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Cath/CT ConferenceLT. S.T. Anthony Kaviratne MDJanuary 20, 2015

+Case Presentation

56 year old male non-smoker with history of HLD and recent NSTEMI treated medically presented with chief complaint of ongoing chest pain with exertion.

The patient initially presented 6 weeks ago to a OSH with 2 days of stuttering chest pain after completing Iron man triathlon. He noted severe chest discomfort at the end of his run but completed the race. Symptoms resolved with rest but would occur with exertion over the next 2 days.

Patient was seen by OSH followed by cath which showed total occlusion of the right coronary artery but otherwise non obstructive mild disease. Per report attempt was made at opening the right coronary which was unsuccessful and medical therapy was pursued.

Current symptoms similar initial which has not improved over the last 6 weeks.

+ Past Medical History Coronary artery disease

HLD

ASA 81mg

Plavix 75mg

Lipitor 80mg

Metoprolol XL 25mg

Lisinopril 2.5mg PO qday

Renexa 1000mg PO BID

Nitro PRN

Medications

+Social and Family History

Tobacco: Denies

Etoh: 6 beers/ week

Recreation drug use: None

Family History:

- No known family members with CAD.

+Physical Exam:

VS: sinus bradycardia but otherwise unremarkable.

Male in NAD with normal work of breathing

Neck: JVD 8 cm, Carotid upstroke was delayed.

Cardiac: Normal S1 and S2. No murmurs/rubs/gallops

Pul: CTAB

Ext: No Edema

Vascular: 2+biltateral and equal

+Labs Labs: WNL

EKG: sinus with nonspecific T wave abnormalities throughout the precordium

Echo: LVEF 55-60% with inferior and lateral wall hypokinesis. Mild MR. otherwise unremarkable.

MPS: moderate to severe ischemia inferior and infralateral wall from mid to apex. SDS of 8

Previous cath LM: no disease LAD: mild luminal irregularities with left to right collaterals LCX: mild luminal irregularities RCA: Total occlusion with small bridging collaterals

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+Approach to this patient?

Should another attempt made at the CTO?

Continue medical management?

Further medical management or referral to CABG?

How will this change the patient’s course?

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Management of Chronic Total Occlusion

+Objectives

Define CTO and epidemiology

PCI success rates and attempts and barriers to attempt

Indications for PCI for CTO (when to consider CABG)

Benefits of PCI to CTO

Strategies for opening CTO with examples

+Chronic Total Occlusion (CTO)

“True CTOs” are characterized by significant narrowing with lumen that results in complete interruption of antegrade blood flow (TIMI 0).

“Functional CTO” which has minimal contrast penetration though the lesion without distal vessel opacification (TIMI 1)

Registry data demonstrate that 15–30% of patients undergoing diagnostic coronary angiography will have at least one occluded coronary artery

Retrospective review of >6500 patients reported CTO lesions in up to 52% of patient

CABG has historically been the preferred revascularization option owing to its higher immediate procedural success rate in the CTO vessel

Christofferson RD, Lehmann KG, Martin GV et al. Effect of chronic total coronary occlusions on treatment strategy. Am. J. Cardiol. 95(9),1088–1091 (2005).

+PCI success rates

SYNTAX trial reported 50% success rates

70% of CTOs were successfully re-opened with PCI in the Canadian Multicenter registry

Angiographic results of the PRAGUE-4 tria: 1-year patency after bypass grafting of collateralized CTO vessels only 23%. LAD CTOs were much better with 100% patency at 12 month

Rathore S et al. Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008: impact of novel guidewire techniques. JACC Cardiovasc. Interv. 2(6),489–497 (2009).

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+Barriers to CTO attempt PCI technical complexity: Difficulty crossing CTO with wires,

Operator skill

Unique complications Vessel perforation Contrast nephropathy Radiation injury: Av floro time 46 min+/- 25 (3.2Gy +/- 2.1) Possible loss of collaterals

Economic disincentive: labor and resources

Physician skepticism

Higher short term MACE rate (in hospital elective 0.9-6.5% vs. 1.2% non CTO)

Higher mortality (in house 0.5% with failed CTO 1-2.6%). 30 day high as 1.1%

+Indications for PCI for CTO PCI is warranted when all three of the following conditions

are met: The occluded vessel is responsible for the patient's symptoms or

in selected patients with silent ischemia in whom there is a large amount of myocardium at risk.

The myocardial territory of the occluded artery is viable The likelihood of success is >60 percent with estimated rate of

death <1% and MI < 5%.

