improving outcomes in cto – new approaches
Post on 27-Nov-2021
7 Views
Preview:
TRANSCRIPT
Improving Outcomes in CTO– New Approaches
William Lombardi MD.
Director Complex Coronary Therapies
CTO Basics
• Myocytes don’t know why they are ischemic
• Myocytes don’t care how the oxygen gets tothem
Indications for revascularization are determinedIndications for revascularization are determinedprior to angiography
Treatment According toAppropriateness
Unadjusted rates and adjusted Hazards of death orrecurrent ACS at 3 Years, According to
Appropriateness Categories and CoronaryRevascularization
AppropriatenessCategory
NNo
RevascularizationRevascularization
HR (95% CI)
0.99 (0.48-Inappropriate* 311 16 (9.4%) 20 (14.2%)
0.99 (0.48-2.02)
Uncertain* 32623 (15.3%)
14 (8.0%)0.57 (0.28-
1.16)
Appropriate† 991 50 (16.1%) 80 (11.8%)0.61 (0.42-
0.88)
SYNTAXCTO subset procedural characteristics: per lesion analysis
Per Lesion
Serruys P, CRT 2009 [modified]; courtesy Prof Serruys and the SYNTAX investigators
SYNTAXCTO Subset Procedural characteristics Per lesion analysis
ITT, Per LesionSerruys P, CRT 2009 [modified]; courtesy Prof Serruys and the SYNTAX investigators
55.557.1
59.2 59.861.9
40
50
60
70 % of total PCI Procedural success MACE
Trends over time
3.2 3.5 3.8 4.2 4.8
0
10
20
30
40
2009 2010 2011 2012 2013
%
Brilakis et al, JACC Cardiovasc Intv 2014 – in press
4%
6%
8%
10%Failed CTO
Successful CTO
BCIS Data
0%
2%
4%
10199 9080 6621 4340 2252Success
4240 3690 2646 1707 806Failure
0 .5 1 1.5 2 2.5 3 3.5 4
Follow-up time (years)
What is limiting the adoption of CTO PCI?
Complexity:• Poor success rates
• Procedure time
• Complication rates
• Cost
Confusion:• Inconsistency
of teaching
• Clinical justification
Confidence:
• Understanding own ability
• Lack of planning
• Post-case analysis
The Hybrid Algorithm for CTO PCIprovisional approaches
Dual Catheter Angiography
1. Clear proximal cap2. Good Distal Target
3. Length < 20mm
Antegrade Retrograde
yes no
yes yes no3. Length < 20mm
Wireescalation
Dissection Reentry(crossboss-stingray)
Wireescalation
Dissection Reentry(reverse CART)
yes yes nono
Dissection Reentry(reverse CART)
Dissection Reentry(crossboss-stingray))
fail
fail
fail
fail
CTO Basics: Set up for success
• Large extra support guide
• Two Guides
• Have all the tools and know how to use them
• Separation is in the Preperation
– Don’t plan for success know your options
Wire Escalation
Pilot 200
Clear Path andTarget
CONFIANZA PRO12g
Gaia 2nd
AN
TE
GR
AD
EWire Escalation
Pilot 200
Clear Path andTarget
CONFIANZA PRO12g
Gaia 3rd
RE
TR
OG
RA
DE
Antegrade
Dissection ReEntry
DissectionMethod
CROSSBOSS
ReentryMethod
STINGRAY
AN
TE
GR
AD
E
Retrograde
Dissection ReEntry
DissectionMethod
KNUCKLEWIRE
ReEntryMethod
REVERSECART
RE
TR
OG
RA
DE
Refractory
Greater chance of success = Hybrid Skills
Why poor uptake?
• Skillsets are taught
• Skills are acquired• Skills are acquired
Skillsets should be:
• Teachable• Reproducible• Successful• Successful
• Understandable
We now know enough to deliverhigh-value educational courses
CTO Mastery
Improving Outcomes in CTO – New Approaches…
Case Examples
• Fellow does ADR.
Fellows Case 2
• Retrograde dissection and re-entry
How to learn
• Fixed mindset with failure.
– It was too hard
– I can’t do that
– Blame the surgeon– Blame the surgeon
Growth Mindset
What did I learn
With more practice I will get better
I need more experience
How to learn
• Fixed Mindset with success
– See I got it I am really good
– I am amazing I clearly can do this
– I am a good person– I am a good person
• Growth Mindset with success
– What did I learn from this case
– How could I have been more efficient
– I am getting better but still need more practice
Conclusions
• You can learn the skillsets
• Takes lots of volume
• No rules just solutions
• Work with the others and always get better.
• Have a Growth Mindset
• Remember its about the patient
top related