Which CTO should be treated by PCI orCABG

&The specific problems of PCI for post

CABG patients

Gerald S. Werner FESC, FACC, FSCAI

Medizinische Klinik I

Klinikum Darmstadt GmbH

1807

Coronary artery chronic total occlusions (CTOs) are an

exacerbation of stable coronary artery disease (CAD) with

advanced calcification. CTOs are defined as 100% coronary

occlusions with Thrombolysis in Myocardial Infarction grade

0 flow persisting for >3 months.1 National database registries

and large single-center series suggest that in patients with

CAD the overall incidence of CTOs may vary from 16% to

19% in Japan2 and 29% to 33% in North America,3 making

this a common problem globally. Treatment of CTOs should

be considered if associated with symptoms or viable/ischemic

myocardial territories. Historically, treatments have been via

coronary artery bypass grafting (CABG) or medical therapy.3–9

Response by Weintraub and Garratt on p 1817

The use of percutaneous coronary intervention (PCI) to

treat CTOs (CTO-PCI) against established practice is contro-

versial.10 This controversy is facilitated by the poor evidence

available and by lack of clarity in the European and American

guidelines for revascularization, including those for patients

with stable CAD.11–15 The lack of robust evidence and the

unclear guidelines can lead to ill-defined clinical indications

determining serious geographical discrepancies in CTO-PCI

medical practice. In a recent report from Japan, >61% of

patients diagnosed with CTOs (19% of all CAD patients) were

treated with CTO-PCI.2 This is a significant increase com-

pared with a previous report from North America in which

only 6% to 9% of all CTOs (29%–33% of all CAD cases)

were treated with CTO-PCI (range, 1%–16% by geographi-

cal area/center).3 The report by Yamamoto and coworkers2

suggests widespread use of CTO-PCI in patients with multi-

vessel CAD. This is likely to be at the expense of more estab-

lished treatments such as CABG. The difference in CTO-PCI

practice observed between Japan and North America is not

easily explained. Contributing factors may be differences in

study period, unclear guidelines, misrepresentation of safety/

efficacy evidence supporting the use of CTO-PCI, neglect of

the evidence supporting more established treatments, gate-

keeper effect, and lack of policies by health authorities.

In this article, we provide evidence to support the view

that CABG surgery remains the gold standard for the treat-

ment of CTOs in patients with isolated left main stem (LMS)

CTOs, left anterior descending (LAD) CTOs, or CTOs in the

context of multivessel CAD. In addition, we explore safety

and efficacy concerns behind the widespread use of CTO-PCI.

Baseline Determinants of Health Outcome

and Decision Making in Patients With CTOsFor patients with CTO, the decision-making process should

be based on a meticulous evaluation of the coronary anatomy,

the complexity of each patient risk profile, the support of the

heart team, the reference to evidence-based medicine, and a

fully informed patient.

Clinical and Cardiac-Specific Variability of Patients

With CTOs

Patients with CTOs may have a complex risk profile with

a higher incidence of diabetes mellitus, multivessel disease

(Circulation. 2016;133:1807-1817. DOI: 10.1161/CIRCULATIONAHA.115.017797.)

© 2016 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.115.017797

From University of Bristol, UK.This article is Part I of a 2-part article. Part II appears on p 1818.Correspondence to Raimondo Ascione, FRCS, FRCS-CTh equiv, MD, ChM, Faculty of Health Sciences, University of Bristol, Bristol Heart Institute,

Bristol Royal Infirmary, Level 7, Upper Maudlin St, Bristol, UK BS2 8HW. E-mail R.Ascione@bristol.ac.uk

Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting?

Chronic Total Occlusion Should Be Treated With Coronary

Artery Bypass GraftingMustafa Zakkar, PhD, MRCS; Sarah J. George, PhD; Raimondo Ascione, FRCS, FRCS-CTh equiv, MD, ChM

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Should chronic total occlusions (CTOs) of coronary arteries

be revascularized by coronary artery bypass graft (CABG)

surgery? It would seem that this is not a question that is often

asked, yet CTOs are common and are more commonly revas-

cularized by CABG than by percutaneous coronary interven-

tion (PCI). In this article, we review the epidemiology of

CTOs; discuss issues and viability of the subtended zone, how

viability could be assessed, indications for revascularization

of CTOs, and the literature on CABG for CTO; and conclude

with recommendations for future research. The fundamental

positions put forward here are that the literature on CABG for

CTOs is not strong enough to justify this common procedure

on a routine basis, that decisions on care still need to be made,

and that additional research is needed.

