This document discusses techniques for percutaneous coronary intervention (PCI) to treat chronic total occlusions (CTOs). It provides statistics on the number of CTO patients treated with PCI versus other options. Success rates for CTO-PCI have increased from around 50% in early studies to over 80% currently. Retrograde approaches and newer wires and devices have improved outcomes. Drug-eluting stents significantly reduce restenosis compared to bare metal stents for CTO-PCI. The Coracto randomized trial demonstrated the Coracto DES significantly reduced rates of restenosis and target vessel revascularization out to 6.5 years compared to a bare metal stent.

1. Nicolaus Reifart
Bad Soden im
Main Taunus Kliniken
Taunus
Bad Soden, Germany
CTO PCI
Current Concepts & Technique
Role of DES

2. Important to know before:
• Will patient benefit from CTO
recanalisation ?
• Are patient and operator the right
candidate for CTO-PCI ?
• Familiar with various procedural
techniques and their outcomes ?

3. Whom should we open a CTO?
• Limiting symptoms most likely
due to CTO
• Or objective evidence of relevant
viability/ischemia in the territory
of the occluded artery

4. Whom should we open a CTO?
• Limiting symptoms most likely
due to CTO
• Or objective evidence of relevant
viability/ischemia (> 10% of LV)
in the territory of the occluded
artery

6. How are CTOs treated today?
• 27% of CAD patients have at least 1 CTO
of these CTO Patients
• 7 % PCI (success about 50 %) *
• 19 % CABG (grafted about 68 %) *
• 74% Medical Treatment
• * SYNTAX G. Werner 2009; EuroCTO 2010

8. Total Occlusion Procedural characteristics
Per lesion analysis
CABG
n=266
12 were not treated with CABG
CABG
n=254
Not Bypassed Bypassed
n=81 n=173
Reason not bypassed:
Not intended to treat (n=12) Overall 68.1 % of TO
Diseased (n=11) were bypassed
Inadequate conduit (n=2)
Too small (n=19)
Unable to find (n=1)
Early Patency ???
Other (n=36) ITT, Per Lesion
SYNTAX: Total Occlusions • Serruys CRT 2009 • March 2009 • Slide 8

9. 2010

10. Changes of Strategy and
Results

11. Euro CTO Club membership
45 43
40 38
35 33
29
30
25 21
20
15 13
10
5
0
2006 2007 2008 2009 2010 2011

12. 11481 CTO Procedures
4000
3500 3591
Online
3000 3090
Registry
2500
2000 1977
1500 1608
1000
1215
500
0
2006 2007 2008 2009 2010

13. EuroIntervention 2011

14. Evidence of viable myocardium
100
%
90
80
70
60
50
40
30 68 64
20 50
10
0
2008 2009 2010

15. Previous STEMI (%)
1900n1900ral
1900n1900ral
1900n1900ral
17 17 18
1900n1900ral
1900n1900ral
1900n1900ral
1900n1900ral
1905n1905ral 1905n1905ral 1905n1905ral

16. Unlike OAT:
• > 80% of CTO patients
had no Q-Infarction
2008/10)

18. Success of CTO
11481 CTO Procedures
100
90 82 86
77 80
80 75
70
60
50
40
30
20
10
0
2006 (3591) 2007 (3090) 2008 (1215) 2009 (1608) 2010 (1977)
06/07: all members - since 2008 online registry

19. Success related to Volume 2008-10
<100/>150/>200>300 CTO
100
95 93
90
89 88 89
83 84 83
85
79 81 81 83
80
75
70 67
65
60
55
50
2008 2009 2010
Remember: Syntax < 50%

20. Success Second Attempt (%)
100
90
80
70
60
50
85
40
69
30
20
10
0
Referral 636 2nd try 260
EuroCTO registry 2011

21. Dont start with level 3 or
4 !!! Stepwise increase in
difficulty important

22. Fluoroscopy & Procedure (min)
200
180
160
140
120
100 89 91 92 94
80
60
40
35 38 47
20
33
0
2007 2008 2009 2010

23. Dye Consumption (ml)
500
450
400
350 278 284 279
300
250
200
150
100
50
0
1905n1905ral 1905n1905ral 1905n1905ral

24. CIN (GFR > – 25%)
5
4.5
4
3.5
3
2.5
2
1.5 0.7 1
1 0.4
0.5
0
2008 2009 2010

25. Complications (%)
5
4.5 AMI: QMI < 0.5 %
4
3.5
3 Bleeding
AMI
2.5
Em-CABG
2
Tamponade
1.5 Death
1
0.5 0.3 0.4 0.4 0.3
0
2007 2008 2009 2010

26. There are different strategies to success…
The goal should be : Most simple aproach with
optimal outcome for the patient ….

