4.50-4.58 pm progress cto update - cpsmd...2017/03/12 · radial approach 7. j-cto score validation...

Progress CTO update

Emmanouil S. Brilakis, MD, PhD Minneapolis Heart Institute

Adjunct Professor of Medicine, UT Southwestern

Friday February 24, 2017

4.50-4.58 pm

ES Brilakis: Disclosures

Consulting/speaker honoraria: Abbott Vascular, Asahi, Cardinal Health, CTI, Elsevier, GE Healthcare

Employment (spouse): Medtronic Grants: InfraRedx, Boston Scientific VA - I01-CX000787-01 VA CSP#571 – DIVA

Appleton Cardiology, WI, K. Alaswad

Mid America Heart Institute, MO, J.A. Grantham

Dallas VAMC, TX, S. Abdullah

Medical Center of the Rockies, CO, A. Doing

Minneapolis VA Medical Center, MN, S. Garcia

Banner Samaritan Medical Center, AZ, A. Pershad

Providence Health Center, TX, C. Shoultz

PeaceHealth St. Joseph Medical Center, WA, W. Lombardi

Henry Ford, MI, K. Alaswad

Little Rock VAMC, B. Uretsky

Baylor Dallas, TX, J. Choi

Houston VAMC, TX, A. Denktas

Denver VAMC, CO, E. Armstrong

Houston Methodist, TX, A. Shah

Tulane N Abi-Rafeh, O Mogabgab

UPMC C. Toma AJ Conrad Smith

Carolina East MC, NC D. Jessup

Piedmont Heart Institute, GA, D. Kandzari N. Lembo

Columbia University, NY, J. Moses D. Karmpaliotis

Massachusetts General Hospital, MA, F. Jaffer

San Diego VAMC and University of California, CA E. Mahmud, M. Patel

Torrance Medical Center, CA, M.R. Wyman

28 Sites - National coordinator: B.V. Rangan - Database managers: A. Karatasakis / P. Tajti

International sites: • Meshalkin Novosibirsk Research Institute, Russia, O. Kristyaninov • Korgialeneio-Benakeio Hellenic Red Cross Hospital, Greece, M. Koutouzis, Z. Kyriakidis

UT Southwestern, TX, S. Banerjee, H. Khalili

Northwestern Bluhm Cardiovascular Institute, IL, M. Ricciardi

PROspective Global REgiStry for the Study of CTO interventions

www.progresscto.org

Minneapolis Heart Institute, MN, N Burke, ES Brilakis

Baylor Plano, TX, L. Holper

www.progresscto.org

5/2012to2/201716centers,2,102lesionsTechnicalsuccess:88%MajorcomplicaAons:2.6%

• AppletonCardiology,WI• BaylorHeartandVascularHospital,TX• ColumbiaUniversity,NY• CentralArkansasVAMC,AR• DallasVAMC/UTSW,TX• HenryFordHospital,MI• MassachuseVsGeneralHospital,MA• MedicalCenteroftheRockies,CO• MinneapolisVAMC,MN• MinneapolisHeartInsAtute,MN• PeaceHealthSt.JosephMC,WA• PiedmontHeartInsAtute,GA• SanDiegoVAMCandUCSD,CA• StLuke’sMidAmericaHeartInsAtute,MO• TorranceMedicalCenter,CA• UPMCMedicalCenter,PA

AntegradewiringAntegradedissecAon/re-entryRetrograde

34.3% 39.5%

20.00%

40.00%

60.00%

80.00%

100.00%

Techniques Used

Antegrade

Antegrade DR

Retrograde

Successfultechnique

0.6%mortality,0.9%MI0.9%pericardiocentesis,0.2%stroke

0.1%CABG,0.3%re-PCI

www.progresscto.org

1.  Application and outcomes of the hybrid approach

2.  Comparison with other studies 3.  Target vessel and outcomes 4.  Mode of failure 5.  Prior CABG 6.  Radial approach 7.  J-CTO score validation 8.  PROGRESS-CTO score 9.  In-stent restenosis 10.  Impact of prior failed CTO PCI 11.  Side-branch loss 12.  Antegrade dissection/re-entry outcomes 13.  Guidewire utilization in AWE 14.  Contrast utilization

15.  Proximal cap ambiguity 16.  Retrograde outcomes 17.  Impact of lesion age 18.  Use of SVGs for retrograde approach 19.  Use of intravascular imaging 20.  Balloon uncrossable occlusions 21.  CTO scores comparative analysis 22.  PROGRESS-CTO Complications score 23.  Impact of age and sex 24.  Impact of diabetes 25.  Approaches to RCA occlusions 26.  Spatial distribution of CTOs 27.  Radiation exposure 28.  Effect of proximal vessel tortuosity 29.  Effect of calcification

Acceptedandpublishedwork

Online score calculator: www.progresscto.org

Progress CTO score

Christopoulos, Kandzari, Yeh, Jaffer, Karmpaliotis, Wyman,

Alaswad, Lombardi, Grantham, Moses, Christakopoulos, Tarar, Rangan, Lembo, Garcia, Cipher, Thompson, Banerjee, Brilakis.

