14th Experts "Live" CTO September 2nd- 3rd, 2022 - Mainz, Germany Main Session - Session 2: Selecting the patient and planning the procedure B Preprocedural CT – which patient needs it Youssef Abdelwahed, Berlin, Germany Room: Guteberg Hall (Auditorium) - Friday 11:10 Chairmen: Alexander Bufe, Krefeld, Germany; Leszek Bryniarski, Krakow, Poland; Hans Bonnier, Nuenen, Belgium

1. Preprocedural CT –
Which Patient needs it
Youssef Abdelwahed
Charité – Campus Benjamin Franklin

2. Preprocedural CT – Which Patient needs it?
….To answer this question, we need to

3. ….To answer this question, we need to
• Know what CT has to offer
Preprocedural CT – Which Patient needs it?

4. ….To answer this question, we need to
• Know what CT has to offer
• Know how to Interpret its images and bring them to real life
and in the Cath Lab
Preprocedural CT – Which Patient needs it?

5. Image Interpretation Methods

6. Volume Rendering

7. Curved - Stretched MPR

8. Curved - Stretched MPR

9. Angiographic View

10. „Sliding Slab MIP“ Method
Recommended MSCT imaging method for Interventional Cardiologists

11. Slab MIP Method

12. Maximum Intensity Projection
Pixels with maximum intensity projected from any direction
Slab/MIP Thickness

13. Visualizes any intended projection
of the coronary tree.
Rotate the Heart and Determine Optimal Projections

14. Changing the Slab Thickness
e.g.: Minimizing the stent structure to
analyze the intra-stent lumen.

15. CT as an Essential Imaging
Modality

16. CT
 Planning
• Plaque Type
• Calcification Type
• Myocardial Mass at Risk (MMAR)
 Guidance
• Anatomical Course of the Vessel
• Bifurcations

17. CT
 Planning
• Plaque Type
• Calcification Type

18. Thin slice,
Cross-sectional view
-1000-0
1-50
101-250
251-350
700- 2000
Plaque characterization on CT-Cross Sectional View
(Color Mapping)
CT Value (HU
Credit:
Yamasaki K MD;
Osaka University

19. Predictive Factor of PCI procedure difficulty
Stone Rock
Bean
Ring
Multi
Full Moon
C-Shape
Calcium Assessment by CT
Credit:
Yamasaki K MD;
Osaka University

20. G. Werner, Y. Abdelwahed; EuroCTO Club, Berlin 2020
Case 1: Live Case No. 5 Euro CTO Club 2020

21. G. Werner, Y. Abdelwahed; EuroCTO Club, Berlin 2020
CT Plaque Analysis

22. Gerald S. Werner. Circulation: Cardiovascular Interventions. Use of Coronary Computed
Tomographic Angiography to Facilitate Percutaneous Coronary Intervention of Chronic
Occlusions, Volume: 12, Issue: 10, DOI: (10.1161/CIRCINTERVENTIONS.119.007387) © 2019 American Heart Association,Inc.
The sheer fact to detect extensive calcium should not prevent the indication to attempt a CTO as it is important where the calcium is located: is it a central
blockage that may prevent the wire advancement,34 or is it circular wall calcification with a central softer core (Figure 4). However, new approaches may even be
able to circumvent these extensive calcium blocks, especially with subintimal wiring techniques and reentry both from the antegrade and retrograde approach.
Nonetheless, selecting the optimal approach based on angiographic characteristics is often more art than science. Selecting the procedural strategy based on
CTA-derived imaging might streamline the approach, reduce contrast use and radiation exposure, and enhance procedural success
Full Moon Calcification

23. G. Werner, Y. Abdelwahed; EuroCTO Club, Berlin 2020
Difficulty crossing devices and the need to
Rotablate

24. G. Werner, Y. Abdelwahed; EuroCTO Club, Berlin 2020

25. CT
 Planning
• Myocardial Mass at Risk (MMAR)

26. Myocardial Mass At Risk (MMAR)

27. COURAGE
Rates of Death or MI by residual Ischaemia
Shaw et al. Circulation 2008:117

28. MMAR（Myocardial Mass At Risk）
Credit: Osaka University; Japan

29. Abdelwahed YS et al., European Heart Journal 2021
Case 2: Side Branch assessment

30. Abdelwahed YS et al., European Heart Journal 2021
CT Analysis

31. Abdelwahed YS et al., European Heart Journal 2021
MMAR（Myocardial Mass At Risk）

32. Abdelwahed YS et al., European Heart Journal 2021
Case 2: Retrograde crossing

33. CT
 Guidance
• Anatomical Course of the Vessel
• Bifurcations

34. Gerald S. Werner. Circulation:CardiovascularInterventions. Use of
Coronary Computed Tomographic Angiography to Facilitate Percutaneous
Coronary Intervention of Chronic Total Occlusions, Volume: 12, Issue: 10,
DOI: (10.1161/CIRCINTERVENTIONS.119.007387) © 2019 American Heart Association,Inc.
The CTA information can be visualized and displayed in many ways. The straightforward cross-sectional display of the coronary
segment can provide the valuable information of the calcium distribution within the segment. The multiplanar reformatted volume
allows the analysis of the longitudinal extent of the occluded segment, and finally, the volume-rendered presentation generates a
view that is familiar to the interventional operator as it is similar to the angiographic presentation with the added information on
plaque density and calcium distributions.
CT Guidance

