Published Data on CTO - Euro CTOThe Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary...

Nikolaos Konstantinidis MD, MSc, PhD

St Luke’s Hospital of Thessaloniki

AHEPA University Hospital

Thessaloniki, Greece

Published Data on CTO Complications

Complication Management in CTOs

September 13th, 2019, Berlin, Germany

Potential Conflicts of Interest

I, Nikolaos Konstantinidis MD, MSC, PhD, do not have any potential conflict of

interest to declare

❖Early CTO PCI reports, initial perception

❖Contemporary series of CTO PCI

❖Randomized trials of CTO PCI

❖Revascularization approach and complication rates

❖Factors associated with CTO PCI complications

❖Predictive CTO Complication score

Published Data on CTO Complications

Procedural Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention; A Report From the NCDR (National

Cardiovascular Data Registry)(22.365 patients with CTO (of 594.510) enrolled between 2009-2013, technical success 59%, in hospital MACE 1.6%)

Brilakis et al, J Am Coll Cardiol Intv 2015;8:245–53

In-hospital outcomes of percutaneous coronary intervention inpatients with CTO: insights from the ERCTO registry

(1983 patients enrolled between 2008-2010, procedural success 82.9%, in hospital MACE 1.8%)

Galassi et al, EuroIntervention 2011;7:472-479

Patel et al, J Am Coll Cardiol Intv 2013;6:128–36

Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary CTO Interventions

A Weighted Meta-Analysis of 18,061 Patients From 65 Studies (published 2000-2011)

Pooled Complication Rates

❖Early CTO PCI reports, initial perception

❖Contemporary series of CTO PCI

❖Randomized trials of CTO PCI

❖Revascularization approach and complication rates

❖Factors associated with CTO PCI complications

❖Predictive CTO Complication score

Published Data on CTO Complications

Brilakis et al, Circulation. 2019;140:420–433.

Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention; A Global Expert Consensus Document

5,2

4,74,4

4,8

0,7 0,7 0,70,5

0,36 0,290,07 0,09

0

1

2

3

4

5

6

2008-2009 2010-2011 2012-2013 2014-2015

Co

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Any periprocedural complication MACE In hospital mortality

Any periprocedural complication: p for time 0.793, p for operator <0.001 MACE: p for time 0.034, p for operator 0.003

In hospital mortality: p for time 0.120, p for operator 0.999

Temporal Trends in Chronic Total Occlusion Interventions in Europe17 626 Procedures From the European Registry of Chronic Total Occlusion(17626 patients enrolled between 2008-2015, J-CTO score increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015 –

p<0.001, procedural success 79.7% in 2008 - 89.3% in 2015 - p<0.001, MACE 0.6%)

Konstantinidis et al, on behalf of the EuroCTO Club, Circ Cardiovasc Interv. 2018;11:e006229

Comparison of PCI for CTO Outcome According to Operator Experience from the Japanese Retrograde Summit Registry

(3229 patients enrolled between 2012-2013, procedural success 88.4%, in hospital MACCE 0.53%)

Habara et al, Catheterization and Cardiovascular Interventions 87:1027–1035 (2016)

Tajti et al, J Am Coll Cardiol Intv 2018;11:1325–35

The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention Update From the PROGRESS CTO Registry

(3055 patients enrolled between 2012-2017, 87% technical success rate, in-hospital MACE was 3.04% (death, 0.85%; acute MI, 1.08%; stroke, 0.26%; emergency CABG, 0.16%; urgent repeat PCI, 0.36%; pericardial tamponade, 0.85%)

In-Hospital Major Complications Classified According to Final Successful Crossing StrategyUse of the retrograde approach was associated with higher overall in-hospital MACE and risk for perforation

Tajti et al, J Am Coll Cardiol Intv 2018;11:1325–35Xenogiannis I, 24 September 2018, San Diego, CA, TCT 2018

The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention Update From the PROGRESS CTO Registry

(3055 patients enrolled between 2012-2017, 87% technical success rate, in-hospital MACE was 3.04% (death, 0.85%; acute MI, 1.08%; stroke, 0.26%; emergency CABG, 0.16%; urgent repeat PCI, 0.36%; pericardial tamponade, 0.85%)

