Consensus document of treatment of calcium within CTO recanalization
- 1. Consensus document: Treatment of calcium within CTO recanalization Stylianos Pyxaras Fürth, Germany
- 2. Disclosure • Proctorship and consultancy fees for Boston Scientific
- 5. Calcium & CTOs: • Definition & Demographics • Histopathology • Clinical impact • Scores and algorithms • Imaging • Treatment
- 6. Calcium & CTOs – Definition & Demographics • Heavy calcification: Multiple persisting opacifications of the coronary wall visible in more than one projection surrounding the complete lumen of the coronary artery at the site of the lesion • Prevalence: 58% in CTO lesions (vs. 20.5% in all patients undergoing PCI) Sianos G et al. EuroIntervention 2005;1:219-27 Bourantas CV et al. Heart 2014;100:1158-64 Karacsonyi et al. Am J Cardiol 2017;120:40-46
- 7. Histopathology – Comparison of CTOs Srivatsa et al. J Am Coll Cardiol 1997;29:955– 63
- 8. Calcification: CABG- vs. native-CTOs Sakakura et al. Eur Heart J 2014; 35, 1683–1693
- 9. Calcification: In-Stent- vs. native-CTOs • Prevalence: 4% (vs. 48-58% of native CTOs) Mori et al. J Am Coll Cardiol Intv 2017;10:367–78
- 10. JACC Cardiovasc Imaging 2010 Aug;3(8):806-10.
- 11. Lee et al. J Am Coll Cardiol Img 2017;10:883–91
- 12. Lee et al. J Am Coll Cardiol Img 2017;10:883–91 Prevalence of Calcified Nodules in Relation to the Maximum Calcium Arc
- 13. Calcium and CTO age Srivatsa et al. J Am Coll Cardiol 1997;29:955– 63
- 14. Bourantas CV et al. Heart 2014;100: 1158–1164.
- 15. Strongest independent predictor of incomplete revascularization: Chronic total occlusion (OR = 2.46, 95% CI 1.66–3.64, P < 0.001)
- 17. Salinas et al. Plos One 2021 16(4):e0245898. Comparison of CTO-scores
- 19. Role of CT in CTO-PCI Velagapudi et al. Current Cardiovascular Imaging Reports (2020) 13: 20
- 20. Circ Cardiovasc Imaging. 2017;10:e005800.
- 21. Fujii et al. Am J Cardiol 2006;97:1455–1462
- 22. Comparison of Imaging Techniques for Coronary Calcium Detection, Characterization, and Quantification De Maria et al. J Am Coll Cardiol Intv 2019;12:1465–78
- 23. Therapeutic options for heavily calcified CTOs • Rotational atherectomy • Cutting/Scoring/High pressure balloons • Intravascular lithotripsy (Schockwave) • Laser
- 24. Rotational atherectomy in CTO Azzalini L, et al. Catheter Cardiovasc Interv. 2017
- 25. Azzalini L, et al. Catheter Cardiovasc Interv. 2017
- 27. Conclusions • Calcifications appear more frequently in CTO vs. non-CTO lesions • Calcifications have a negative impact on procedural outcome and long-term patient prognosis • Diagnostic methods can accurately describe localisation and severity of coronary calcification within CTO-segments • There is a plethora of therapeutic options, however the indications for specific types of calcifications need still to be validated
Editor's Notes
- #11: (A) Acute plaque rupture is shown, with luminal thrombus resulting in chronic total occlusion (CTO). (B) Inflammation with early thrombus organization is shown. Note early recanalization accompanied by proteoglycan matrix (green) in the area of total occlusion (TO). (C) The late chronic phase of healed TO is shown, with deposition of collagen type I where the cross-linking of collagen promotes negative remodeling of the vessel. (D) Physiologic recanalization is accompanied by restoration of normal flow distally, thus preventing negative remodeling.
- #14: IP calcium content is observed to increase with advancing CTO age
- #19: RDR preferred over RWE for severe calcification
- #21: Representative case. A to D, Successful guidewire crossing ≤30 minutes. A, Proximal tapered entry (red arrow), occlusion length=7 mm, absence of significant calcification. B, Angle of chronic total occlusion segment=3°. C, No significant calcification in crosssectional view (yellow arrow). D, Coronary angiography showing proximal tapered entry (red arrow). E to H, Fail to cross guidewire ≤30 minutes. E, Proximal blunt entry (red arrow), occlusion length=41 mm, severe calcification (yellow arrow). F, Angle=102°. G, “Full-moon” type central calcification. H, proximal blunt entry (red arrow).
- #22: At the proximal end of the CTO, perimedial calcium is located opposite the ramus take-off (asterisk). (C) At the midportion of the occluded segment, calcium is not identified. (D) At the distal end of the CTO, intraplaque calcium is distributed perpendicular to the side branch take-off