Transcript Organisation du service EuroPCR

CHRONIC TOTAL OCCLUSIONS:
WHAT IS KNOWN AND
WHAT IS UNKOWN
Giuseppe Biondi Zoccai
University of Turin, Turin, Italy
[email protected]
4th International Interventional Forum – Turin 26-27 February 2009
LEARNING OBJECTIVES
 What
is known

Prevalence of chronic total occlusions (CTO)

Pathophysiologic basis and clinical impact

Possible techniques
 What
is unknown

When is revascularization indicated?

If yes, which type of revascularization?

Which technique?

Which stent?
LEARNING OBJECTIVES
 What
is known

Prevalence of chronic total occlusions (CTO)

Pathophysiologic basis and clinical impact

Possible techniques
 What
is unknown

When is revascularization indicated?

If yes, which type of revascularization?

Which technique?

Which stent?
INCIDENCE AND IMPACT
CLUSTERING WITH
MULTIVESSEL DISEASE
LEARNING OBJECTIVES
 What
is known

Prevalence of chronic total occlusions (CTO)

Pathophysiologic basis and clinical impact

Possible techniques
 What
is unknown

When is revascularization indicated?

If yes, which type of revascularization?

Which technique?

Which stent?
CORONARY OCCLUSION AND
MYOCARDIAL APOPTOSIS
COLLATERALS MOST OFTEN FAIL TO
PREVENT SYMPTOMATIC ISCHEMIA
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0,00 0,09 0,13 0,16 0,17 0,21 0,25 0,28 0,31 0,34 0,36 0,38 0,40 0,42 0,43 0,47 0,69 1,00
FFRcoll
Moretti et al, J Cardiovasc Med 2008 – in press
PCI MAY PROVIDE CARDIAC
REMODELING BENEFITS
Before PCI for CTO
5 months after PCI for CTO
Baks et al, J Am Coll Cardiol 2006;47:721-725
LONG-TERM DATA FROM NONRANDOMIZED STUDIES SUPPORT
THE BENEFITS OF PCI FOR CTO
Suero et al, J Am Coll Cardiol 2001;38:409-14; Safley et al, J Am Coll Cardiol Intv 2008;1:295-302
LEARNING OBJECTIVES
 What
is known

Prevalence of chronic total occlusions (CTO)

Pathophysiologic basis and clinical impact

Possible techniques
 What
is unknown

When is revascularization indicated?

If yes, which type of revascularization?

Which technique?

Which stent?
POSSIBLE TECHNIQUES

Standard antegrade

Parallel wire

Drilling wire

Retrograde

CART

IVUS-guided puncture

Subintimal IVUS

STAR

Micro-channel injection
POSSIBLE DEVICES

Standard wires

Monorail or OTW balloon

Stent

CTO wires (eg Asahi’s, Shinobi)

Microcatheters

Tornus

Frontrunner

Crosser

Safecross
LEARNING OBJECTIVES
 What
is known

Prevalence of chronic total occlusions (CTO)

Pathophysiologic basis and clinical impact

Possible techniques
 What
is unknown

When is revascularization indicated?

If yes, which type of revascularization?

Which technique?

Which stent?
INTERVENTIONISTS’ NEW OATH:
I WILL NOT TREAT CTO
Hochman, New Engl J Med 2006;355:2395-2407
SHOULD THUS INTERVENTIONISTS
BE DISCOURAGED?
Boden et al, New Engl J Med 2007;356:1503-1516
IS ANY SYNTHESIS POSSIBLE?
Abbate et al, J Am Coll Cardiol 2008;51:956-64
IS ANY SYNTHESIS POSSIBLE?
Schomig et al, J Am Coll Cardiol 2008;52:894-904
LEARNING OBJECTIVES
 What
is known

Prevalence of chronic total occlusions (CTO)

Pathophysiologic basis and clinical impact

Possible techniques
 What
is unknown

When is revascularization indicated?

If yes, which type of revascularization?

Which technique?

Which stent?
A SYNTAX FOR EVIDENCE
Serruys et al, New Engl J Med 2009;360:961-72
LEARNING OBJECTIVES
 What
is known

Prevalence of chronic total occlusions (CTO)

Pathophysiologic basis and clinical impact

Possible techniques
 What
is unknown

When is revascularization indicated?

If yes, which type of revascularization?

Which technique?

Which stent?
BEGIN WITH A THOROUGH BUT
SIMPLE APPROACH, BUT BE
READY FOR ESCALATION
Dedicated CTO wires
Contralateral injection
Parallel wires
Drilling wire
Retrograde approach
CART
Microcatheter
Tornus
LEARNING OBJECTIVES
 What
is known

Prevalence of chronic total occlusions (CTO)

Pathophysiologic basis and clinical impact

Possible techniques
 What
is unknown

When is revascularization indicated?

If yes, which type of revascularization?

Which technique?

Which stent?
USE DES WHENEVER POSSIBLE,
BUT WHICH DES EXACTLY?
TAKE HOME MESSAGES
TAKE HOME MESSAGES

CTO are highly prevalent and have a significant clinical and
management impact

It is thus paramount to appropriately risk-stratify each patient
depending on his baseline and angiographic features, to clarify
the clinical indication for CTO recanalization

Several types of interventional techniques and devices are
currently available for CTOs

Improvements in stents (ie drug-elution), wires (ie dedicated
wire for CTOs) and ancillary devices (eg microcatheters)
together with new or refined techniques have improved acute
and long-term results of PCI for CTOs