Most common cause of Death is perforation/tamponade

Mortality 0.8%

Perforation type

Danek et al, Am J Cardiol 2017;120:1285–1292

Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention

(2049 patients enrolled between 2012-2017, 88% technical success rate, in-hospital MACE was 2.64%; Coronary perforation was 4.1%; Ellis class 1, 2, and 3 perforations were 21%, 26%, and 53%, respectively)

Outcomes of Percutaneous Coronary Interventions for Chronic Total Occlusion Performed by Highly Experienced Japanese Specialists

The First Report From the Japanese CTO-PCI Expert Registry(2847 patients enrolled between 2014-2015, technical success 89.9%, in hospital MACCE <2%)

Suzuki et al, J Am Coll Cardiol Intv 2017;10:2144–54

The Hybrid Algorithm for Treating Chronic Total Occlusions in EuropeThe RECHARGE Registry

(1253 patients enrolled between 2014-2015, procedural success 86%, in hospital MACE 2.6%)

Maeremans et al, J Am Coll Cardiol 2016;68:1958–70

Hybrid approach improves success of chronic total occlusion angioplasty; The UK HYBRID CTO Registry

(1156 patients enrolled between 2012-2014, procedural success 90%, 30 day MACE 1.6%)

Wilson et al. Heart 2016;102:1486–1493

Complication rates at 30 days according to final strategy

Early Procedural and Health Status Outcomes After Chronic TotalOcclusion Angioplasty A Report From the OPEN-CTO Registry

(1000 patients enrolled between 2014-2015, core-lab adjudicated, J-CTO 2.3± 1.3, technical success 86%, in hospital MACE 7%)

Sapontis et al, J Am Coll Cardiol Intv 2017;10:1523–34

❖Early CTO PCI reports, initial perception

❖Contemporary series of CTO PCI

❖Randomized trials of CTO PCI

❖Revascularization approach and complication rates

❖Factors associated with CTO PCI complications

❖Predictive CTO Complication score

Published Data on CTO Complications

A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of CTOs; The EUROCTO Trial

(396 patients enrolled between 2012-2015, J-CTO 1.82±1.07 86.6% success rate, 12 month follow up)

Werner et al, European Heart Journal (2018) 39, 2484–2493

Percutaneous Intervention for Concurrent Chronic Total Occlusionsin Patients With STEMI; The EXPLORE Trial

(304 patients enrolled between 2007-2015, J-CTO 2.0±1.0, 73% success rate, 4 month follow up)

Henriques et al, J Am Coll Cardiol 2016;68:1622–32

Mashayekhi et al, J Am Coll Cardiol Intv 2018;11:1982–91

A Randomized Trial to Assess Regional Left Ventricular Function After Stent Implantation in Chronic Total Occlusion; The REVASC Trial

(205 patients enrolled between 2007-2015, J-CTO 2.0±1.0, 86% success rate (97% after 2nd attempt), 6&12 month follow up)

Obedinskiy et al, J Am Coll Cardiol Intv 2018;11;Issue 13:1309–11

The IMPACTOR CTO Trial(94 patients with CTO RCA enrolled between 2010-2014, 83% success rate, 12 month follow up)

❖ Among patients who underwent CTO PCI attempts, 4 of 47 (8.5%) experienced

periprocedural complications: 2 vascular complications and 2 tamponades.

❖ No death was observed in either group.

❖ In the PCI group, 2 patients underwent target vessel revascularization 5 and 6 months

following the index procedure.

❖ No significant difference was found in MACE-free survival between the PCI and OMT

groups at 12 months (94.9% vs. 100%; p . 0.19).

Randomized Trial Evaluating Percutaneous Coronary Intervention for the treatment of CTO; The DECISION-CTO trial

(834 patients enrolled between 2010-2016, J-CTO 2.2± 1.2, 90.6% success rate, 4-year follow up)

Lee et al, Circulation; 2019 Apr 2;139(14):1674-1683.

