Room: Salon Schinkel Which setting? – Top 10 lessons learned from my time as CTO beginner Gerald S. Werner, Germany The Experts “Live” Workshop 2017 Saturday, September 16th, 2017

1. Which setting ? – Top 10 lessons
learned from my time as CTO beginner
Gerald S. Werner, MD, FESC, FACC, FSCAI
Klinikum Darmstadt - Germany

2. Do I remember my time as beginner?

3. Why should I do a CTO ?
1992-2017
• Should we do it ?
• How to do it
• How to keep it open

4. The 3 main issues for the treatment of CTOs
1992
• Should we do it ?
• Guidelines: NO
• How to do it
• No specific technique
• How to keep it open
• Balloons

5. Katoh‘s view on the evolution of CTO PCI

6. The primitive stage in Göttingen 1995/97
• Of 2464 PCIs within 2 years we did
365 PCIs of “occluded” arteries (14.8%)
• Prof. Kreuzer 44, Buchwald 181, Figulla 29,
Scholz 51, Werner 100
• Of 365 PCIs 153 were successful: 58%
• My personal “record”: 64% …
… selected cases:
the stiffest wire was the ACS Standard
Lesson 1: Too many operators for the same
lesion subset do not help developing enough
experience

7. Tools: IVUS and subintimal course
Werner et al. Cathet Cardiovasc Diagn 1997;40:46-51

8. Das BridgePoint StingRay Reentry System
Werner GS et al. EuroIntervention 2011; 7:192-200.

9. The 3 main issues for the treatment of CTOs
2002
• Should we do it ?
• Guidelines: NO
• How to do it
• Dedicated wires, devices
• How to keep it open
• Stents

10. Restenosis Reocclusion TLR MACE
DES (n=330) BMS recent gen. (n=527)
8
36
2
9 5
25
10
35
[%]
BMS 1st gen. (n=620) POBA (n=604)
32
17
30
1515
8
64
38
CTO patency: DES – BMS - POBA
Adapted from J Woehrle, Univ. Ulm

11. Stent (number) no longer an issue in CTOs ?
1 2 >2
0
10
20
30
40
50
60
70
80
90
100
4
11
9
17
5
10
61628
Patients[%]
Number of implanted stents
No TVF Restenosis Reocclusion
1 2 >2
0
10
20
30
40
50
60
70
80
90
100
113747
Patients[%]
Number of implanted stents
No TVF Restenosis Reocclusion
2012: 2.7 stents (1-6) in 183 CTOs
12 % 28 % 60 %
Werner GS et al Catheter Cardiovasc Interv 2006;67:1-7
49% 39% 12%

12. Did new technologies get you through a CTO ?
• Early ideas: Magnum wire, ROTACS
• Safecross
OCR and RF
• Frontrunner
mechanical
• Crosser vibration
Lesson 2: Too many fancy devices do not
make the trick, it is the operator and the wire
only

13. ”Collateral Connection Size“ (CC)
Werner et al. Circulation 2003;107:1972-7
CC0 14% CC1 51% CC2 35%
B
D E
A C
F

14. How to improve CTO success in Europe ?
Lesson 3: Collaborate and share your
experience and problems, keep an open ear to
alternative opinions

15. Learning together from the masters …
You profit from a peer
Lesson 4: Look for a senior guide to help you
through the difficulties of the procedure, revisit
during the stages of your development

16. The 3 main issues for the treatment of CTOs
2017
• Should we do it ?
• Guidelines: if symptomatic
• How to do it
• Specialized approach
• How to keep it open
• DES

17. Do you think twice about opening this lesion ?
And why do I have to defend opening this lesion ?

18. Do you think twice about opening this lesion ?
And why do I have to defend opening this lesion ?
Lesson 5: A CTO is just like any other coronary
lesion regarding the indication, but you need to
prepare..

19. Lessons for the proper approach: Patience
1. A CTO procedure takes time, and you need
to have enough time
2. Take your time before you start and plan,
what are the options, what is the most likely
way to success
3. Be patient, if you cannot stay with a case as
long as it takes, do not start it
4. Always stay vigilant, the worst complications
can occur at the end through carelessness
5. The patient’s safety is more important than
your ego