JACC Intv 2016;9:1–9

98.2 97.5 91.6

0 10 20 30 40 50 60 70 80 90

0 1 2 ≥3

www.progresscto.orgEffect of age and sex

2012to201615centers,1,675lesionsTechnicalsuccess:88%MajorcomplicaAons:2.7%

Karatasakis A, Iwnetu R, Danek BA, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Kandzari DE, Lembo NJ, Patel MP, Mahmud E, Lombardi WL, Wyman RM, Grantham JA, Doing AH, Toma C, Choi JW, Uretsky BF, Moses JW, Kirtane AJ, Ali ZA, Parikh M, Karacsonyi J, Rangan BV, Thompson CA, Banerjee S, Brilakis ES. J Invasive Cardiol. 2017 Jan

Progress CTO complications score

Danek, Karatasakis, Karmpaliotis, Alaswad, Yeh, Jaffer, Patel,

Mahmud, Lombardi, Wyman, Grantham, Doing, Kandzari, Lembo,

Garcia, Toma, Moses, Kirtane, Parikh, Ali, Karacsonyi, Rangan, Thompson, Banerjee, Brilakis.

JAHA 2016

www.progresscto.org

11 centers, 1,569 lesions In-hospital major adverse cardiovascular events 2.8%

MACE = MI, stroke, urgent re-PCI or CABG, tamponade requiring pericardiocentesis, death

www.progresscto.org

N=394 9 US centers Median lesion age=12 months ; Mean lesion age 43.3 months 1st tertile <5 months, 2nd tertile ≥5 months and <36.3 months, 3rd tertile ≥36.3 months

Lesion Age

Danek, Karatasakis, Karmpaliotis, Alaswad, Yeh, Jaffer, Patel, Bahadorani, Lombardi, Wyman, Grantham, Doing, Moses, Kirtane, Parikh, Ali, Kalra, Kandzari, Lembo, Garcia, Nguyen-Trong, Karacsonyi, Alame, Kalsaria, Rangan, Thompson, Banerjee, Brilakis. Canadian Journal of Cardiology 2016 Apr 22

www.progresscto.org

Danek, Karatasakis, Karmpaliotis, Alaswad, Yeh, Jaffer, Patel, Bahadorani, Lombardi, Wyman, Grantham, Doing, Moses, Kirtane, Parikh, Ali, Kalra, Kandzari, Lembo, Garcia, Nguyen-Trong, Karacsonyi, Alame, Kalsaria, Rangan, Thompson, Banerjee, Brilakis. Canadian Journal of Cardiology 2016 Apr 22

Lesion Age

93.0 89.0

89.6 87.4

87.8 86.3

3.10.0

10.020.030.040.050.060.070.080.090.0

Technical success Procedural success MACE

Young lesions

Intermediate lesions

Oldest lesions

Δ=5.2% p=0.37 Δ=2.7%

p=0.80

Δ=3.3% p=0.31

www.progresscto.orgImpact of prior failure

2012-2015 12 centers, 1,232 lesions Prior failure: 17.5%

88.0 93.7

90.0 90.0

Technical Success (%) Procedural Success (%) MACE (%)

Prior failed CTO PCI attempt

No prior failed CTO PCI attempt

Karacsonyi,Karatasakis,Karmpalio8s,Alaswad,Yeh,Jaffer,Wyman,Lombardi,Grantham,Kandzari,Lembo,Moses,Kirtane,Parikh,Green,Finn,Garcia,Doing,Patel,Mar8nezParachini,Resendes,Rangan,Ungi,Thompson,Banerjee,Brilakis.

Am J Cardiol 2016; 2016Apr15;117(8):1267-71

P=0.390 P=0.184

P=0.067

www.progresscto.org

N=1313 11 US centers ADR=458 (34.9%), ADR after exclusion of retrograde cases=248 (32.3% of 767 antegrade-only cases) Complications 2.9 vs. 2.2% all cases, 1.5 vs. 0.6% antegrade-only Danek, Karatasakis, Karmpaliotis, Alaswad, Yeh, Jaffer, Patel, Bahadorani, Lombardi, Wyman, Grantham, Doing,

Moses, Kirtane, Parikh, Ali, Kalra, Kandzari, Lembo, Garcia, Rangan, Thompson, Banerjee, Brilakis. Int J Cardiol 2016 Jul 1;214:428-37