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Class IIa: PCI of a chronic total occlusion in patients with appropriate

clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise. (Level of Evidence: B)

Stone et al. “Percutaneous Recanalization of Chronically Occluded Coronary Arteries: A Consensus Document”. Circulation. 2005;112:2364-2372

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+CABG over PCI for CTO

Left main disease

Complex three-vessel disease, particularly in patients with insulin-requiring diabetes, severe left ventricular dysfunction, or chronic kidney disease.

An occluded proximal left anterior descending coronary artery that supplies a viable anterior wall that is not favorable for PCI.

Multiple CTOs with a low anticipated rate of success

Multivessel disease

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What are the benefits?

+Long term survival with CTO

Hannan EL, Racz M, Holmes DR, et al. Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era. Circulation 2006;113:2406–12

+Long Term outcome of Recanalization of CTO: Survival

Jones et al JACC:CV intervention April 2012 Muhammad et al, Cath and CV intervention 3/2013

+Impact on angina

TOAST-GISE (Total Occlusion An- gioplasty Study–Societa ̀Italiana di Cardiologia Invasiva) trial, CTO-PCI success was associated with 86% angina-free survival, whereas CTO-PCI failure was associated with 70% angina-free survival (p =0.008)

The COURAGE nuclear substudy reported reduction in ischemic myocardium measured by MPS showed PCI plus OMT (-2.7%) vs. OMT (-0.5%)

PRISON II trial, the proportion of patients with CCS angina class ≥3 was reduced from 62% at baseline to 25% at 6 month

Other trials, 85–90% of patients with CTO lesions are reported as symptomatic of 'typical angina

+Improved Tolerability of Acute Coronary Syndrome Events

In a STEMI CTO of a nonculprit vessel is a independent predictor of early mortality and cardiogenic shock.

Van der Schaaf et al showed CTO is increased twofold compared with STEMI patients with single-vessel disease (1-year mortality 63 vs 31%)

The presence of CTO in a non-IRA has a comparable effect on the outcome of non-STEMI (NSTEMI) patients

Bataille Y, Dery JP, Larose E et al. Deadly association of cardiogenic shock and chronic total occlusion in acute ST-elevation myocardial infarction. Am. Heart J. 164(4),509–515 (201

van der Schaaf RJ, Timmer JR, Ottervanger JP et al. Long-term impact of multivessel disease on cause-specific mortality after ST elevation myocardial infarction treated with reperfusion therapy. Heart 92(12),1760–1763 (2006

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+Other possible benefits

Reduction in ICD therapy In patient’s with LVEF >35% CTOs have a greater risk of sudden

cardiac death or appropriate ICD therapy compared with non-CTO patients (VACTO trial 21% CTO vs. 7% non CTO)

Benefit on LV function and geometry Using CMR demonstrated wall thickening improved in

successful PCI

+Factors influencing procedural outcomes

More experienced operators leads to be more success rates (FAST-CTO study report 67% first 75 cases rising to 87% in second 75 cases)

Geometry of the lesion (shorter length, tapered cap, microchannels, duration of CTO, calcium, tortuosity)

Bridging collateral, cap continuation with minor branches

Using specific guidewires for CTO (from expert-CTO trial) greater stiffness at the tip tapered tip to engage in microchannels (nl 0.014, CTO 0.009) hydrophilic or very lubricious coating to traverse

Low profile balloon for pre-dilatation

+PCI strategies

Antegrade approach

Parallel wire technique

Retrograde technique

IVUS guided

“knuckle wire” technique

Controlled Antegrade Retrograde Tracking (CART)

+Control antegrade retrograde tracking (CART)

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Questions?

+Summery

CTO are common angiographic finding and a common reason for referral to CABG

PCI to CTO are complex requiring a lot of resources with unique risk/complications associated with it.

PCI to CTO technically challenging and financial disincentives prevent more attempts.

PCI to CTO should be considered in patients who are symptomatic despite OMT, CABG but now with failed grafts, and in patients with large area of myocardium in jeopardy (specially if they are unwilling to undergo CABG).

+Patient outcome

PCI of the CTO attempted with antegrade approach and was successful. Procedure took 4 hours with 65 min of fluoro time.

His symptoms resolved and returned to exercising 1 month later without any symptoms.

6 month follow up: Patient started training for “fun”

12 month outcome: Patient had atypical symptoms was re cathed with patent RCA stent with no other significant lesions.

18 months: Patient completed his 2 half marathon and 1 full. Planning on attempting Iron man again.