Thierry Lefèvre

J’aborde toute les CTO ….

Quand le territoire est viable et ischémique

Prévalence des CTOs

Fefer P et al. J Am Coll Cardiol. 2012;59:991-

Patients

54%

10%

18%

What do we currently know?

1. 95% of patients with CTO have inadequate distal collateral supply (FFR <0.80)

2. Ischaemia is prognostically adverse

3. Successful CTO PCI cases have better prognosis than failed CTO PCI cases

Amélioration de l’angor

Amélioration de la capacité à l’effort

Amélioration de la qualité de vie

Amélioration de l’ischémie

Amélioration de la fonction VG

Diminution du risque rythmique

Diminution des indications de pontage

Amélioration de la survie

Succès vs Echec

Ischaemia

Shaw et al, Circulation 2008; 117; 1283-91

Residual ischaemia

Shaw et al, Circulation 2008; 117; 1283-91

Incomplete Revascularisation is associated with Poor Outcome

Kirschbaum Am J Cardiol 2008;101:179 –

IRM et Indication de Revascularisation

CTO-PCI Améliore la Qualité de Vie

N=42

N=83

Grantham JA et al. Circ Cardiovasc Qual Outcomes. 2010;3:284-290

Effectiveness of recanalization of CTO

Residual/recurrent angina during FU

Joyal Am Heart J 2010;160:179-87

All causes of Mortality

Khan et al. CCI 2013; 82: 95–1

Meta-Analysis (successfull vs Unsuccessfull)

Sudhakar et al. JACC 2014; 64: 235–

CTO-PCI in the UK central cardiac audit database

28% mortality

CTO data from SYNTAX

Farooq et al. JACC 2013; 61: 282-9

51% non revasc. 32% non pontée

Genereux et al. JACC 2012; 59: 2165-74

“Residual Syntax Score”, a new predictor of outcomes

Genereux et al. JACC 2012; 59: 2165 74

“Residual Syntax Score”, a new predictor of outcomes

Theoretical

• If the muscle subtended by the CTO is – Alive (> 50%)

– Ischemic (10-20%)

• Then the patient would be better off if that artery

were magically reopened (i.e.at zero risk)

To maximize potential benefit

Know the predictors of success

Assess the risk of the procedure

Start by treating the CTO in Pts with MV disease

Concentrate expertise

Minimise contrast use and radiation exposure

Adjust the difficulty to your level of expertise

Know when to stop and ask to an expert

Lesion morphology

Patient characteristics

Learning curve

The Success Rate of CTO

Guidewire Crossing < 30 min.

Morino et al. JACC Interv 2011; 4: 213-221

Successfull CTO PCI

Morino et al. JACC Interv 2011; 4: 213-221

CTO Success

No ad Hoc PCI !

Good CTO Angiography

No panning, large field

Optimal view of the distal run off

Optimal view of the donor vessel

Good views of the collaterals

Several views of the occluded vessel

At least 1 same view for both vessels

What are the Questions ? Proximal and/or distal ambiguity ? Lesion length ? Vessel course, Island ? Lesion calcification and tortuosity ? Distal run off ? Collaterals ? Good and safe support ?

What about the support ?

What about the support ?

What about the support ?

What about the support ?

What about the support ?

Fielder XT + Finecross

What about the support ?

3D right

Miracle 12 + Finecross

What about the support ?

Anchoring balloon

What about the support ?

What about the support ?

What about the support ?

Ostial and calcified lesion GC Support, Stability ?

Risk of ostial dissection ?

Which Approach ?

Which Approach ?

Which Approach ?

Which Approach ?

Which Approach ?

Which Approach ?

Which Approach ?

« Mother and Child Technique »

Which Approach ?

Which Approach ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

No Calcification Lesion length < 20 mm Proximal ambiguity ? No distal ambiguity Good distal run-off ?

Proximal ambiguity ?

Proximal Ambiguity

Proximal ambiguity ?

Proximal ambiguity ?

Proximal ambiguity ?

What about the support ?

Proximal ambiguity ?

Proximal ambiguity ?

Finecross + Fielder XT

Proximal ambiguity ?

Proximal ambiguity ?

Proximal ambiguity ?

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

Successful PCI of CTO’s improves symptoms, ischemia, quality of life, left ventricular function, reduce the need for CABG and even may improve survival.

The net benefit is strongly related to the amount of pre procedural myocardial ischemia.

Conclusions

PCI of CTO’s is not a high risk procedure in experience centers.

Conclusions

The success rate is relatively high in non selected cases (70-90%) in Europe, depending mainly on the operator’s and Team center experience.

The balance between benefit (amount of

ischemia) and risk (PCI attempt in a center x

or y) should always be assessed before

taking the decision.

Conclusions

It is time to build strong networks

between centers in order to treat better

more patients.

CTO et IDM

Claessen BE et al. Eur Heart J, 2012; 33 :768-775

8.6% des patients avec IDM

NCDR 2005-2008: BMS and DES in CTOs 92069 patients, of these 10766 with a CTO PCI and stent (BMS: 2043, DES: 8218)

Patel MR et al. JACC Interv 2012; 5: 1054-6

EURO-CTO Trial Evaluation of the Utilisation of Revascularisation vs Optimal medical therapy for CTOs

1200 patients 30-40 operators >80% success rate First patient enrolled March 2012 Primary efficacy endpoint: Improvement of QoL Safety endpoint: MACE

Conclusion

Take extra time during the diagnostic angiogram to obtain specific anatomic information that will guide strategy (ies) for the subsequent CTO PCI.

Study the film in detail (Team).

Educate refering physicians

Start the procedure with powerfull bilateral injection in the majority of cases