Antegrade Dissection Re-entry

89.9 87.0

93.2 91.8

Technical success Procedural success

ADR Non-ADR Δ=3.3% P<0.01

89.9 87.0 93.2 91.8

ADR AWE-only

Antegrade-only cases

All cases

Δ=5.7% P<0.01

Δ=2.3% P=0.23

Δ=1.5% P=0.43

www.progresscto.orgRetrograde vs. antegrade-only: outcomes

2012-2015 11 centers, 1,301 lesions Retrograde utilization: 41%

84.8 81.993.7 93.3

Technical Success Procedural Success

RetrogradeAntegrade-only

Δ= 8.9% P<0.001

Δ=11.4% P<0.001

Karmpalio8sD,KaratasakisA,AlaswadK,JafferFA,YehRW,WymanRM,LombardiW,GranthamJA,KandzariDE,LemboNJ,DoingA,PatelM,BahadoraniJ,MosesJW,KirtaneAJ,ParikhM,AliZ,KalraS,Nguyen-TrongPJ,DanekBA,KaracsonyiJ,RanganBV,RoesleM,ThompsonCA,BanerjeeS,BrilakisES.CircCardiovascInterv2016Jun;9(6)

www.progresscto.org

0.60.8

0.3 0.3 0.30.1 0.1

licati

Retrograde

Antegrade-only

Retrograde vs. antegrade-only: in-hospital MACE p<0.001

p=0.003

p=0.999

p=0.039

P=0.314p=0.167

Karmpalio8sD,KaratasakisA,AlaswadK,JafferFA,YehRW,WymanRM,LombardiW,GranthamJA,KandzariDE,LemboNJ,DoingA,PatelM,BahadoraniJ,MosesJW,KirtaneAJ,ParikhM,AliZ,KalraS,Nguyen-TrongPJ,DanekBA,KaracsonyiJ,RanganBV,RoesleM,ThompsonCA,BanerjeeS,BrilakisES.CircCardiovascInterv2016Jun;9(6)

www.progresscto.org

J-CTOscoreandCTOPCIapproach

J-CTOscorevalida8on

ProceduralAmeandJ-CTOscore

1/2012to7/20146centers,n=650lesions

Christopoulos,Wyman,Alaswad,KarmpalioAs,Lombardi,Grantham,Yeh,Jaffer,Cipher,Rangan,Christakopoulos,Kypreos,Lembo,Kandzari,Garcia,Thompson,Banerjee,Brilakis

CircCardiovascInterv2015;8:e002171

www.progresscto.org

10 10 719 19

3045 50

6479 84

171196

WiringaVem

Guidewire

SuccessfulTotal

2012-2015 15 centers, 1,011 lesions Antegrade wire escalation: 694 (69%)

Antegrade guidewire utilization

Karatasakis, Tarar, Karmpaliotis, Alaswad, Yeh, Jaffer, Wyman, Lombardi, Grantham, Kandzari, Lembo, Moses, Kirtane, Parikh, Garcia, Doing, Pershad, Shah, Patel, Bahadorani, Shoultz Jr., Danek, Thompson, Banerjee, Brilakis. Catheter Cardiovasc Interv 2016 May 17

www.progresscto.org

Radiation exposure

2012-2015 9 centers, 748 lesions Procedural success: 90% Median AK dose: 3.4 (2.0, 5.4) Gy

Christakopoulos G, Christopoulos G, Karmpaliotis DK, Alaswad K, Yeh RW, Jaffer FA, Wyman MR, Lombardi WL, Tarar MNJ, Grantham JA, Kandzari DE, Lembo N, Moses JW, Kirtane AJ, Parikh M, Green P, Finn M, Garcia S, Doing AH, Hatem R, Thompson CA, Banerjee S, Brilakis ES. Can J Cardiol (in press)

www.progresscto.org

Contrast Utilization

Christakopoulos GE, Karmpaliotis D, Alaswad K, Yeh RW, Jaffer FA, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Moses JW, Kirtane AJ, Parikh M, Green P, Finn M, Garcia S, Doing A, Patel

M, Bahadorani J, Christopoulos G, Karatasakis A, Thompson CA, Banerjee S, Brilakis ES. J Invasive Cardiol. 2016 Jul;28:288-94.

2012-2015 12 centers, 1,330 lesions Technical Success: 90% Mean contrast: 289±138mL

Parameters independently associated with contrast

www.progresscto.orgBalloon uncrossable lesions

2012-2016 11 centers, 755 lesions Balloon uncrossable: 9%

90.5% 88.9%

98.3% 96.6%

Balloon uncrossable lesions Balloon crossable lesions

Δ=7.8% p<0.001

Δ=0.6% p=0.751

Δ=7.7% p=0.004

[PERCENTAGE]

[PERCENTAGE][PERCENT

AGE]1511

Grenadoplasty Guideanchoringtechniques

Laser Guidecatheterextensions

Tornus RotaAonalatherectomy

Other Threader

Techniquesusedtotreatballoonuncrossablelesions

Karacsonyi J, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel M, Bahadorani J, Doing A, Ali ZA, Karatasakis A, Danek BA, Rangan BV, Alame AJ, Banerjee S, Brilakis ES.

Catheter Cardiovasc Interv. 2016 Sep 21

www.progresscto.org

N=109 Sidebranchlossoccurredin28cases(25.7%)Highercardiovascularmortality(7.4%vs.0%,logrankp=0.017)Single center – Dallas VA Major complications: 1.8% (perforation with pericardiocentesis, stent thrombosis within 24 hours)

Nguyen-TrongPJ,RanganBV,KaratasakisA,DanekBA,ChristakopoulosGE,MarAnez-ParachiniJR,ResendesE,AyersCR,LunaM,AbdullahS,KumbhaniDJ,AddoT,GrodinJ,BanerjeeS,BrilakisES.