35. Case 3: Course determination using CT
Credit: Satoru Sumitsuji

36. Case 3: Subintimal Tracking?
Credit: Satoru Sumitsuji

37. Case 3: Course determination using CT
Credit: Satoru Sumitsuji

38. Case 3: Course determination using CT
Credit: Satoru Sumitsuji

39. Case 3: Course determination using CT
Credit: Satoru Sumitsuji

40. Case 3: Successful crossing
Credit: Satoru Sumitsuji

41. Abdelwahed YS et al., J Invasive Cardiology 2022
Case 4: Antegrade crossing supported by CT

42. Abdelwahed YS et al., J Invasive Cardiology 2022
Case 4: Antegrade crossing supported by CT

43. Abdelwahed YS et al., J Invasive Cardiology 2022

44. Abdelwahed YS et al., J Invasive Cardiology 2022

45. Abdelwahed YS et al., J Invasive Cardiology 2022

46. Abdelwahed YS et al., J Invasive Cardiology 2022

47. Effect of Coronary CTA on Chronic Total Occlusion
Percutaneous Coronary Intervention: A Randomized Trial
• Successful recanalization: 187
patients (93.5%) in the CCTA–guided
group and 168 patients (84.0%) in the
angiography-guided group.
• Pre-procedural coronary CTA-
guidance for CTO resulted in higher
success rates with fewer immediate
periprocedural complications than
angiography guidance.
• Higher success rates were more
prominently observed in patients with
CTO who had a high J-CTO score ≥2
than those who did not. (p
interaction = 0.035).

48. Use of Coronary Computed Tomographic Angiography to Facilitate
Percutaneous Coronary Intervention of Chronic Total Occlusions
1. Luo et al: Independent CTA features determining procedural failure of the antegrade approach
– Lesion length >32 mm
– location at the ostium or at a bifurcation site.
– The absence of an effect of calcification on the outcome is at odds with previous and subsequent reports and may
be explained mainly by a selection bias
2. CT-RECTOR score (CT-Registry of Chronic Total Occlusion Revascularization) was suggested to
predict 30-minute wire crossing.
– 4 variables derived:
– (multiple occlusions, stump morphology, calcification extent>50% of the vessel cross-section, bending within the occlusion
>45°) and 2 clinical factors (previous attempt, duration of CTO>12 months).
– The main difference to the J-CTO score is the identification of multiple lesions within the body of the occlusion, which is
hard to do with angiography alone. Compared with the original J-CTO score,
– the CT-RECTOR score had a better prediction of the study end point (antegrade wire passage within 30 minutes), also
independently confirmed by another group from China.
3. Fujino et al: Advantage of CTA predictability of not only wire crossing times, but procedural success
– Regarding the calcification, a cutoff of >50% area of calcification of a vessel cross-section is considered as best
discriminator to define a complex lesion morphology
4. KCCT: 2 new factors: Side branch at the over angiography to define lesion characteristics using a
CTA-derived J-CTO score with a better entry of the occlusion and Central calcification within the
occlusion
Werner GS. Circ Cardiovasc Interv. 2019

50. Fujino A. et al. JACC Cardiovasc Imaging. 2018

51. Fujino A. et al. JACC Cardiovasc Imaging. 2018

52. Fujino A. et al. JACC Cardiovasc Imaging. 2018

53. Fujino A. et al. JACC Cardiovasc Imaging. 2018

54. Fujino A. et al. JACC Cardiovasc Imaging. 2018

55. • The discriminating accuracy of the CTA-derived J-CTO score was significantly higher than
that of the angiography-derived J-CTO score for predicting procedural success and 30-min
wire crossing. Coronary CTA has the potential to provide more detailed information
regarding CTO morphology compared to Angiography. These data need to be validated in a
prospective, multicenter study; and if confirmed, a randomized trial examining whether
procedural outcomes are improved by pre-procedural CTA imaging is warranted.

56. To Summarize
• CT is a great tool for preparation and for performing CTO
procedures as it helps in:
• Planning
– Predicting Complexity
– Vessel Course
– Calcification
– Landmarks
– Optimal Projections
• Guidence

57. Preprocedural CT – Which Patient needs it?

58. Preprocedural CT – Which Patient needs it?
• It depends on what Information we need and what are we missing
from the information we have

59. CBF
KARDIOLOGIE
Thank You!
youssef.abdelwahed@charite.de