❖Early CTO PCI reports, initial perception

❖Contemporary series of CTO PCI

❖Randomized trials of CTO PCI

❖Revascularization approach and complication rates

❖Factors associated with CTO PCI complications

❖Predictive CTO Complication score

Published Data on CTO Complications

Any periprocedural complication: p <0.001 MACE: p 0.217

Temporal Trends in Chronic Total Occlusion Interventions in Europe17 626 Procedures From the European Registry of Chronic Total Occlusion(17626 patients enrolled between 2008-2015, J-CTO score increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015 –

p<0.001, procedural success 79.7% in 2008 - 89.3% in 2015 - p<0.001, MACE 0.6%)

Konstantinidis et al, on behalf of the EuroCTO Club, Circ Cardiovasc Interv. 2018;11:e006229

3,7

5,7

8,2

0,6 0,6 0,8

0

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6

8

10

Antegrade wire escalation Antegrade Dissection Reentry Retrograde

Co

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ion

rat

e (%

)

Any periprocedural compication MACE

Periprocedural complication trend according to the recanalization approach (AWE, ADR, retrograde); p for adopted strategy <0.001, p for operator <0.001, p for time >0.05.

Temporal Trends in Chronic Total Occlusion Interventions in Europe17 626 Procedures From the European Registry of Chronic Total Occlusion(17626 patients enrolled between 2008-2015, J-CTO score increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015 –

p<0.001, procedural success 79.7% in 2008 - 89.3% in 2015 - p<0.001, MACE 0.6%)

Konstantinidis et al, on behalf of the EuroCTO Club, Circ Cardiovasc Interv. 2018;11:e006229

4,9

4

3,5

2,3

4,8

8,6

4,1

6,7

7,88,1

7

9,7

0

1

2

3

4

5

6

7

8

9

10

2008-2009 2010-2011 2012-2013 2014-2015

Co

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tio

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(%)

Years

Antegrade wire escalation Antegrade Dissection Reentry Retrograde Approach

Tajti et al, J Am Coll Cardiol Intv 2018;11:1325–35

The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention Update From the PROGRESS CTO Registry

(3055 patients enrolled between 2012-2017, 87% technical success rate, in-hospital MACE was 3.04% (death, 0.85%; acute MI, 1.08%; stroke, 0.26%; emergency CABG, 0.16%; urgent repeat PCI, 0.36%; pericardial tamponade, 0.85%)

In-Hospital Major Complications Classified According to Final Successful Crossing StrategyUse of the retrograde approach was associated with higher overall in-hospital MACE and risk for perforation

IVUS Analysis of Intraplaque Versus Subintimal Tracking in CTO PCI and Association With Procedural Outcomes

(219 patients enrolled between 2014-2016, subintimal tracking in 52.1% of cases (86.7% dissection re-entry, 27.9% wire escalation, success 89.5%, in hospital outcomes)

Song et al, J Am Coll Cardiol Intv 2017;10:1011–21

IVUS Analysis of Intraplaque Versus Subintimal Tracking in CTO PCI and Association With Procedural Outcomes

(219 patients enrolled between 2014-2016, subintimal tracking in 52.1% of cases (86.7% dissection re-entry, 27.9% wire escalation, success 89.5%, in hospital outcomes)

Song et al, J Am Coll Cardiol Intv 2017;10:1011–21

Procedural and longer-term outcomes of wire- versus device-basedantegrade dissection and re-entry techniques for the percutaneous

revascularization of coronary chronic total occlusions(223 patient, J-CTO 2.3 ± 1.2, technical success 86%, procedural complications 2.7%)

Azzalini et al, Int J Cardiol 231 (2017)78-83

24-month MACE rates were higher in STAR (15.4%) and LAST (17.5%), as compared withdevice-based ADR with CrossBoss/Stingray (4.3%, p = 0.02)

Tajti et al, J Am Coll Cardiol Intv 2019;12:346–58

Procedural Outcomes of Percutaneous Coronary Interventions for Chronic Total Occlusions Via the Radial Approach

Insights From an International Chronic Total Occlusion Registry(3790 patients enrolled between 2012-2018, 89% technical success rate, in-hospital major complication (2.47% vs. 3.40% vs.

2.18%; p . 0.830) were similar in all 3 groups, major bleeding was lower in the RA group (0.55% vs. 1.94% and 0.88%; p .0.013).