JInvasiveCardiol.2016Apr;28(4):168-73.

Side Branch Loss

www.progresscto.orgIntravascular imaging

2012-2015 7 centers, 619 lesions Intravascular imaging: 38%

KaracsonyiJ,AlaswadK,JafferFA,YehRW,PatelMP,BahadoraniJN,KaratasakisA,DanekBA,DoingAH,GranthamJA,Karmpalio8sD,MosesJW,KirtaneAJ,ParikhM,AliZ,LombardiWL,KandzariDE,LemboNJ,GarciaS,WymanRM,AlameAJ,Nguyen-TrongPJ,ResendesE,KalsariaP,

RanganBV,UngiI,ThompsonCA,BanerjeeS,BrilakisES.J Am Heart Assoc. 2016 Aug 20;5(8)

[PERCENTAGE] [PERCE

NTAGE]

[PERCENTAGE]

Proximalcapambiguity

Toguidewiring

Toguidereverse-CART

StentopAmizaAon

Stentsizing

www.progresscto.orgIntravascular imaging

KaracsonyiJ,AlaswadK,JafferFA,YehRW,PatelMP,BahadoraniJN,KaratasakisA,DanekBA,DoingAH,GranthamJA,Karmpalio8sD,MosesJW,KirtaneAJ,ParikhM,AliZ,LombardiWL,KandzariDE,LemboNJ,GarciaS,WymanRM,AlameAJ,Nguyen-TrongPJ,ResendesE,KalsariaP,RanganBV,UngiI,ThompsonCA,BanerjeeS,BrilakisES.J Am Heart Assoc. 2016 Aug 20;5(8)

92.8% 89.6%

90.1% 88.3%

Imaging for crossing No imaging or imaging for stent optimization

Δ=3.2% p=0.302

Δ=1.8% p=0.588

Δ=0.5% p=0.772

1. CTO PCI: high success + acceptable complication rates

2. Scores (success+complications) can facilitate decision making

3. Prior failure – lesion age: still high success

4. Balloon uncrossable: 9% 5. Side branch loss: undesirable 6. Wide variability in contrast +

radiation use

Conclusions

FormoreinformaAonortojoin:www.progresscto.org

www.progresscto.org

1.  Application and outcomes of the hybrid approach

2.  Comparison with other studies 3.  Target vessel and outcomes 4.  Mode of failure 5.  Prior CABG 6.  Radial approach 7.  J-CTO score validation 8.  PROGRESS-CTO score 9.  In-stent restenosis 10.  Impact of prior failed CTO PCI 11.  Side-branch loss 12.  Antegrade dissection/re-entry outcomes 13.  Guidewire utilization in AWE 14.  Contrast utilization

15.  Proximal cap ambiguity 16.  Retrograde outcomes 17.  Impact of lesion age 18.  Use of SVGs for retrograde approach 19.  Use of intravascular imaging 20.  Balloon uncrossable occlusions 21.  CTO scores comparative analysis 22.  PROGRESS-CTO Complications score 23.  Impact of age and sex 24.  Impact of diabetes 25.  Approaches to RCA occlusions 26.  Spatial distribution of CTOs 27.  Radiation exposure 28.  Effect of proximal vessel tortuosity 29.  Effect of calcification

Acceptedandpublishedwork

www.progresscto.orgCrossingstrategyselec8on

Christopoulos,Karmpalio8s,Alaswad,Yeh,Jaffer,Wyman,Lombardi,Menon,Grantham,Kandzari,Lembo,Moses,Kirtane,Parikh,Green,Finn,Garcia,Doing,Patel,Bahadorani,Tarar,Christakopoulos,Thompson,Banerjee,Brilakis.IntJCardiology

2015;198:222-228

www.progresscto.org

Success and target vessel

Targetvessel

RCA(61%)

LAD(21%)

LCX(18%)

RCA LAD LCX

Technicalsuccess

p=0.013

N=6366UScentersRetrogrademorefrequentlyinRCAintervenAon:Ini8alstrategy(26%),finalsuccessfulstrategy(33%)

Christopoulos,KarmpalioAs,Wyman,Alaswad,McCabe,Lombardi,Grantham,Marso,Kotsia,Rangan,Garcia,Lembo,Kandzari,Lee,Kalynych,Carlson,Thompson,Banerjee,Brilakis.

CanJCardiol2014;30:1588-94

www.progresscto.org

Mode of failure

[VALUE]%

Failure Success

380procedures

9 technical successes •  Death (n=1) •  MI (n=4) •  Urgent PCI (n=1) •  Pericardiocentesis (n=3)

1 technical failure •  Death from

tamponade

•  Appleton,•  Peacehealth•  MidAmericaHeartInsAtute•  DallasVAMC

<TIMI 3 flow •  Distal dissection (n=2) •  Side branch loss (n=3)

Failure to wire (n=18)

SaponAs,Christopoulos,Grantham,Wyman,Alaswad,KarmpalioAs,Lombardi,McCabe,Marso,Kotsia,Rangan,Christakopoulos,Garcia,Thompson,Banerjee,Brilakis.CathCardiovascInterv2015;85:1115-22

[VALUE]%

MACE Technicalfailure

www.progresscto.org

2006-2011 2012-2013

No prior CABGPrior CABGPreHybridera

Michael,Karmpalio8s,Brilakis,Abdullah,Kirkland,Mishoe,Lembo,Kalynych,Carlson,Banerjee,Lombardi,Kandzari.

