Do we need new definitions for CTO PCI
- 1. Do we need new definitions for CTO PCI Or should we revisit what terms we use Gerald S. Werner, MD, FESC, FACC, FSCAI Klinikum Darmstadt GmbH Darmstadt gerald.werner@mail.klinikum-darmstadt.de
- 2. Do we need new definitions for CTO PCI Or should we revisit what terms we use Gerald S. Werner, MD, FESC, FACC, FSCAI Klinikum Darmstadt GmbH Darmstadt gerald.werner@mail.klinikum-darmstadt.de
- 3. Conflict of interest statement • I, Gerald S. Werner, MD, have no financial relation to disclose regarding the following presentation
- 4. Do we talk the same language in CTO PCI ? The need for consensus on definitions • What is a CTO ? • Which patient benefits from CTO PCI ? • Ambiguity is an ambiguous term ! • Which technique do we apply ? • What is a successful CTO PCI ?
- 5. Do we talk the same language in CTO PCI ? The need for consensus on definitions • What is a CTO ? • Which patient benefits from CTO PCI ? • Ambiguity is an ambiguous term ! • Which technique do we apply ? • What is a successful CTO PCI ? Will be discussed by Tony
- 6. Just one comment • In a recent study from UK (CONSISTENT) a repeat intervention within 3 months of the initial attempt was not considered an event • This is going beyond a consensus on what is a procedural success and what is not. • We should be clear, that a procedure consists of one date with the patient • Anything else is a second attempt, which is not bad in itself
- 7. Do we talk the same language in CTO PCI ? The need for consensus on definitions • What is a CTO ? • Which patient benefits from CTO PCI ? • Ambiguity is an ambiguous term ! • Which technique do we apply ?
- 8. What is a CTO ? • A complete occlusion of a coronary vessel with no flow through the occluded segment (TIMI 0) • ... and an occlusiuon duration of >3 months
- 9. Do we talk the same language in CTO PCI ? The need for consensus on definitions • What is a CTO ? • Which patient benefits from CTO PCI ? • Ambiguity is an ambiguous term ! • Which technique do we apply ?
- 10. Who will benefit ? No prior MI – Evidence of ischemia and/or symptoms Prior MI – Evidence of viability In MVD with CTO – Staged procedure with goal of complete revascularization
- 11. 0 10 20 30 40 50 60 70 80 90 100 OMT PCI Physical limitation Anginal frequency Anginal stability Treatment satisfaction Quality of life Primary Endpoint: SAQ health status (ITT) For multiple testing the significance level is 0.01 BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU BL FU P=0.02 P=0.003 P=0.007 P=0.89 P=0.47 Eur Heart J 2018
- 12. Do we talk the same language in CTO PCI ? The need for consensus on definitions • What is a CTO ? • Which patient benefits from CTO PCI ? • Ambiguity is an ambiguous term ! • Which technique do we apply ?
- 13. A B D E F C Figure 12 from EAPCI Textbook on Cardiovascular Intervention; Part III 3.13: CTO 2018 version What is an ambiguous cap ? Blunt tapered Tapered Tapered No cap, side branches Side branch, notch No cap, side branch
- 14. Ambiguity can be resolved by imaging modalities • Proximal cap at a side branch take-off – IVUS assessment from the side branch – MSCT as a preplanning option
- 15. LAD CTO: Where is the proximal cap ?
- 16. LAD CTO: Where is the proximal cap ? • An occluded vessel ostium is a solid structure • There is a considerable step-up in vessel size
- 17. LAD CTO: Where is the proximal cap ?
- 18. LAD CTO: Where is the proximal cap ?
- 19. Do we talk the same language in CTO PCI ? The need for consensus on definitions • What is a CTO ? • Which patient benefits from CTO PCI ? • Ambiguity is an ambiguous term ! • Which technique do we apply ?
- 20. Strategic options for recanalization of a CTO Bilateral Maximal Guide backup Antegrade Fielder XT -> Gaia 2 or -> Progress 200T/Conf.Pro 12 Penetration, then step down Distal good target Parallel with stiff wire Reentrysystem BridgePoint Antegrade no Stump IVUS for guided Penetration ? Retrograde With feasible collateral pathways
- 21. A misconseption about parallel wire approach • Citation from a UK hybridologist: “My way of parallel wiring is to take a second, stronger wire to replace the first” • This is misunderstanding the change of game by the presence of the first wire
- 22. Parallel wiring still a valid and quick option Gaia 2 in parallel
- 23. Why parallel wiring works well in the RCA: the wire straightens the vessel architecture
- 24. Why parallel wiring works well in the RCA: the wire straightens the vessel architecture
- 25. Strategic options for recanalization of a CTO Bilateral Maximal Guide backup Antegrade Fielder XT -> Gaia 2 or -> Progress 200T/Conf.Pro 12 Penetration, then step down Distal good target Parallel with stiff wire Reentrysystem BridgePoint Antegrade no Stump IVUS for guided Penetration ? Retrograde With feasible collateral pathways
- 26. Copyright © The American College of Cardiology. All rights reserved. From: Fundamental Wire Technique and Current Standard Strategy of Percutaneous Intervention for Chronic Total Occlusion With Histopathological Insights J Am Coll Cardiol Intv. 2011;4(9):941-951. doi:10.1016/j.jcin.2011.06.011 What is CART and what is RDR ? • If we connect the antegrade and retrograde wires within the occlusive plaque, there is a high likelihood of staying intimal • Separation within the plaque between wires is not constituting a subintimal position Reverse CART = Controlled Antegrade and Retrograde Tracking
- 27. IVUS detection of subintimal wire positionIVUS Image Intimal vs. Sub-Intimal Tracking a = IVUS catheter , b = the intimal-medial layer, c = the occluded true lumen, d = false lumen in the adventitia Intimal Tracking Sub-intimal Tracking
- 28. Results Acute IVUS classification CTO Cases Antegrade ( 59 ) Retrograde ( 104 ) Intimal Tracking 87.7%(50) Intimal Tracking 75.3%(73) Sub-Intimal Tracking 12.3%(7) Sub-Intimal Tracking 24.7%(24) P= P=p=0.10 Analysis impossible: 2 Analysis impossible: 7 87.7% 12% 75% 25% 0% 20% 40% 60% 80% 100% Intimal Tracking Subintimal Tracking Antegrade Retrogarade P=0.10 P=0.16
- 29. The hybrid approach The big misunderstanding of definitions The Hybrid Algorithm for CTO PCI provisional approaches Dual Catheter Angiography 1. Clear proximal cap 2. Good Distal Target 3. Length < 20mm Antegrade Retrograde yes no Wire escalation Dissection Reentry (crossboss-stingray) Wire escalation Dissection Reentry (reverse CART) yes yes nono Dissection Reentry (reverse CART) Dissection Reentry (crossboss-stingray) fail fail fail fail
- 30. Higher rate of subintimal tracking in US ! Song L, Maehara A et al. JACC Int 2017; 10:1011
- 32. The hybrid approach Do not use the term CART when you do RDR The Hybrid Algorithm for CTO PCI provisional approaches Dual Catheter Angiography 1. Clear proximal cap 2. Good Distal Target 3. Length < 20mm Antegrade Retrograde yes no Wire escalation Dissection Reentry (crossboss-stingray) Wire escalation Dissection Reentry (reverse CART) yes yes nono Dissection Reentry (reverse CART) Dissection Reentry (crossboss-stingray) fail fail fail fail
- 33. Do we need new definitions ? • The terminology we have is pretty clear and defined • The problem is more that terms are misused and mixed-up • One of the most obvious misunderstandings are related to the description and application of the retrograde approach