15th Experts Live CTO: Mohamed Ayoub: Aorto-ostial CTO
- 1. MOHAMED AYOUB Director CHIP and CTO Program University Heart Center Bad Oeynhausen Aorto-ostial CTO PCI
- 2. Within the past 12 months, I or my spouse/partner have had a financial interest, arrangement, or affiliation with the organization(s) listed below: Within the past 12 months, I or my spouse/partner have had a financial interest, arrangement, or affiliation with the organization(s) listed below: Affiliation/Financial Relationship Company Consultant, Proctor Boston Scientific, Teleflex, Asahi intecc, Cordis, Terumo Disclosures
- 3. Ostial Lesions Definition Ostial disease is defined as a lesion arising within 3 mm of the vessel origin Classification –Aorto-ostial – involving the ostia of the RCA, LMS, and ACB grafts. –Non-aorto-ostial – involving the ostia of the major coronary arteries not arising directly from the aorta; i.e., the LAD, Cx and RIM. –Branch ostial – involving the ostia of branches of the major coronary vessels; (diagonals, marginals, PL and PD) Percy Eurointerverntion2009
- 4. Ostial Lesions - Incidence 33% 12% 32% 18% Overall Incidence around 3% Patel CCI 2016
- 5. Ojeda et. al, 2020, DOI: 10.1016/j.rec.2020.01.008 Types of aorto-ostial CTOs flush aorto-ostial occlusion (total absence of a stump at the aortocoronary junction) aorto-ostial CTO with a minimal proximal cap
- 6. Success Rate? Limited data Euro CTO Registry 2012-2015 RCA Ostial Other Lesions n 378 (4%) 9030 (96%) lesion length(mm) 43,4 30,7 J CTO score (men) 3,2 2,3 antegrade only (%) 38 73 retrograde only (%) 37 11 antegradea and retrograde (%) 25 16 stent length (mm) 78,4 62,3 procedural time 140,1 106,2 fluoro time 62,5 41,2 Contrast (ml) 317,5 292,2 Success rate (%) 78 87
- 7. Predictors of technical failure in ostial CTO Ojeda et. al, 2020, DOI: 10.1016/j.rec.2020.01.008
- 8. Aorto - Ostial Lesion - Management Non Ao-ostial Ao - ostial + +/- ++ +/- ++ ++ +++ - +/- +/- ++ +++ How to predict the vessel origin in the absence of stump? – Microchannels – Bridging Collaterals – Calcium in the vessel course – Additional imaging modalities • IVUS • CT angio of CTO – Utility of Retrograde Approach
- 9. Nicholson et. al. J Am Coll Cardiol Intv. 2016 Nov, 9 (22) 2356–2358 Retrograde Puncture into the Aorta
- 10. Nicholson et. al. J Am Coll Cardiol Intv. 2016 Nov, 9 (22) 2356–2358 Retrograde Puncture into the Aorta E-CART (ElectroCautery-Assisted Re-enTry) of an Aorto-Ostial Right Coronary Artery Chronic Total Occlusion:
- 11. Calcified ostial lesions 1 Consider imaging before stenting (sufficient plaque modification?) 2 Use stents with high radial force (better stent cross ability, due to thinner struts results in higher recoil)
- 12. ▪ High-Pressure Balloon dilatation ▪ Intravascular Lithotripsy ▪ Rotablation atherectomy ▪ Cutting balloon dilatation Plaque Modification Aorto-ostial Lesions
- 13. J-CTO Score 4, post CABG, EF 29% CTO ostial RCA, Post CABG
- 14. J-CTO Score 4, post CABG, EF 29% CTO ostial RCA, Post CABG
- 15. J-CTO Score 4, post CABG, EF 29% CTO ostial RCA, Post CABG
- 16. CTO ostial LM- Post CABG 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP
- 17. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP CTO ostial LM- Post CABG
- 18. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP CTO ostial LM- Post CABG
- 19. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP CTO ostial LM- Post CABG
- 20. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP CTO ostial LM- Post CABG
- 21. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP CTO ostial LM- Post CABG
- 22. Take Home Message Aorto-ostial CTO PCI • Aorto-ostial occlusions represent a challenging subset for PCI • The presence of interventional collaterals allowing the use of the retrograde approach is key for achieving procedural success • Use enough support • Use IVUS for optimal Plaque Modification and stent Expansion
- 23. Thank You!