Heart2013;99:1515-8

Δ=9.1%P<0.001

Christopoulos,Menon,Karmpalio8s,Alaswad,Lombardi,Grantham,Michael,Patel,Rangan,Kotsia,Lembo,Kandzari,Lee,Kalynych,Carlson,

Garcia,Banerjee,Thompson,Brilakis.AmJCardiol2014;113:1990-4

EffectofPriorCABG

N=1,3633USsitesPriorCABG:37%Complica8ons:1.5%vs.2.1%Retrograde:27.1%vs.46.7%

Δ=3.7%P=0.092

Hybridera

N=6306USsitesPriorCABG:37%Complica8ons:2.5%vs.0.8%Retrograde:34%vs.39%

www.progresscto.orgRadial vs femoral access

N=6506UScentersTransradial(17%):mainlyAppletonWITechnicalsuccess:92.6%femoralvs.93%radial,p=0.87

Alaswad,Menon,Christopoulos,Lombardi,KarmpalioAs,Grantham,Marso,Wyman,Pokala,Patel,Kotsia,Rangan,Lembo,Kandzari,Lee,Kalynych,Carlson,Garcia,Thompson,Banerjee,Brilakis.CathCardiovascIntv2015;85:1123-29

www.progresscto.org

ROCcurve

J-CTOscorevalida8on

Areaundercurve=0.705forfinalsuccess

Rinfretetal.AUC=0.77forGWcrossing<30minAUC=0.39forfinalsuccess

Previousstudies

Morinoetal.AUC=0.82forGWcrossing<30min

Christopoulos,Wyman,Alaswad,KarmpalioAs,Lombardi,Grantham,Yeh,Jaffer,Cipher,Rangan,Christakopoulos,Kypreos,Lembo,Kandzari,Garcia,Thompson,Banerjee,Brilakis

CircCardiovascInterv2015;8:e002171

Progress CTO score

Christopoulos, Kandzari, Yeh, Jaffer, Karmpaliotis, Wyman,

Alaswad, Lombardi, Grantham, Moses, Christakopoulos, Tarar, Rangan, Lembo, Garcia, Cipher, Thompson, Banerjee, Brilakis.

JACC Intv 2016;9:1–9

98.2 97.5 91.6

0 10 20 30 40 50 60 70 80 90

0 1 2 ≥3

www.progresscto.org

PROGRESSCTOscorePROGRESS score model

2/3 sampling rate for derivation set, 521 CTO lesions

PROGRESSAUC=0.720

J-CTOAUC=0.746

Variable

OR for technical

failure (95% CI)

p b coefficient points

No Interventional collaterals

2.40 (0.92-6.55) 0.076 0.88 1

Proximal cap ambiguity

3.86 (1.49-10.43)

0.006 1.35 1

Moderate or severe tortuosity

3.25 (1.22-9.28) 0.021 1.18 1

LCX CTO 2.69 (1.00-7.14) 0.046 0.99 1

Prior PCI 1.64 (0.54-6.13) 0.391 0.25 0

Christopoulos,Kandzari,Yeh,Jaffer,KarmpalioAs,Wyman,Alaswad,Lombardi,Grantham,Moses,Christakopoulos,Tarar,Rangan,Lembo,Garcia,Cipher,Thompson,Banerjee,Brilakis.JACCIntv2016Jan11;9(1):1-9

www.progresscto.org

93.291.8

ISR De novoΔ=3.3%p=0.31

Δ=4.8%p=0.18

N=642In-stentrestenosis=69(10.7%),Denovolesions=5736UScentersMajorcomplicaAons:ISR2.9%vs.Denovo1.6%

Christopoulos,KarmpalioAs,Alaswad,Lombardi,Grantham,Rangan,Kotsia,Lembo,Kandzari,Lee,Kalynych,Carlson,Garcia,Banerjee,Thompson,Brilakis.

CatheterCardiovascInterv.2014;84:646-51

In-stent restenosis

AmJCardiol2016;2016Apr15;117(8):1267-71

Successfulcrossingstrategy

10.1Overall(%)

Priorfailure(%)

Nopriorfailure(%)

Antegrade

Retrograde

AntegradedissecAonandre-entry

260.0 260.0

050100150200250300350400

Contrast0volume0(ml)

AmJCardiol2016;2016Apr15;117(8):1267-71

P=0.893

P=0.015

P=0.163 4.0

AK*radiation*dose*(Gray)

Prior*failed*CTO*PCI*attemptNo*prior*failed*CTO*PCI*attempt

Fluoroscopy2time2(min)

www.progresscto.orgProximal cap ambiguity

2012-2015 11 centers, 1,021 lesions Proximal cap ambiguity: 31%

93 9185 84

Technical Success Procedural Success

Non-ambiguous capAmbiguous cap

Δ= 8% P<0.001 Δ=7%

P=0.012

Karatasakis, Danek, Karmpaliotis, Alaswad, Jaffer, Yeh, Patel, Bahadorani, Wyman, Lombardi, Grantham, Kandzari, Lembo, Doing, Moses, Kirtane, Parikh, Ali, Garcia, Karacsonyi, Kalra, Kalsaria,

Thompson, Banerjee, Brilakis. J Invasive Cardiol. 2016 Oct;28(10):391-396.

