distal Vessel Healthy
Proximal Cap: Ambiguous/SB
Distal vessel diffusely diseased
IVUS
AWE
PW
ADR
AWE
PW
ADR
AWE
RWE
RDR

13. Long CTO segment and distal cap at Bifurcation, Interventional Collateral
RWE
RDR

14. Proximal Cap: Ambiguous
Ipsilateral epicardial collateral
CC2 Septal Collateral: Interventional Collateral
ADR
RWE
RDR

15. Patterns of Septal Collaterals
1.< 90 degree
2.>90 degree
3.Corkscrew
4.Corkscrew
5.Recepient
vessel>90
6.>90 R
Vessel

16. Patterns of Epicardial channel
•Usually very tortuous,
Large, visible.
•Easier to cross with
Corsair.

17. Procedural characteristics, Outcomes and Complications
in patients undergoing percutaneous coronary chronic
total occlusion angioplasty: Pooled analysis from
RECHARGE, Expert JCTO, EURO CTO, PROGRESS and
OPEN CTO Registries
Sudhir Rathore1, 2, SRS Seshasai 2, Alfredo Galassi 3,
Marouane Boukhris 4, Etsuo Tuschikane 5, Joseph Dens 6,
Kambis Mashayekhi 7, J Aron Grantham 8, Emmanouil Brilakis 9, Gerald S. Werner 10.
1: Frimley Health NHS Trust, UK, 2: St George’s Hospital, London, 3: University of Catalonia, Italy,
4: Abderrahmen Miami Hospital, Tunisia, 5: Toyohashi Heart Centre, Toyohashi, Japan 6: Ziekenhuis Oost Limnburg, Belgium, 7: University Heartcenter Bad Krozigen, Germany, 8:
University of Missouri Kansas city and Mid America Heart Institute, USA, 9: Minneapolis Heart Institute, USA, 10: Klinikum Darmstadt Germany.

18. Registries Design and Overview
RECHARGE Expert JCTO EURO CTO PROGRESS OPEN CTO
Total number of
patients
1253 2596 2549 2102 1000
Centres 17, European 41, Japan 45, European 16, US 12, US
Experience Hybrid/ADR
62+/-40
300 CTO
>50 /Year
> 50/year Dedicated CTO
operators
Dedicated CTO
operators
Strategy Hybrid Algorithm Japanese
Algorithm
Hybrid Hybrid

19. Final Successful Strategies
RECHARGE Expert JCTO EURO CTO PROGRESS OPEN CTO
AWE (62%) (91%) 88.1% (55%) 59%
Parallel wire
IVUS usage entry
NA 14.4 (82.5%)
3.2 (75%)
Retrograde
RWE
RDR(RCART)
CART
Kissing Wire
(62%)
28
67
3
(87%)
16.3
62.4
3
17.7
79.3%
31
20
15
16
(60%)
17.8
66.1
1.7
1.7
62%
30
70
Collateral used
Septal
Epicardial
Bypass
64
25
6
57.9
19.6
3
65
13
5
57.3
34.7
15.7
ADR
Sting ray
STAR
LAST
(66%)
78
9
13
NA (66%)

20. Procedural Characteristics
RECHARGE Expert JCTO EURO CTO PROGRESS OPEN CTO Mean (95% CI)
P value
Technical Success, % 86 89.9 85.9 88 86.2 87.8(85.5-89.9)
Procedure Time,
Minutes
120+/- 46 160.4+/-89.6 120+/-51.8 145.08+/-89.52 120.7+/-64.4 133.1 (109.8-156.3)
Fluroscopy Time.
Minutes
35 (21-55) 66.7+/37.3 55.20+/-36.40 50.4+/-34.1 57.4 (36.7-77.8)
Contrast Volume,
Millilitres
250+/-118.5 230.8+/-105.9 250+/-111.1 289+/-138 262.0+/-139.5 256.8 (229.6-283.9)
Stent Length,
millimetres
72+/-34 63.2+/29.6 46.6+/16.2 52.3+/-45.6 58.52 (40.53- 17.51)
Final Successful
Strategy,%
AWE
RG
ADR
58
24
18
72.1
27.9
74.9
25.6
49
27
24
40.8
34.9
24.3

21. MACCE Events
RECHARGE Expert JCTO EURO CTO PROGRESS OPEN CTO Mean (95% CI)
P value
MACE, % 2.6 1.6 1.65 2.6 2.6 2.6 (1.1-4.2)
Death, % 0.2 0.2 0.3 0.2 0.9 0.36(0.09-0.62)
Stroke, % 0.2 0.2 0.05 0.2 0.0 0.13(0.04-0.21)
MI, % 2.2 1.2 1.3 0.9 2.6 1.62 (1.0-2.27)
Cardiac Tamponade, % 1.3 0.4 0.5 0.9 1.4 0.9 (0.50-1.29)
Vascular
Complication, %
2.5 1.3 0.7 4.3 2.2 (2.0-4.5)
CIN, % 0.2 (ARF) 1.7 0.9 0.7
TVF/TVR, % 0.08 0.2 0.15 0.3 0.7 0.18(0.09-0.27)

22. Conclusions
• Careful Coronary angiogram evaluation after Bilateral angiogram.
• High success rate with low complication could be achieved by
following different algorithm.
• Efficient use of resource, skills and moving in the process towards
success.
• Avoid too long in failure mode!!
• Switch operator / strategy etc??
• Proctored training improves the skill sets
• Step wise transition in doing more complex cases JCTO 1……. 4/5