P:0.641 & P:0.009

One-Year Clinical Outcomes of the Hybrid CTO Revascularization Strategy After Hospital Discharge: A Subanalysis of the Multicenter

RECHARGE Registry(1253 patients enrolled between 2014-2015, 1067 analyzed post 1 year - MACE 8.7%)

Maeremans et al, J Invasive Cardiol 2018;30(2):62-70

Procedural parameters according to MACE events

In-hospital Outcomes of Attempting More Than One CTO Through Percutaneous Intervention During the Same Procedure

(2955 patients enrolled between 2012-2017, 2% had more than one CTO lesions attempted during the same procedure -70% in different major epicardial arteries, technical success was similar (86% vs 87%, p = 0.633), in-hospital major

complication rate was higher (10.3% vs 2.7%, p = 0.005))

Tajti et al, Am J Cardiol 2018;122:381 387

❖Early CTO PCI reports, initial perception

❖Contemporary series of CTO PCI

❖Randomized trials of CTO PCI

❖Revascularization approach and complication rates

❖Factors associated with CTO PCI complications

❖Predictive CTO Complication score

Published Data on CTO Complications

Procedural Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention; A Report From the NCDR (National

Cardiovascular Data Registry)(22.365 patients with CTO (of 594.510) enrolled between 2009-2013, technical success 59%, in hospital MACE 1.6%)

Brilakis et al, J Am Coll Cardiol Intv 2015;8:245–53

Operator CTO PCI Volume Association With Procedural Success and Complications

Patel et al, J Am Coll Cardiol Intv 2013;6:128–36

Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary CTO Interventions

A Weighted Meta-Analysis of 18,061 Patients From 65 Studies (published 2000-2011)

Temporal Trends in Cumulative Angiographic Success Rates and Major Procedural Complication Rates

OPEN-CTO Registry (1000 patients enrolled between 2014-2015, core-lab adjudicated, technical success 86%, in hospital MACE 7%)

Salisbury AC et al, 24 October 2017, Denver, Colorado, TCT 2017

Predictors of CTO PCI Complications

❖ Age

❖ Retrograde approach

❖ High J-CTO score

Danek et al, Am J Cardiol 2017;120:1285–1292

Incidence, Treatment, and Outcomes of Coronary Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention

(2049 patients enrolled between 2012-2017, 88% technical success rate, in-hospital MACE was 2.64%; Coronary perforation was 4.1%; Ellis class 1, 2, and 3 perforations were 21%, 26%, and 52%, respectively.

Tajti et al, Circ Cardiovasc Interv. 2019;12:e007338.

In-Hospital Outcomes of CTO PCI in Patients With Prior CABG SurgeryInsights From an International Multicenter Chronic Total Occlusion Registry

(3486 patients enrolled between 2012-2018, Prior CABG patients had lower technical (84% versus 89%; P<0.001) success, but similar incidence of in-hospital major complications (3.1% versus 2.5%; P=0.287).

One-Year Clinical Outcomes of the Hybrid CTO Revascularization Strategy After Hospital Discharge: A Subanalysis of the Multicenter

RECHARGE Registry(1253 patients enrolled between 2014-2015, 1067 analyzed post 1 year - MACE 8.7%)

Maeremans et al, J Invasive Cardiol 2018;30(2):62-70

Demographic characteristics according to MACE events

❖Early CTO PCI reports, initial perception

❖Contemporary series of CTO PCI

❖Randomized trials of CTO PCI

❖Revascularization approach and complication rates

❖Factors associated with CTO PCI complications

❖Predictive CTO Complication score

Published Data on CTO Complications

Danek et al, J Am Heart Assoc. 2016;5: e004272

Development and Validation of a Scoring System for Predicting Periprocedural Complications During PCI of CTOs

The PROGRESS CTO Complications Score(1569 patients enrolled between 2012-2016, 90% success rate, In hospital MACE 2.8%)

Take home message

❖ Contemporary well controlled series and RCTs report higher complication and MACE rates

compared to early CTO PCI reports

❖ Expert operators consistently achieve success rates >90% and address lesions of increasing

complexity over time, while complication and MACE rates seem to remain unchanged

❖ In-hospital MACE in CTO PCI is in the range of 3%

❖ Perforation is the most common periprocedural complication (4%), responsible for the

majority of deaths (18% with Ellis III perforation)

❖ Retrograde approach and ADR are associated with higher complication rate

❖ Radial approach is associated with lower major bleeding and MACE rate (12 month FU)

❖ PROGRESS-CTO complications score is a useful tool for estimating in-hospital complication

risk

Thank you very much..

Thank you very much..