[PERCENTAGE]

AntegradeWiringAntegradedissecAon/re-entryRetrograde

Successful technique for lesions with ambiguous caps

www.progresscto.orgProximal cap ambiguity

Karatasakis, Danek, Karmpaliotis, Alaswad, Jaffer, Yeh, Patel, Bahadorani, Wyman, Lombardi, Grantham, Kandzari, Lembo, Doing, Moses, Kirtane, Parikh, Ali, Garcia, Karacsonyi, Kalra, Kalsaria, Thompson, Banerjee, Brilakis. J Invasive Cardiol. 2016 Oct;28(10):391-396.

www.progresscto.orgUse of SVGs in retrograde CTO PCI

Nguyen-Trong PJ, Alaswad K, Karmpaliotis D, Lombardi W, Grantham J, Lembo NJ, Kandzari DE, Karatasakis A, Karacsonyi J, Danek BA, Rangan BV, Roesle M, Ayers CR, Thompson CA, Banerjee S, Brilakis ES. J Invasive Cardiol. 2016 Jun;28:218-24

2012-2015 4 centers, 572 lesions Retrograde PCI: n=144 (25.2%) Retrograde through SVG: n=21 (14.6% of retrograde)

www.progresscto.org

93%98% 96%

87%90%97% 94%

3% 2% 2% 4%

IMG for crossing IMG for stentoptimization

IMG for both imagingand stent optimization

No imaging

PurposeofintravascularimagingtechniquesIntravascular imaging

KaracsonyiJ,AlaswadK,JafferFA,YehRW,PatelMP,BahadoraniJN,KaratasakisA,DanekBA,DoingAH,GranthamJA,Karmpalio8sD,MosesJW,KirtaneAJ,ParikhM,AliZ,LombardiWL,KandzariDE,LemboNJ,GarciaS,WymanRM,AlameAJ,Nguyen-TrongPJ,ResendesE,KalsariaP,

RanganBV,UngiI,ThompsonCA,BanerjeeS,BrilakisES.J Am Heart Assoc. 2016 Aug 20;5(8)

www.progresscto.org

6%2% 3%

0.6% 2% 1% 0.2% 0.6% 4% 0.6% 3%

Balloon OTW Corsair CrossBoss Finecross Tornus Venture MulticrossCentercross Micro14 Turnpike Twin-pass Other

Balloon uncrossable Balloon crossable

Balloon uncrossable lesions

p=0.390

p<0.001

p=0.911

Karacsonyi J, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel M, Bahadorani J, Doing A, Ali ZA, Karatasakis A, Danek BA, Rangan BV, Alame AJ, Banerjee S, Brilakis ES.

Catheter Cardiovasc Interv. 2016 Sep 21

p=0.047

p=0.093

p=0.718

p=0.266

p=0.756

p=0.534

p<0.001

p=0.534

p=0.938

Microcathetersamongstudylesions

www.progresscto.org

CTO score comparative analysis

KaratasakisA,DanekBA,Karmpalio8sD,AlaswadK,JafferFA,YehRW,PatelMP,

BahadoraniJN,LombardiWL,WymanRM,GranthamJA,KandzariDE,LemboNJ,

DoingAH,TomaC,MosesJW,KirtaneAJ,ParikhM,AliZA,GarciaS,KalsariaP,KaracsonyiJ,AlameAJ,ThompsonCA,BanerjeeS,BrilakisES.IntJCardiol.Aug

23;224:50-56

2012to201613centers,664lesions(lesionsfromPROGRESSscorederivaAonsetexcluded)Technicalsuccess:88%MajorcomplicaAons:3.6%

www.progresscto.org

CTO score comparative analysis

KaratasakisA,DanekBA,Karmpalio8sD,AlaswadK,JafferFA,YehRW,PatelMP,

BahadoraniJN,LombardiWL,WymanRM,GranthamJA,KandzariDE,LemboNJ,

DoingAH,TomaC,MosesJW,KirtaneAJ,ParikhM,AliZA,GarciaS,KalsariaP,KaracsonyiJ,AlameAJ,ThompsonCA,BanerjeeS,BrilakisES.IntJCardiol.Aug

23;224:50-56

www.progresscto.orgProgress CTO complications score

Danek, Karatasakis, Karmpaliotis, Alaswad, Yeh, Jaffer, Patel, Mahmud, Lombardi, Wyman, Grantham, Doing, Kandzari, Lembo, Garcia, Toma, Moses, Kirtane, Parikh, Ali, Karacsonyi, Rangan, Thompson, Banerjee, Brilakis. JAHA 2016 Oct 11;5(10).

