CTO PCI today – A summary of recent publications
- 1. CTO PCI today A summary of recent publications Alessio Mattesini, MD on behalf of Carlo Di Mario, MD, PhD, FESC, FACC, FSCAI Careggi University Hospital, Florence, Italy
- 2. RANDOMIZED CONTROL TRIALS: UPDATES NOT AVAILABLE Galassi AR, Werner GS et al Eurointervention 2019
- 4. • Performed by Euro CTO Club • To promote the widespread applications of state-of-the-art CTO PCI not only in Europe but also in neighboring communities
- 5. The modified hybrid algorithm for CTO PCI using the contemporary techniques
- 6. Perforation algorithm for CTO PCI
- 7. Brilakis E et al Circulation 2019 140:420-433 The seven rules !
- 8. • New CTO scores Rapid Review of the Recent CTO Literature
- 9. CTO scores J-CTO score (n=494) CL-score (n=1657) PROGRESS-CTO score (n=781) ORA score (n=1073) CT-RECTOR score (n=240) RECHARGE score (n=880) EURO-CTO CASTLE score (n=20000) Proximal cap blunt 1 Proximal cap blunt 1 Proximal cap ambiguity 1 Age 75 years 1 Proximal cap blunt 1 Proximal cap blunt 1 Proximal cap blunt 1 Calcification 1 Severe calcification 2 Moderate/sever e tortuosity * 1 Ostial location 1 Severe calcification 1 Calcification 1 Calcification 1 Tortuosity > 45° 1 Lesion lenght 20 mm 1. 5 Circumflex CTO 1 Collateral filling Rentrop 0-1 2 Tortuosity >45° 1 Tortuosity > 45° 1 Severe tortuosity 1 Lesion lenght 20 mm 1 Non-LAD CTO 1 Absence of interventional collaterals 1 Multiple occlusion 1 Lesion lenght 20 mm 1 Lesion lenght 20 mm 1 Previous CABG 1. 5 Second attempt 1 Previous CABG on CTO target vessel 1 Previous CABG 1 Previous MI 1 CTO duration >12 months or unknown 1 Diseased distal landing zone 1 Age >70 years 1
- 10. EURO CTO CASTLE score Szijgyarto Z, Rampat R et al J Am Coll Cardiol Intv 2019 Boudou N, Avran et al EuroIntervention 2019;14:e1814-e181
- 11. 660 consecutive CTO PCIs: the mean J-CTO score were 1.86 ± 1.2 ; the mean EuroCTO (CASTLE) score were 1.74 ± 1.2 Kalogeropoulos AS et al , Eurointervention 2019 Equal overall discriminatory capacity between the two scores (AUC: 0.698, 95%CI: 0.653-0.742 p<0.001 for J-CTO vs. AUC: 0.676, 95%: CI 0.627- 0.725, p<0.001 for EuroCTO; AUC difference: 0.022, p=0.5)
- 12. For more complex procedures (J-CTO > 3 or EuroCTO CASTLE >4), the predictive capacity of EuroCTO (CASTLE) score appeared superior (AUC: 0.588, p=0.03 for EuroCTO (CASTLE) score vs. AUC: 0.473 p=NS for the J-CTO score, AUC difference: 0.115, p=0.04) Kalogeropoulos AS et al , Eurointervention 2019
- 13. Nagamatsu W, Tsuchikane E et l, Eurointervention 2019
- 14. • Hybrid approach: evolution over the years • New CTO scores • CTO PCI outcome Rapid Review of the Recent CTO Literature
- 15. Konstantinidis NV, …. Sianos et al, Circ Cardiovasc Interv.2018;11:e006229 • CTO PCI outcome
- 16. Konstantinidis NV, …. Sianos et al, Circ Cardiovasc Interv.2018;11:e006229 • CTO PCI outcome
- 17. • CARDIO-ARSIF (Agence Régionale de Santé Ile de France) registry from 2012 to 2015 • Among 128,739 included patients, 10,468 (8.1%) had at least 1 CTO • PCI success rate was 75.9% in the CTO group • CTO-PCI volume per center did not correlate with CTO-PCI success rate Boukantar M, Loyeau A et al, Am J Cardiol 2019 • CTO PCI outcome
- 18. • 17 randomized and observational studies • 11,493 participants Ka Hou Christien Li et el Curr Atheroscler Rep (2019) 21: 42 ALL CAUSE MORTALITY EVENTS 11 observational studies 3 randomized controlled trials
- 19. Ka Hou Christien Li et el Curr Atheroscler Rep (2019) 21: 42 MACE EVENTS MYOCARDIAL INFARCTION
- 20. Ka Hou Christien Li et el Curr Atheroscler Rep (2019) 21: 42 CARDIAC DEATH
- 21. • Data from EuroCTO Registry in the period 2015-2017 • Three groups were created based on occlusion age: 3 to 6 months (n= 1415), 7 to 12 months (n= 973), > 12 months (n= 1656) Bryniarski KL, Werner GS et al, Adv Interv Cardiol 2019; 15, 1 (55): 28–41
