Complex Coronary Cases

Supported by:

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Abbott Vascular

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Boston Scientific Corporation

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Medtronic, Inc.

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Astrazeneca

Disclosures

Samin K. Sharma, MBBS, FACC

Speaker’s Bureau – Boston Scientific Corporation, Abbott Vascular Inc, AngioScore, The Medicines Company, Daiichi Sankyo, Inc. and Lilly USA, LLC

Annapoorna S. Kini, MBBS, FACC

Nothing to disclose

Sameer Mehta, MBBS, FACC

Consulting Fees – The Medicines Company American College of Cardiology Foundation staff involved with this case have nothing to disclose

August 20th 2013 Case #14: SD, 62 yr M

Presentation: Patient with new onset cresendo angina and positive stress echo for infero-lateral ischemia underwent cardiac cath on June 26, 2013 which revealed 3 V CAD (60% prox LAD, 80% distal LCx and 100% distal RCA) and normal LV function; SYNTAX score 22. CABG was recommended but declined and pt underwent Resolute Integrity (3.5/30mm) DES PCI of distal LCx. Pt continued to have class II angina on MMT. Prior History: Hypertension, NIDDM, +F/H Medications: All once daily dosage Atenolol 50mg, Amlodipine 5mg, Aspirin 81mg, Prasugrel 5mg, Metformin XR 1000mg, Glimeperide 2mg, Omeprazole 20mg

Case# 14: cont…

Cardiac Cath 6/26/2013: Right Dominance 3 V CAD with LVEF 65% Left Main: No obstruction LAD: 60% prox LAD and 60% D1 non-bifurcation lesions LCx: 80% distal LCx, large vessel RCA: 80% mid and 100% distal RCA occlusion and distal vessel fills via bridge as well as retrograde collaterals Pt underwent successful DES PCI of distal LCx using 3.5/30mm Resolute Integrity DES. Pt did well but had class II angina despite MMT. Did not tolerate ISMN Plan Today: - PCI of distal RCA CTO using retrograde recanalization.

Appropriateness Criteria for Coronary Revascularization

Issues Involving The Case

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Current status of CTO lesion success

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Retrograde recanalization approach

Issues Involving The Case

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Current status of CTO lesion success

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Retrograde recanalization approach

Chronic Total Occlusion (CTO)

From Randomized Trials to Daily Practice

1. CTO is present in 20-22% of cath cases but PCI is attempted only in 5-13% of these cases 2. From BARI trial (1994) to SYNTAX trial (2007) , the single most common reason for a patient to be referred to surgery and not randomized was a CTO with low success rate of recanalization 3. Even in the recent era of increasing success rate of CTO recanalization (60-85%), the PCI success rate for CTO lesions in the SYNTAX trial was only 53%

Current Perspective on Coronary CTO

The Canadian Multicenter CTO Registry

Management of CTO Registry Patients by Treating Center Fefer et al, J Am Coll Cardiol 2012;59:991

Anatomic Descriptors of Procedural Success In the current ERA; Severe calcification

Predictors of CTO Procedural Success

Multivariate analysis from TOAST-GISE Variables Length ≥15 vs. <8 mm Severe calcification Duration ≥ 180 days Multi-vessel disease Bridge collaterals present Stump morphology Hazard Ratio 3.9

3.5

3.1

2.3

2.2

p

0.028

0.023

0.013

0.009

0.023

2.2

0.048

Olivari et al., J Am Cardiol Coll 2003;41:1672

Incidence of Procedural Complications in Successful vs. Unsuccessful CTO PCI

Complications MACE (%) Death (%) Emergent CABG (%) Stroke (%) MI (%) Q-wave MI (%) Coronary perforation (%) Tamponade (%) Vascular complication (%) Contrast nephropathy (%) Successful 3.7

0.4

0.03

0.07

2.8

0.3

3.7

0.0

1.7

5.0

Unsuccessful 4.3

1.5

0.17

0.4

3.0

0.5

10.7

1.7

0.9

4.6

p value 0.68

<0.0001

0.74

0.04

0.87

0.26

<0.0001

<0.0001

0.20

0.86

Patel et al., JACC Cardiovasc Interv 2013;6:128

Temporal Trends in Cumulative Angiographic Success Rates and Major Procedural Complication Rates 80% 0.5%

Patel et al., JACC Cardiovasc Interv 2013;6:128

Meta-Analysis of CTO Outcomes

13 Observational Studies, 7288 patients weighted averaged follow-up 6 years Mortality MI Subsequent CABG Residual Angina OR for Success vs. Failure 0.56

0.74

0.22

0.45

95% Cl 0.43-0.72

0.44-1.25

0.17-0.27

0.30-0.67

p Value <0.001

0.26

<0.001

0.001

Joyal et al., Am Heart J 2010;160:179.

All-Cause Mortality for Successful and Failed Groups of CTO Duration >3 Months

Khan et al., Cath & Cardiovasc Intervn 2013;82:95

25 20 15 10 5 Residual SYNTAX Score: 1-Year Outcomes According to the rSS rSS = 0 P = 0.006

22,4 rSS = 0-2 rSS = 3-8 rSS = >8 20 16,3 18 P =0.32

P = 0.007

P = 0.001

9,7 10,4 12 12,6 13,1 10,9 11,1 P = 0.23

7,1 1,4 2,8 2,1 4,8 1 1,6 1,6 2,5 0 MACE Death MI Stent Thrombosis uTVR

Généreux et al., JACC2012;59:2165

PCI: Four-Year Clinical Outcomes in Patients by Complete vs. Incomplete Revascularization Complete Revascularization (n=578) Incomplete Revascularization (n=510) p=<0.001

p=0.011

p=0.052

p=0.059

p=0.23

p=0.046

Farooq et . al., J Am Coll Cardiol 2013;61:282

Total Charges, Payments and Direct Costs per Patient Undergoing CTO and Non-CTO PCI p=<0.001