11 centers, 1,569 lesions In-hospital major adverse cardiovascular events 2.8%

MACE = MI, stroke, urgent re-PCI or CABG, tamponade requiring pericardiocentesis, death

www.progresscto.org

Table 4. Multivariable logistic regression in the derivation set (n=1065)

Variable Odds ratio 95% CI p Points

Age>65 4.85 1.82-16.77 0.001 +3

Prior heart failure

Prior valve procedure

Length ≥23mm 3.22 1.08-13.89 0.035 +2

Blunt/no stump

Retrograde approach used 2.41 1.04-6.05 0.041 +1

www.progresscto.org

Derivation set (n= 1065) AUC = 0.758 Validation set (n= 504) AUC = 0.793

www.progresscto.orgProgress CTO complications score

www.progresscto.orgEffect of age and sex

2012to201615centers,1,675lesionsTechnicalsuccess:88%MajorcomplicaAons:2.7%

Karatasakis A, Iwnetu R, Danek BA, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Kandzari DE, Lembo NJ, Patel MP, Mahmud E, Lombardi WL, Wyman RM, Grantham JA, Doing AH, Toma C, Choi JW, Uretsky BF, Moses JW, Kirtane AJ, Ali ZA, Parikh M, Karacsonyi J, Rangan BV, Thompson CA, Banerjee S, Brilakis ES. J Invasive Cardiol. 2017 Jan

www.progresscto.org

55.344.6

Nodiabetes Diabetes

101520253035404550

Overall Nodiabetes

Diabetes

Retrograde(%)

Antegrade(%)

AntegradedissecAonandre-entry(%)

Overall Nodiabetes Diabetes

Technicalsuccess(%)

Proceduralsuccess(%)

2012to201511centers,1,333lesionsTechnicalsuccess:90.3%MajorcomplicaAons:2.4% Successfulcrossing

DiabetesvsNodiabetes

p=0.80

p=0.93

JoseRobertoMar8nezParachini,ArisKaratasakis,DimitriKarmpalio8s,KhaldoonAlaswad,FaroucA.Jaffer,RobertW.Yeh,MichaelWyman,WilliamL.Lombardi,AaronGrantham,David,Kandzari,NicholasLembo,AnthonyDoing,MitulPatel,JohnBahadorani,JeffreyW.Moses,AjayKirtane,ManishParikh,AliZiad,SanjogKalra,Phuong-KhanhJNguyen-Trong,BarbaraA.Danek,JuditKaracsonyi,AyaAlame,BavanaV.

Rangan,CraigA.Thompson,SubhashBanerjee,EmmanouilS.Brilakis.DiabetMed2016(inpress)

www.progresscto.org

BMIkg/m2

230240250260270280

ContrastVolume

J-CTOscore p=0.82

p=0.001* p=0.02*

PaAentAirKermadosep=0.043*

JoseRobertoMar8nezParachini,ArisKaratasakis,DimitriKarmpalio8s,KhaldoonAlaswad,FaroucA.Jaffer,RobertW.Yeh,MichaelWyman,WilliamL.Lombardi,AaronGrantham,David,Kandzari,NicholasLembo,AnthonyDoing,MitulPatel,JohnBahadorani,JeffreyW.Moses,AjayKirtane,ManishParikh,AliZiad,SanjogKalra,Phuong-KhanhJNguyen-Trong,BarbaraA.Danek,JuditKaracsonyi,AyaAlame,BavanaV.

Rangan,CraigA.Thompson,SubhashBanerjee,EmmanouilS.Brilakis.DiabetMed2016(inpress)

DiabetesvsNodiabetes

www.progresscto.orgApproaches to RCA CTOs

173237

Antegrade WireEscalation

Antegrade Dissection/Re-entry

Retrograde

Lesions attempted

Successful PCI

2012-2015 11 centers, 1,308 lesions RCA CTOs: 56% Technical success for RCA: 90%

Karatasakis A, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel MP, Bahadorani JN, Lombardi WL, Wyman RM, Grantham JA, Kandzari DE, Lembo NJ, Doing AH, Toma C, Moses JW, Kirtane AJ, Ali Z, Parikh M, Garcia S, Danek BA, Karacsonyi J, Alame AJ, Kalsaria P, Thompson CA, Banerjee S, Brilakis ES.

EuroIntervention 2016 Dec 10;12(11)

www.progresscto.org

29.2% 27.9%

18.2% 17.4%

31.9% 33.3%

Proximal RCA Mid RCA Distal RCA Right PDA/PAV/PL

Antegrade Wire Escalation

Antegrade Dissection/Re-entry

Retrograde

RCA CTOs: successful strategy according to lesion location

p=0.045

Technicalsuccess:

89% 89% 96% 79%

p=0.11

Karatasakis A, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel MP, Bahadorani JN, Lombardi WL, Wyman RM, Grantham JA, Kandzari DE, Lembo NJ, Doing AH, Toma C, Moses JW, Kirtane AJ, Ali Z, Parikh M, Garcia S, Danek BA, Karacsonyi J, Alame AJ, Kalsaria P, Thompson CA, Banerjee S, Brilakis ES.