Response by Zakkar et al on p 1826

Background on CTOsCTOs are common findings on coronary arteriograms.1,2

Although there has been extensive literature on the subject of

PCI for CTOs, there is less literature on CABG for CTOs.3–5

This is despite data from the early 2000s showing that patients

with CTO are treated more often with CABG than with

PCI.1 Christofferson et al1 studied 8004 consecutive patients

undergoing diagnostic catheterization at a single institution

between 1990 and 2000. CTOs were defined as 100% coro-

nary occlusion present for at least 3 months. Patients with pre-

vious CABG or recent myocardial infarctions (n=1423) were

excluded. Of the remaining 6581 patients, 3087 (47%) had

significant coronary artery disease (>70% coronary stenosis).

Of patients with significant coronary artery disease, a CTO

was present in 1612 patients (52%), of whom 375 (12%) had

>1 CTO. Among patients with significant coronary artery

disease and a CTO, 11% were treated with PCI, 40% with

CABG, and 49% with medical therapy. In comparison, among

patients with significant coronary artery disease but no CTO,

36% were treated with PCI, 28% with CABG, and 35% medi-

cally (P<0.0001). In a multivariable analysis, the presence of

a CTO was associated with reduced odds of undergoing PCI

(odds ratio, 0.26; 95% confidence interval [CI], 0.22–0.31;

P<0.0001). Multivessel disease, not a CTO, was found on

multivariable analysis to be associated with the increased

choice of CABG. However, multivessel disease and CTO are

collinear, and it difficult to know which is the main driver in

decision making.

More recently, the choice of therapy for patients under-

going coronary angiography and found to have CTOs was

studied in the Canadian Multicenter Chronic Total Occlusions

Registry.6 CTOs were identified in consecutive patients under-

going nonurgent diagnostic coronary angiography at 3 sites in

Canada between April 2008 and July 2009. CTOs were identi-

fied in 2630 of 14 439 patients (18.4%). There was a history of

myocardial infarction in 40%; 25% had Q waves correspond-

ing to the CTO artery territory; and left ventricular function

was normal in the majority. Half of the CTOs were in the

right coronary artery. Almost half of the patients with CTOs

were treated medically, and 25% underwent CABG (CTOs

bypassed in 88%). PCI was performed in 30%, although CTO

lesions were attempted in only 10%, with 70% success rate.

Although more patients with CTOs have historically been

(Circulation. 2016;133:1818-1826. DOI: 10.1161/CIRCULATIONAHA.115.017798.)

© 2016 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.115.017798

From the Christiana Care Health System, Newark, DE.This article is Part II of a 2-part article. Part I appears on p 1807.Correspondence to William S. Weintraub, MD, Cardiology Section, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Newark, DE 19718.

E-mail wweintraub@christianacare.or g

Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting?

Chronic Total Occlusion Should Not Routinely Be Treated

With Coronary Artery Bypass GraftingWilliam S. Weintraub, MD; Kirk N. Garratt, MD

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CTO-PCI and CABG

• What are the results of CABG for CTOs ?

• Thesis: Should we not prefer CTO PCI over CABG and use CABG as the final resort ?

• The specific problem of CTO PCI in post CABG patients

SYNTAX Study: The only randomized study tocompare PCI and CABG for CAD including CTOs

The presence of a CTO was the main reason not to

be randomized -> CABG Registry

Patrick Serruys, MD PhDCRT 2009, March 4, 2009

SYNTAX and CTO revascularization

Farooq et al. JACC 2013; 61: 282-94

PCI

No revasc.

51%

CABG

No revasc.

32%

47 years, male: PCI or CABG ?

Impact of SYNTAX Score on PCI

Wijns W, Kolh P, et al. Eur Heart J 2010

Recently published European guidelines for revascularization

What is the actual patency rate post CABG ?

PREVENT IV JAMA. 2005;294(19):2446-2454

About 30% of all venous grafts were occluded after 1 yearIn 45% of patients at least 1 graft was occluded

8% of all LIMA(LITA) were occluded after 1 year

Venous graft patency for occluded vessels

PRAGUE IV. Circulation 2004;110:3418-3423

Study goal: compare on-pump with off-pump surgery

Venous graft patency for occluded vessels

PRAGUE IV. Circulation 2004;110:3418-3423

More than 50% of CTOs are located in the RCA, 20% in the LCX

Higher Mortality with longer CTOs post CABG

Banerjee SR et al. J Cardiac Surg 2012; 27: 662-7

605 CABG patients42% with CTO, 48% in RCA

Bypass to CTO in LAD LCX RCA100% 92% 85%

The problem of the anstomoses to occluded vessels

Werner et al. Circulation 2003;107:1972-7

The distal epicardial territory acute and at follow-up

6 months later

Epicardial diameter depends on shear stress, which is increasingwith increasing perfusion pressureand flow

Lumen increase 6 months after PCI of CTO

Park JJ et al. JACC Interv, 2012; 5:1827-36

However:Total occlusion defined with <1 month duration and TIMI 0 and I

LIMA graft patency for occluded vessels

PRAGUE IV. Circulation 2004;110:3418-3423

CTO-PCI or CABG

• We need to accept that a LIMA to LAD-CTO will still be superior to PCI especially for the long-term benefit