27. No Discussion:
• Referral is not a shame – go and watch the
expert
• View of distal vessel 100% (contralateral
injection required in 70%)
• Start with OTW
• Limit dye to 4-6 x GFR
• Failures are worth a 2nd try (success >
70%)

28. Use of hydrophylic wires (%)
(polimer & non-polimer)
100
90
80
70
60
50
49 55
40 46
30 35
20 25
10
0
2006 2007 2008 2009 2010

29. Successful wire
50
45
40
*
39 < 1g
35 1-3g
32 31
28 6-9g
30 27
24 25 > 9g
25 22
20 19
20 16 17
15
10
5
0
2008 2009 2010
* mostly Fielder XT

30. Use of IVUS and MSCT (%)
10
9
8
7
6 6
5
4
3 4 MSCT
3 2.6
2
1 2 1.5 IVUS
0
2008 2009 2010

31. Use of Tornus and Corsair
20
18
16
14 13
12
10 Tornus
8
8 Corsair
6 5 5
4
2 0.08 0.08
0
2008 0.08 2010

32. Retrograde Aproach
% of all CTO
20
18
16
14
12 10.6 9.8 10.8
10
8
6
4
2
0
2008 2009 2010

33. Ante - versus Retrograde
450
400 383
350
300 268
250
ante (4299)
200
154 retro (501)
150
100 81 87
50 36
0
Fluoro (min) Procedure (min) Dye (ml)

34. Success Antegrade vs Retrograde
100
90 84 87
81 79
80
70 65
70
60
50 Antegrde
40 Retrograde
30
20
10
0
2008 2009 2010

35. 5075265
CTO CX 26
months
2nd try
Corcescrew
orthograde
epicardial
collateral

37. 2
Confianza 9

42. Externalisation
with RG3 and
antegrade
dilation

43. Nobori
3.0 x 28
2.5 x 18

44. Conclusion
• Antegrade should be turned into
retrograde before the distal vessel
is ruined
• Retrograde with Corsair feasable
via orthograde corc-screw like
collaterals of the same vessel

45. 5075369
8 years old
very calcifyed
CTO of LAD

46. PCI failure
5 years ago
CCS 2

47. Confianza
12
Corsair

48. Allways
check 2nd
view

50. Antegrade
no chance

51. Retrograde
try via
septal
collaterals

53. Wire in
guiding but
impossible to
follow with
Corsair
(severe
calcification)

54. Again
antegrade
„Kissing
wires“

55. Failed with
Corsair in
situ
Corsair
pulled back

56. Then wire
could be
placed through
existing lumen

57. And
successfully
finished

58. Conclusion
• Severe calcification easier to penetrate
retrogradely
• If retrograde fails, why not complete
antegradely….
• Ante- and retrograde procedures are often
complimentary

59. Use of DES EuroCTO Club
95 97
100
85
90
80 72
66
70
60
50
40
30
20
10
0
2006 2007 2008 2009 2010

60. 14 comparative studies, 4394 patients

64. Conclusion
• DES definitely reduce TVR and
Reocclusion and should be 1st choice
• Suspiscion of more Late stent thrombosis at
least with 1st generation DES
• DES with bioabsorbable coating likely to
be superior – but not yet proven

65. There are only 2 randomised
trials with DES for CTO
Prison II
Coracto

66. The DES Coracto ®
• Rapamycin as an anti-restenotic drug and a
poly(lactic co-glycolic acid) (PLGA)
biodegradable polymer (3-4 µm)
• Stent struts 80 µm
• Crimped on semi-compliant balloon
catheter

67. CORACTO Randomised trial
• Constant Stent with Rapamycine in chronic
total occlusions (> 3 mos) or long (> 20
mm) functional occlusions
• Bad Soden/Trier- trial 95 pts randomised
• PE: 6 mos late loss and restenosis
• SE: 6 mos TLR clinically driven
• Clinical Fu 12 mos - 24 mos – 78 mos
EuroIntervention 2010

68. 6m Restenosis Reocclusion and TVR*
(n= 91 pts; 249 stents)
% 75 <0.0001 p<0.0001 Constant
65 60 CORACTO
53.3
55
45
35
25 17.4 15.5
15 10.8
5 0
-5
in segment iS Reocclusion TVR
Restenosis
TVR if Restenosis + angina/ischemia or Stenosis > 70%

69. PRISON II vs CORACTO 6m
relative risk reduction TVR (%)
100
90
80
70
60
50 64 79 CYPHER
CORACTO
40
30
20
10
0

71. 6.5 Years Follow-up (20% lost)
Death and TVR
N= 95 N = 91 N = 78
80
68.8
70
60
60
Death 53.3 TVR ***
50
40 *** ***
30
20 17.8 17.4
15.2
10.8 10.8
10
2.5 4.5
0 0
0
1 year 2 years 6,5 years

72. Conclusion Coracto
• Superbe early and late results of Coracto ®
versus similar BMS for CTO-PCI namely:
• Sustained rel. reduction of TVR of 75%
• No Stent-Thrombosis despite only 6 mos
dual antiplatelet therapy
• No late catch-up
• The only available DES with evidence for
CTO-PCI