EuroIntervention 2016 Dec 10;12(11)

www.progresscto.org

CTO spatial distribution 2012-2016 13 centers, 1,369 lesions Procedural success: 88%

LesionLocaAon

Proximal

Distal

87% 90%85%

Proximal Mid Distal

Proceduralsuccess

Garcia S, Alraies MC, Karatasakis A, Yannopoulos D, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel MP, Bahadorani JN, Karacsonyi J, Kalsaria P, Danek BA, Banerjee S, Brilakis ES. Cath Cardiovasc Interv 2016 Nov 10.

www.progresscto.org

Radiation exposure

2012-2015 9 centers, 748 lesions Procedural success: 90% Median AK dose: 3.4 (2.0, 5.4) Gy

www.progresscto.org

Radiation exposure - variables associated with AK dose

Variable Univariable Multivariable p-value for univariable

p-value for multivariable

BMI (kg/m2) 0.10 (0.017) 0.08 (0.017) <.0001 <.0001 Dyslipidemia 0.668 (0.236) 0.10 (0.239) 0.005 0.661 Hypertension 0.335 (0.182) 0.022 (0.172) 0.066 0.9 Prior PCI 0.31 (0.11) 0.138 (0.109) 0.005 0.208 Prior CABG 0.633 (0.11) 0.311 (0.110) <0.001 0.005 Prior PVD 0.267 (0.14) 0.011 (0.137) 0.058 0.936 Calcification (moderate/severe)

0.762 (0.105) 0.293 (0.116) <.0001 0.012

Tortuosity (moderate/severe)

0.402 (0.115) 0.032 (0.113) 0.005 0.778

Proximal cap ambiguity 0.362 (0.126) -0.250 (0.147) 0.004 0.09

Distal cap at bifurcation 0.374 (0.117) 0.222 (0.113) 0.002 0.051

J-CTO score 0.60 (0.09) 0.39 (0.12) <.0001 0.001 Blunt stump/ 1.208 (0.212) 0.993 (0.247) <.0001 <.0001 No stump

www.progresscto.org

84.0 93.7

91.0 90.0

Technical Success (%) Procedural Success (%) MACE (%)

Moderate or severe tortuosity

Mild or no tortuosity

Karacsonyi J, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel M, Mahmud E, Doing A, Toma C, Uretsky B, Choi J, Moses JW, Kirtane A, Parikh M, Ali Z, Lombardi WL, Kandzari DE, Lembo N, Garcia S, Wyman MR, Martinez-Parachini JR, Karatasakis A, Danek BA, Alame AJ, Resendes E, Rangan BV, Ungi I,

Thompson CA, Banerjee S, Brilakis, ES. J Invasive Cardiol (in press)

Proximal vessel tortuosity

P<0.0001 P<0.0001

P=0.587

2012-2016 14 centers, 1,618 lesions Moderate or severe proximal vessel tortuosity: 35.7% Technical success overall: 90%

[PERCENTAGE]

Straight SlightModerate Severe

www.progresscto.org

Thompson CA, Banerjee S, Brilakis, ES. J Invasive Cardiol (In press)

MulAvariateanalysesfortechnicalsuccess

www.progresscto.org

93.72.0 0.4

90.00.5 1.0

Guide/extension/catheter/(%)

Side/branch/anchor/(%)

Distal/anchor/(%) Other/(%)

Moderate/or/severe/tortuosity

Mild/or/no/tortuosity

Guidesupporttechniquesamongstudylesions,classifiedaccordingtoproximalvesseltortuosity

P=0.085

P=0.001 P=0.002 P=0.124

Thompson CA, Banerjee S, Brilakis, ES. J Invasive Cardiol (in press)

www.progresscto.org

86.6 93.7

93.8 90.0

Technical3Success3(%) Procedural3Success3(%) MACE3(%)

Moderate3or3severe3calcification

Mild3or3no3calcification

Calcification

P<0.0001 P<0.0001

P=0.033

Karacsonyi J, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel M, Mahmud E, Lombardi W, Wyman MR, Doing A, Moses JW, Kirtane A, Parikh M, Ali Z, Kandzari D, Lembo N, Garcia S, Danek BA, Karatasakis A, Resendes E, Karsaria P, Rangan BV, Ungi I, Thompson CA, Banerjee S, Brilakis ES.

2012-2016 11 centers, 1,476 lesions Moderate or severe proximal vessel tortuosity: 57.7% Technical success overall: 90%

[PERCENTAGE]

21[PERCENTAGE]

None Mild Moderate Severe

www.progresscto.org

Calcification MulAvariateanalysesfortechnicalsuccess

www.progresscto.org

Guide catheter utilization in calcification

www.progresscto.org

Future direction - works in Progress

1.  MechanicalCirculatorySupport2.   EpicardialcollateraluAlizaAon3.   ClinicalpresentaAonandoutcomes4.   TwoCTOsaVemptedduringthesameprocedure5.   Longtermoutcomes:MACE/TLR6.   Effectofrace/ethnicity7.   Impactofnewequipment

FormoreinformaAonortojoin:www.progresscto.org

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