- 22. Bryniarski KL, Werner GS et al, Adv Interv Cardiol 2019; 15, 1 (55): 28–41
- 23. Coronary artery CTO duration is associated with greater extent of calcification, lesion length, development of collateral circulation and, most importantly, with lower procedural success. Bryniarski KL, Werner GS et al, Adv Interv Cardiol 2019; 15, 1 (55): 28–41
- 24. • Hybrid approach: evolution over the years • New CTO scores • CTO PCI outcome • CTO PCI subgroups Rapid Review of the Recent CTO Literature
- 25. • 943 diabetic patients with RCA-CTO who had clinical presentations of symptomatic stable angina or silent ischemia • 46.98% of patients in the CTO-medical therapy group (CTO-MT) • 53.02% of patients in the CTO-revascularization group (CTO-SR) • 309 pts PCI; 191 CABG • mid-term follow-up: CTO-SR: 48 months; CTO-MT: 42 months Yan et al. Cardiovasc Diabetol (2019) 18:108 • CTO PCI subgroups
- 26. ALL CAUSE DEATH CV DEATH Yan et al. Cardiovasc Diabetol (2019) 18:1 • CTO PCI subgroups
- 27. Yan et al. Cardiovasc Diabetol (2019) 18:1 For stable RCA-CTO patients with diabetes, successful revascularization offered patients more clinical benefits than medical therapy • CTO PCI subgroups
- 28. Chronic Total Occlusion Represents an Independent Predictor for Mortality in Malignant Arrhythmia and Sudden Cardiac Death 1587 pts from retrospective registry including all consecutive patients with VT, VF and sudden cardiac death undergoing to coronary angiography in the period 2002-2016 Prevalence of CTO 22% CTO group compared with no CTO group CTO was associated with higher all-cause mortality at short-term (33% vs25%, p=0.002) CTO was associated with higher all-cause mortality at mid-term (46% vs 33%, p=0.001) irrespective of the underlying malignant arrhythmia (VT/VF), degree of left ventricular dysfunction, myocardial infarction Behnes et al Eurointervention 2019
- 29. • Hybrid approach: evolution over the years • New CTO scores • CTO PCI outcome • CTO PCI subgroups • Vascular access Rapid Review of the Recent CTO Literature
- 30. Radial Approach:inside PROGRESS-CTO • 3,790 CTO interventions performed between 2012 and 2018 at 23 centers in the United States, Europe, and Russia • 747 via radial-only access (RA) • 844 via radial-femoral access (RFA) • 2199 femoral-only access (FA) • Transradial access (RA and RFA) was used in 42% and significantly increased over time from 11% in 2012 to 67% in 2018 (p < 0.001) • Patients treated via transradial access were youger, less prior PTCA and less prior CABG Tajiti P, Alaswad K et al JACC Cardiovasc Interv. 2019 ;12(4):346-358
- 31. Technical success, procedural success and in-hospital major complication were similar in three groups Tajiti P, Alaswad K et al JACC Cardiovasc Interv. 2019 ;12(4):346-358
- 32. Konstantinidis NV, …. Sianos et al, Circ Cardiovasc Interv.2018;11:e006229
- 33. • Hybrid approach: evolution over the years • New CTO scores • CTO PCI outcome • CTO PCI subgroups • Vascular access • Coronary physiology in CTO • CTO-PCI: complications Rapid Review of the Recent CTO Literature
- 34. • 1,811 consecutive patients undergoing CTO PCI at five centers between 2011 and 2018. • Coronary perforation was observed in n=99 (5.5%) • In 53% of cases perforations required intervention • Patients with perforation were older, had higher J-CTO score, more often required antegrade dissection/re-entry and the retrograde approach, and had lower success rates. Azzalini L, Poletti E et al Eurointervention 2019 • CTO-PCI: complications
- 35. Sites of perforation Azzalini L, Poletti E et al Eurointervention 2019 • CTO-PCI: complications
- 36. Azzalini L, Poletti E et al Eurointervention 2019 • CTO-PCI: complications
- 37. Brilakis et al EuroIntervention. 2019 Jun 20;15(2):137-139 CTO PCI : the road ahead !!!
- 38. Brilakis et al EuroIntervention. 2019 Jun 20;15(2):137-139 CTO PCI : the road ahead !!!