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Gerald S. Werner, MD, FESC, FACC
Klinikum Darmstadt, Germany
BSIC, Manchester, September 15, 2006
Chronic total occlusions update
A European perspective
Gerald S. Werner, MD, FESC, FACC
Klinikum Darmstadt, Germany
BSIC, Manchester, September 15, 2006
CTO – The European perspective
• What you may want to know about collaterals
• Why should we open a CTO ?
• The past and presence of CTO treatment
• CTOs in the DES era
• The remaining challenges in CTOs
Pathophysiology of collaterals in CTOs
• How to assess collaterals ?
• What happens to collaterals after PCI ?
• Can collaterals replace an open artery ?
Assessment of collaterals: pressure and flow
PAo
POccl APVOccl
RColl
RP
PAo
POccl APVOccl
RCollPressure/Doppler Wire
Pressure/Doppler Wire
Before recanalization Reocclusion after PTCA
TCO Balloon
RA RA
RP
Baseline collateral function
PAo
POccl APVOccl
RColl
RP
PAo
POccl APVOccl
RCollPressure/Doppler Wire
Pressure/Doppler Wire
Before recanalization Reocclusion after PTCA
TCO Balloon
RA RA
RP
Recruitable collateral function
Werner et al. Circulation 2001;104:2784-90
Collateral function in CTOs
0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7
0
5
10
15
20N
um
be
r o
f pa
tie
nts
Collateral pressure index
0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7
0
5
10
15
20
Num
ber
of patients
Collateral pressure index
79% 46%
Werner et al. Circulation 2003;108:2877-82
Before PCI After PCI
Loss of collateral function not due to embolization
0 25 50 75
Rcoll [mmHg/(cm*sec)]
0,0
0,5
1,0
1,5
2,0
ma
xim
ale
CK
[µ
mo
l/(L
*se
c)]
R-Quadrat = 0,01
Bahrmann et al. Z Kardiol 2002;91:937-945
Collateral function in CTOs
0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7
0
5
10
15
20N
um
be
r o
f pa
tie
nts
Collateral pressure index
0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7
0
5
10
15
20
Num
ber
of patients
Collateral pressure index
79% 46%
0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7
0
5
10
15
20
Num
ber
of patients
Collateral pressure index
18%
Werner et al. Circulation 2003;108:2877-82
Before PCI After PCI
6 mo FUP
Evidence for preformed collaterals in man
0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7
0
5
10
15
20N
um
be
r o
f pa
tie
nts
Collateral pressure index
0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7
0
5
10
15
20
Num
ber
of patients
Collateral pressure index
79% 46%
0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,7
0
5
10
15
20
Num
ber
of patients
Collateral pressure index
18%
20%
Wustmann et al. Circulation 2003;107:2213-20 Werner et al. Circulation 2003;108:2877-82
Before PCI After PCI
6 mo FUP
Can good collaterals replace an open artery ?
Collateral function assessed as collateral flow reserve
In 98 Pat. with CTO during adenosine stress
Adapted from Werner et al. JACC 2006;48:51-8
Can good collaterals replace an open artery ?
95% of collaterals are no
substitute for the open artery
CTO – The European perspective
• What you may want to know about collaterals
• Why should we open a CTO ?
• The past and presence of CTO treatment
• CTOs in the DES era
• The remaining challenges in CTOs
CTOs – Should we treat them all ?
• Improvement of symptoms (angina, dyspnea)
• Improvement of LV function
• Improvement of prognosis
Benefit of recanalisation on LV function
Werner et al. Am Heart J 2005;149:129-37
No improvement in case of
Reocclusion !!!
Indication for revascularization: MRI function and
vitality
LV recovery after recanalization of CTOs - MRI
Baks T et al. JACC 2006;47:721-5
PCI success and survival
Suero et al. JACC 2001;38:409-14
Ramanathan & Buller, ACC 2003
2000 Pat, 74% successful
1458 Pat, 77% successful
871 Pat, 65% successful Hoye et al. Eur Heart J 2005;26:2630-6
If PCI fails … at least consider CABG
Suero et al. JACC 2001;38:409-14
But CABG seems to be
only the second best option
A CTO left occluded makes life more dangerous
Leaving a CTO alone means taking risks in low risk
patients
0
1
2
3
4
5
6
7
8
Periprocedural
MACE
Death within 12
months
CTO (n= 122)
Non-CTO (n= 88)
No PCI (n= 451)
STAR Registry, Institute for infarct research, Ludwigshafen
PCI of
CTO – The European perspective
• What you may want to know about collaterals
• Why should we open a CTO ?
