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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
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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
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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
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PROspective Global REgiStry for the Study of CTO interventions
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
49%
24%
27%
AntegradewiringAntegradedissecAon/re-entryRetrograde
77.1%
34.3% 39.5%
0.00%
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
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PROspective Global REgiStry for the Study of CTO interventions
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
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8.
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Online score calculator: www.progresscto.org
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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
76.7
0 10 20 30 40 50 60 70 80 90
100
0 1 2 ≥3
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PROspective Global REgiStry for the Study of CTO interventions
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
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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
PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
N=394
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
6.3
89.6 87.4
3.0
87.8 86.3
3.10.0
10.020.030.040.050.060.070.080.090.0
100.0
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.orgImpact of prior failure
2012-2015 12 centers, 1,232 lesions Prior failure: 17.5%
88.0 93.7
4.2
90.0 90.0
2.10
20
40
60
80
100
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
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PROspective Global REgiStry for the Study of CTO interventions
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
70
80
90
100
Technical success Procedural success
%
ADR Non-ADR Δ=3.3% P<0.01
89.9 87.0 93.2 91.8
70
80
90
100
Technical success Procedural success
%
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.orgRetrograde vs. antegrade-only: outcomes
2012-2015 11 centers, 1,301 lesions Retrograde utilization: 41%
84.8 81.993.7 93.3
0
50
100
Technical Success Procedural Success
Succ
ess
rate
(%)
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)
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
4.3
2.1
0.4
1.3
0.60.8
1.1
0.3 0.3 0.30.1 0.1
0
Comp
licati
on ra
te (%
)
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)
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
10 10 719 19
3045 50
88
158
3049
6479 84
138
171196
312
389
0
50
100
150
200
250
300
350
400
450
WiringaVem
pts
Guidewire
SuccessfulTotal
41%
28%
24%
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
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PROspective Global REgiStry for the Study of CTO interventions
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)
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.orgBalloon uncrossable lesions
2012-2016 11 centers, 755 lesions Balloon uncrossable: 9%
90.5% 88.9%
1.6%
98.3% 96.6%
2.2%
Technical success Procedural success MACE
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
168 4
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
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
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]
38%
26%
Proximalcapambiguity
Toguidewiring
Toguidereverse-CART
StentopAmizaAon
Stentsizing
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PROspective Global REgiStry for the Study of CTO interventions
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%
2.7%
90.1% 88.3%
3.2%
Technical success Procedural success MACE
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
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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
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FormoreinformaAonortojoin:www.progresscto.org
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
Success and target vessel
Targetvessel
RCA(61%)
LAD(21%)
LCX(18%)
75%
80%
85%
90%
95%
100%
RCA LAD LCX
Technicalsuccess
97%
87%
p=0.013
93%
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
Mode of failure
[VALUE]%
[VALUE]%
Failure Success
380procedures
n=33
n=347
n=10
n=23
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]%
[VALUE]%
MACE Technicalfailure
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
87.2
93.7
78.1
90.0
70
80
90
100
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%
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
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
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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
76.7
0 10 20 30 40 50 60 70 80 90
100
0 1 2 ≥3
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PROspective Global REgiStry for the Study of CTO interventions
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
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Christopoulos,Kandzari,Yeh,Jaffer,KarmpalioAs,Wyman,Alaswad,Lombardi,Grantham,Moses,Christakopoulos,Tarar,Rangan,Lembo,Garcia,Cipher,Thompson,Banerjee,Brilakis.JACCIntv2016Jan11;9(1):1-9
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
89.9
87.0
93.291.8
70
80
90
100
Technical success Procedural success
%
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.orgImpact of prior failure
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.
AmJCardiol2016;2016Apr15;117(8):1267-71
Successfulcrossingstrategy
40.4
26.3
23.1
10.1Overall(%)
33.6
26.2
28.5
11.7
Priorfailure(%)
41.9
26.4
229.7
Nopriorfailure(%)
Antegrade
Retrograde
AntegradedissecAonandre-entry
None
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.orgImpact of prior failure
260.0 260.0
050100150200250300350400
Contrast0volume0(ml)
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.
AmJCardiol2016;2016Apr15;117(8):1267-71
P=0.893
P=0.015
P=0.163 4.0
3.4
0
1
2
3
4
5
AK*radiation*dose*(Gray)
Prior*failed*CTO*PCI*attemptNo*prior*failed*CTO*PCI*attempt
55.0
45.0
0
10
20
30
40
50
60
Fluoroscopy2time2(min)
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.orgProximal cap ambiguity
2012-2015 11 centers, 1,021 lesions Proximal cap ambiguity: 31%
93 9185 84
0
100
Technical Success Procedural Success
Succ
ess
rate
(%)
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]
[PERCENTAGE]
[PERCENTAGE]
AntegradeWiringAntegradedissecAon/re-entryRetrograde
Successful technique for lesions with ambiguous caps
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PROspective Global REgiStry for the Study of CTO interventions
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.