• We need to establish the long-term benefit of CTO PCI for our patients in the range beyond a few years

• To do CTO PCI for a LAD we should respect a future LIMA anastomoses option

CTOs are frequent in chronic CAD

0

2000

4000

6000

8000

10000

12000

14000

16000

Post-CABG STEMI Coronary angio

CTO

No CTO

Fefer P et al. J Am Coll Cardiol. 2012;59(11):991-997

Number of patients

54%10%

18%

Post CABG prevalence in the literature

Muramatsu T et al. EuroIntervention 2014

Alessandrino G et al. JACC CI 2015

Alaswad K et al. CCI 2015

CABG prevalence in CTO patients ranged from 7.5% to 36%

CTO Scores and CABG ?

J-CTO score PROGRESS score

Morino Y et al. JACC Interv 2011; 4: 213 Christopoulos G et al. JACC Interv 2016; 9: 1

Post CABG CTO PCI success

Michael TT et al. Heart 2013;99:1515-18

Post CABG CTO PCI success (RECHARGE)

Maeremans J et al. JACC 2016; 68: 1958-70

CTO Scores and CABG ?

Alessandrino G et al. JACC CI 2015; 8: 1540

RECHARGE score(based on 880 lesions)

Maeremans et al CCI 2018; 91: 192-202

The EURO CTO “CASTLE” Score

Previous CABG

No 1.00

Yes 1.42 (1.25 – 1.61) <0.0001

Based on 17238 procedures

CASTLE:CABGAge>70Stump (non-tapered)Tortuosity (proximal to CTO)Length>20Calcification severe

Risk groupsRisk scores 0-1 2 3 4-6

0.0

0.1

0.2

0.3

0.4

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Failure rate

Szijgyarto et al JACCInterv 2019

Post CABG CTOs are unpredictable ?A personal experience

• If CTO developed post CABG the CTO is often functional, and can be easily passed

• If it is a prior CTO it often is also compromised by long-term calcification

• Remember that an occluded venous graft may still be a viable option for a retrograde access

Disease progression after CABG

Pereg et al JACC Interv. 2014;7:761-7

Pre-op lesion severity and post op CTO

Pereg et al JACC Interv. 2014;7:761-7

20 years Post CABG: Ostial RCA CTOWhat is the best strategy ?

Retrograde options are challenging

Moderate calcification -> medium-strengh wire

OPEN CTO Registry – High prevalence of CABG

Considerable Mortality

SafetyIn Hospital Frequency

Death 0.9%*

MI 2.4%

Emergent surgery 0.6%

Perforation 6.0%

Clinical perforation 4.9% (82%)

Bleeding Access 4.0%

Radiation injury 0.1%

30 Day Frequency

Death 1.3%

Rehospitalization 14.7%

Unplanned 12.1% (82%)

Revascularization 2.6%

Planned 2.6%

PCI 2.3%

CABG 0.3%

Skin change 3.1%

6 Month Frequency

Death 2.8%

Rehospitalization 32.65%

Skin change 3.4%

*STS risk estimate for OPEN patients 1.67%

Not Adjudicated

Be aware of perforations in post CABG patients

Deaths and Adverse EventsPatient In Hosp Perforation Periproc MI Post CABG

1 Yes Yes Yes Yes

2 Yes Yes Yes No

3 Yes Yes No No

4 Yes Yes No Yes

5 Yes Yes No No

6 Yes Yes No No

7 Yes Yes No Yes

8 Yes Yes No Yes

9 Yes Yes No Yes

5/9 deaths associated with perforation were in post CABG patients

similar mortality of perforation with and without prior CABG

(1.1% vs. 0.8%, p=0.62)

All 9 deaths were associated with a perforation

Sapontis et al. JACC CI. 2017;10(15):1523.

Conclusion: The post CABG patient with a CTO

• Post CABG patients with CTO are found in about 10-15% in Europe, >30% in US

• A post CABG patient is often more difficult to treat, especially if the CTO was preexistent

• The complication from a perforation during CTO PCI may be even higher than with non-CABG patients due to the restriction of the pericardium and difficulty to drain

Final thoughts

• Should we not stop referring non-proximal LAD CTOs to surgery ?

• We would minimize the problem of post CABG CTO PCI after graft failure

• And we could reserve non-LAD bypass surgery to failed CTO PCI cases with then an urge for an arterial revascularization

Final thoughts

• Should we not stop referring non-proximal LAD CTOs to surgery ?

• We would minimize the problem of post CABG CTO PCI after graft failure

• And we could reserve non-LAD bypass surgery to failed CTO PCI cases with then an urge for an arterial revascularization