• The past and presence of CTO treatment
• CTOs in the DES era
• The remaining challenges in CTOs
CTOs in the cathlab routine in 2003
• In a German registry (STAR – Stable Angina
pectoris Registry - IHF, Ludwigshafen) 2002
consecutive diagnostic angiographies were
evaluated:
• 33% had at least one CTO
• CTO pts had more severe symptoms, and LV
dysfunction
• the 1-year mortality with CTOs was 5.5% vs. 3.1%
• Only one third of CTOs underwent PCI
• Half of all CTOs were referred to CABG
Why bother, you can‘t open it … most times CTO success rates – historical perspective
Why bother with PCI – you can‘t keep it open
anyhow Binary angiographic restenosis with balloon vs BMS
Woehrle CTO Workshop Munich 2005
Stenting in CTOs: long and multiple stents required
Werner et al. J Am Coll Cardiol 2003;42:219-25
1 2 >20
10
20
30
40
50
60
70
80
90
100
4
11
9
17
5
10
61628
Pa
tie
nts
[%
]
Number of implanted stents
No TVF Restenosis Reocclusion
1 2 >20
10
20
30
40
50
60
70
80
90
100
4
11
9
17
5
10
61628
Pa
tie
nts
[%
]
Number of implanted stents
No TVF Restenosis Reocclusion
1 2 >20
10
20
30
40
50
60
70
80
90
100
4
11
9
17
5
10
61628
Pa
tie
nts
[%
]
Number of implanted stents
No TVF Restenosis Reocclusion
1 2 >20
10
20
30
40
50
60
70
80
90
100
4
11
9
17
5
10
61628
Pa
tie
nts
[%
]
Number of implanted stents
No TVF Restenosis Reocclusion
CTO – The European perspective
• What you may want to know about collaterals
• Why should we open a CTO ?
• The past and presence of CTO treatment
• CTOs in the DES era
• The remaining challenges in CTOs
Published studies using DES in CTOs
Hoye Ge Nakamura Prison II PACTO
Stent Cypher Cypher Cypher Cypher Taxus
Patients 56 122 60 100 95
Reference diameter [mm]
2.35 2.67 3.12 3.38 2.65
Stent length 24 42 36.5 32 40
Stents per lesion 2.0 1.4 1.4 ? 1.4 1.7
TVF 9 % 9 % 3 % 8 % 10 %
Reocclusion 3 % 2.5 % 0 % 4 % 1 %
Follow-up 59 % 83 % 75 % 94 % 100 %
Events in PRISON II: BMS vs. Cypher
Suttorp et al. TCT 2005
30 90 150 0 60 120 210 180 240 270
Days Since Index Procedure
300 330 360
100%
90%
80%
70%
Fre
edom
of T
LR
TAXUS MR Control
9 mos. 12 mos.
P=0.0003
91.3 %
79.4 %
Control=bare metal stent
TAXUS= TAXUSTM stent
TAXUSTM MR stent is not available for sale
CTO vs. Complex Nonocclusive Lesions (Taxus VI)
12%
NNT 8
Werner et al. J Am Coll Cardiol 2004;44:2301-6
35%
NNT 3
Long stenting no longer a problem for recurrence
2.75x32
3.0x32
3.0x28
3.0x32 3.5x8
2214/05 471/05
6 months later
Taxus restenosis in CTOs: focal
All nonocclusive restenosis were focal at the edges and
successfully treated with another Taxus stent ->99 % patency
95 pts
85 pts.
No TVF
10 pts.
TVF
93 pts.
9 pts.
Repeat PCI
6 months
1 pt. Reoccl.
No PCI
9 pts. *)
No TVF 12 months
1 pt. Late
Reoccl.
Longterm patency
Werner GS et al; ACC 2006
0
2
4
6
8
10
12
Overall Cardiac Death
TLR MI
1.7% n=1
1.7% n=1
6.7% n=4
Inc
ide
nc
e (
%)
N = 65/778 Patients
WISDOM 12-Month TAXUS Related
Cardiac Events: Total Occlusions
3.3% n=2
Only 8.4% !!!
0
2
4
6
8
10
Overall Cardiac Death
Treated Vessel Re-intervention
MI
2.2% n=4 1.1%
n=2
4.3% n=8
Inc
ide
nc
e (
%)
N = 186/3688 Patients
MILESTONE II 12-Month TAXUS Related
Cardiac Events: Total Occlusions
1.6% n=3
Stent thrombosis = 1.0% (2/186)
Only 5% !!!
Opening a CTO …
• Improves symptoms (angina, dyspnea)
• Improves LV function
• Improves prognosis
• Can be kept open with DES
• Why are they still undertreated ?
CTO success rates
1995/96 1997/98 1999/01 2001/03
Penetration power of dedicated wires
New wire techniques
Mitsudo; www.tctmd.com
Parallel wire technique - example
230/05
Parallel wire technique with ASAHI
Miracle Bros and Conquest wires
Case example: Double blunt occlusion
12/05/06
Blunt proximal cap with 2 large sidebranches and blunt distal cap with one large side branch.
Case example: Double blunt occlusion
12/05/06
Bilateral approach: Confianza Pro over Spectranetics versus Miracle 3G over Transit
Case example: Double blunt occlusion
12/05/06
Bilateral approach: A major new option for 2nd attempts But the majority of CTOs are not treated in live courses
Determinants of procedural success
• Experience, dedication and patience
of interventionist
• Duration of occlusion
• < > 2 weeks
• < > 3 months
• < > 12 months
• Angiographic criteria … not many
• Heavy calcification
• Vessel tortuosity
PCI of CTOs is dangerous … really ?
Bahrmann et al. EuroInterv 2006;2:231-7
Why do we not apply what is possible ?
1995/96 1997/98 1999/01 2006
CTO – The European reality
• Opening a CTO …
• Costs a lot of lab time
• Costs a lot of work time
• Costs a lot of material
• Costs a lot of radiation exposure
• Requires a lot of patience
• Does not pay in our reimbursement system