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PROspective Global REgiStry for the Study of CTO interventions
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)
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
93%98% 96%
87%90%97% 94%
85%
3% 2% 2% 4%
IMG for crossing IMG for stentoptimization
IMG for both imagingand stent optimization
No imaging
Technical success Procedural success MACE
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)
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
19%
59%
6%
19%
6%2% 3%
0% 0%
16%
0%3%
15%
46%
7%12%
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
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PROspective Global REgiStry for the Study of CTO interventions
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%
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
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
NS
Prior valve procedure
NS
Length ≥23mm 3.22 1.08-13.89 0.035 +2
Blunt/no stump
NS
Retrograde approach used 2.41 1.04-6.05 0.041 +1
!
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 Oct 11;5(10).
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PROspective Global REgiStry for the Study of CTO interventions
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Derivation set (n= 1065) AUC = 0.758 Validation set (n= 504) AUC = 0.793
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 Oct 11;5(10).
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PROspective Global REgiStry for the Study of CTO interventions
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).
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PROspective Global REgiStry for the Study of CTO interventions
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.org
55.344.6
Nodiabetes Diabetes
05
101520253035404550
Overall Nodiabetes
Diabetes
Retrograde(%)
Antegrade(%)
AntegradedissecAonandre-entry(%)
88
88.5
89
89.5
90
90.5
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)
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PROspective Global REgiStry for the Study of CTO interventions
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28
28.5
29
29.5
30
30.5
31
31.5
Overall Nodiabetes Diabetes
BMIkg/m2
230240250260270280
Overall Nodiabetes Diabetes
ContrastVolume
2.45
2.5
2.55
2.6
Overall Nodiabetes Diabetes
J-CTOscore p=0.82
p=0.001* p=0.02*
2.8
3
3.2
3.4
3.6
3.8
Overall Nodiabetes Diabetes
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
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PROspective Global REgiStry for the Study of CTO interventions
www.progresscto.orgApproaches to RCA CTOs
491
293
370
253
173237
0
250
500
Antegrade WireEscalation
Antegrade Dissection/Re-entry
Retrograde
Lesi
ons
atte
mpt
ed (n
)
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)
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PROspective Global REgiStry for the Study of CTO interventions
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32.1%
40.2%
48.5%
56.5%
29.2% 27.9%
18.2% 17.4%
38.7%
31.9% 33.3%
26.1%
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)
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PROspective Global REgiStry for the Study of CTO interventions
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CTO spatial distribution 2012-2016 13 centers, 1,369 lesions Procedural success: 88%
633
557
179
0
LesionLocaAon
Proximal
Mid
Distal
87% 90%85%
0%
25%
50%
75%
100%
Proximal Mid Distal
Proceduralsuccess
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.
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PROspective Global REgiStry for the Study of CTO interventions
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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)
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PROspective Global REgiStry for the Study of CTO interventions
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Radiation exposure - variables associated with AK dose
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)
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
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PROspective Global REgiStry for the Study of CTO interventions
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84.0 93.7
3.0
91.0 90.0
2.50
20
40
60
80
100
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]
[PERCENTAGE]
26
[PERCENTAGE]
Straight SlightModerate Severe
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PROspective Global REgiStry for the Study of CTO interventions
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Proximal vessel 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)
MulAvariateanalysesfortechnicalsuccess
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PROspective Global REgiStry for the Study of CTO interventions
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24.0
93.72.0 0.4
21.0
90.00.5 1.0
0
10
20
30
40
50
Guide/extension/catheter/(%)
Side/branch/anchor/(%)
Distal/anchor/(%) Other/(%)
%
Moderate/or/severe/tortuosity
Mild/or/no/tortuosity
Proximal vessel tortuosity
Guidesupporttechniquesamongstudylesions,classifiedaccordingtoproximalvesseltortuosity
P=0.085
P=0.001 P=0.002 P=0.124
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)
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86.6 93.7
3.7
93.8 90.0
1.80
20
40
60
80
100
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]
[PERCENTAGE]
21[PERCENTAGE]
None Mild Moderate Severe
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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.
Calcification MulAvariateanalysesfortechnicalsuccess
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Guide catheter utilization in calcification
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.
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PROspective Global REgiStry for the Study of CTO interventions
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Future direction - works in Progress
1. MechanicalCirculatorySupport2. EpicardialcollateraluAlizaAon3. ClinicalpresentaAonandoutcomes4. TwoCTOsaVemptedduringthesameprocedure5. Longtermoutcomes:MACE/TLR6. Effectofrace/ethnicity7. Impactofnewequipment
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FormoreinformaAonortojoin:www.progresscto.org