CTO (n=154) Non-CTO (n=1,847) p=<0.001

p=0.58

Karmpaliotis et al., Cath & Cardiovasc Interv 2013;82:1

Issues Involving The Case

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Current status of CTO lesion success

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Retrograde recanalization approach

Retrograde Wire Technique of CTO Recanalization

Retrograde Techniques for CTO Recanalization

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Typically reserved for LAD or RCA CTOs via septal collaterals; avoid using epicardial collaterals

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Four techniques:

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Direct retrograde crossing

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Kissing wire crossing

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Controlled Antegrade and Retrograde Subintimal Tracking (CART); balloon dilatation or knuckle wire

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Reverse CART

Retrograde Wire Technique for Chronic Total Occlusion Recanalization Four Patterns of Success in Retrograde CTO Recanalization

Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.

% Increased Use of Retrograde Approach and Technical Success Rate Over Time 2006 2007 2008 2009 2010 2011 30%

Michael et al., Am J Cardiol 2013;112:488

Summary of Published Retrograde CTO PCI Series Study Sianos Rathore Kimura Tsuchikane Year N Prior CABG % Septal Collateral Used % Reverse CART, % Technical Success % Major Complic % Flouroscopy Time, min, mean ± SD Contrast Use, ml mean ± SD 2008 2009 2009 2010 175 157 224 93 10.9

17.8

17.6

10.8

Morino 2010 136 9.6

US Registry 2012 462 50.0

79.4

67.5

79.0

82.8

63.9

71.0

NR NR 14.0

60.9

NR 41.0

83.4

84.7

92.4

98.9

79.2

81.4

4.6

4.5

1.8

0.0

NR 2.6

59 ± 29 NR 73 ± 42 60 ± 26 NR 61 ± 421 ± 167 NR 457 ± 199 256 ± 169 NR 345 ± 177

Karmpaliotis et al., JACC Cardio Interv 2012;5:1273

Retrograde PCI: 5 Steps

Retrograde PCI for recanalization of CTOs has gained acceptance as a necessary technique to improve success

The procedure involves five key steps:

1. Wiring of the collateral from the donor artery into the distal bed of the recipient artery, usually with the use of hydrophilic jacketed guidewires 2. Delivery of over-the-wire microcatheters especially Corsair channel dilator to allow an exchange for a CTO-specific guidewire 3. Crossing the total occlusion with the CTO guidewire and dilating the CTO with the retrograde small balloon (1.25-1.5/8-10mmsize) 4. Placing an antegrade guidewire into the distal bed through the recanalized CTO. Rarely exteriorization of the long retrograde guidewire (Viper wire 360cm) is needed to advance antegrade monorail or over-the-wire small balloon 5. Stenting the lesion over the antegrade guidewire

Retrograde Wire Technique for CTO Recanalization

When to do Retrograde technique?

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Minimum 200 CTO cases via antegrade technique

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Dedicated setup, equipments and ability to handle compl.

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Usually after failed antegrade (once or twice) approach

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Ostial stump occlusion (RCA, LAD, LCx)

Fundamental Wire Technique and Current Strategy for Chronic Total Occlusion PCI

Procedural Steps of Current CTO-PCI

CTO - PCI

Cotralateral Dual Injection Single Wire Technique Antegrade approach x2 Parallel Wire Technique Retrograde approach (ostial) Retrograde Wire Cross Kissing Wire Cross IVUS guide re-entry CART Reverse CART Success Failure

Take Home Message: Status of CTO lesion PCI and Retrograde recanalization approach

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Improvement in the procedural techniques and devices has resulted in increasing success of CTO PCI. A successful CTO PCI is associated with better long-term outcome, decreased cost & lower mortality.

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Technique of retrograde recanalization is gaining increasing momentum and adds to the already increasing technical success rates. Every advanced CTO PCI center should dedicated experienced operators for the retrograde approach.

Question # 1

Which one of the angiographic lesion morphology is associated with the highest rates of unsuccessful CTO recanalization : A. Blunt stump B. Side branch at the site of occlusion C. Short occlusion length D. Severe calcification E. Bridge collaterals

Question # 2

A successful CTO recanalization is associated with following except : A. Lower MACE B. Lower mortality C. Lower stent thrombosis D. Lower incidence of long-term CABG E. Lower angina

Question # 3

Following are the techniques for retrograde recanalization except : A. Kissing wire approach

B.

Retrograde wire cross C. Controlled antegrade and retrograde tracking (CART) D. Reverse CART E. Parallel wire technique

Question # 1

Which one of the angiographic lesion morphology is associated with the highest rates of unsuccessful CTO recanalization : A. Blunt stump B. Side branch at the site of occlusion C. Short occlusion length D. Severe calcification E. Bridge collaterals The correct answer is D as of these unfavorable factors severe calcification still is associated with highest failure Olivari et al., J Am Cardiol Coll 2003;41:1672.

Question # 2

A successful CTO recanalization is associated with following except : A. Lower MACE B. Lower mortality C. Lower stent thrombosis D. Lower incidence of long-term CABG E. Lower angina The correct answer is C as stent thrombosis may even be higher in successful vs. unsuccessful CTO recanalization Joyal et al., Am Heart J 2010;160:179.

Question # 3

Following are the techniques for retrograde recanalization except : A. Kissing wire approach

B.

Retrograde wire cross C. Controlled antegrade and retrograde tracking (CART) D. Reverse CART E. Parallel wire technique The correct answer is E as all others are the techniques of retrograde CTO recanalization while the parallel wire technique is for antegrade recanalization Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.