◆ 12/2/17 Disclosures Research Support: Siemens Medical Systems, Svelte, PCI of Chronic Total Cardiovascular Systems Inc. Occlusion: Is It Helpful? Consulting: Terumo, TransAortic Medical, Medeon Bio Kendrick Shunk, MD PhD Director, Interventional Cardiology SFVA Professor of Clinical Medicine, UCSF CTO PCI ■ Perception of higher level of ◆ Difficulty ✦ Time ✦ Radiation ✦ Contrast ◆ Risk (MACE and procedural success) ◆ Benefit! ✦ ORBITA Controversy: NYT Nov2, 2017 ‘Unbelievable’: Heart Stents Fail to Ease Chest Pain Moving Target! ■ ◆ 1
◆ 12/2/17 Pt presentation ■ 67 yo male Veteran, DM, HTN, HL ◆ Prior CABG 2004 ✦ LIMA->LAD ✦ SVG->OM ✦ SVG->RCA ◆ Cath 2013 for angina Pt presentation Pt presentation ■ 67 yo male Veteran, DM, ■ 67 yo male Veteran, DM, HTN, HL HTN, HL ◆ Prior CABG 2004 ◆ Prior CABG 2004 ✦ LIMA->LAD (patent) ✦ LIMA->LAD (patent) ✦ SVG->OM (occluded) ✦ SVG->OM (occluded) ✦ SVG->RCA (occluded) ✦ SVG->RCA (occluded) ◆ Cath 2013 for angina ◆ Cath 2013 for angina ✦ PCI native OM ✦ OMT for CTO of native RCA ◆ 2
◆ 12/2/17 Pt presentation Pt presentation ■ 67 yo male Veteran, DM, ■ 67 yo male Veteran, DM, HTN, HL HTN, HL ◆ Prior CABG 2004 ◆ Prior CABG 2004 ✦ LIMA->LAD ✦ LIMA->LAD ✦ SVG->OM ✦ SVG->OM ✦ SVG->RCA ✦ SVG->RCA ◆ PCI of native Cx/OM 2013 with DES ◆ PCI of native Cx/OM 2013 with DES ◆ Persistent Sx despite OMT Pt presentation ■ 67 yo male Veteran, DM, HTN, HL ◆ Prior CABG 2004 ✦ LIMA->LAD ✦ SVG->OM ✦ SVG->RCA ◆ PCI of native Cx/OM 2013 with DES ◆ Persistent Sx despite OMT ◆ Referred for PCI of RCA CTO ◆ 3
◆ 12/2/17 “H “Heads y you g get C CTO P PCI, Ta Tails yo you take ke a baby y aspirin” n” ◆ Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. Main Findings: NCDR Of 594,510 PCI performed between 2009 ■ and 2013 ◆ 3.8% were CTO PCI ◆ Success: ✦ Non-CTO: 96% ✦ CTO: 59% ◆ MACE ✦ Non-CTO: 0.8% ✦ CTO: 1.6% ◆ Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. ◆ 4
◆ 12/2/17 ◆ Success and MACE rates over time ◆ Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. ◆ Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. Success and MACE as a function of CTO Volume ◆ Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. ◆ Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. ◆ 5
◆ 12/2/17 Pt presentation ■ 67 yo male Veteran, DM, HTN, HL ◆ Prior CABG 2004 ✦ LIMA->LAD ✦ SVG->OM ✦ SVG->RCA ◆ PCI of native Cx/OM 2013 with DES ◆ Persistent Sx despite OMT ◆ Referred for PCI of RCA CTO ◆ Brilakis et al, CTO Interventions in the NCDR, JACC: CI 8(2): 2015. ◆ CTO Procedure Dual Injections RAO • Bilateral Femoral access • RCA: 8F 90cm AL1 + GL • LM: 6F EBU3.5 • NATO algorithm /Hybrid approach • Initial AWE 135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL) • Poor re-entry zone for ADR • CC 0 septal collaterals 150 Corsair/Sion via SP1 to PDA • Guideliner reverse CART Externalized wire, balloon, 3 successful stents • TIMI III antegrade flow • IVUS ◆ 6
◆ 12/2/17 ◆ CTO Procedure AWE • Bilateral Femoral access • RCA: 8F 90cm AL1 + GL • LM: 6F EBU3.5 • NATO algorithm /Hybrid approach Algorithm nodes • Initial AWE 135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL) • Poor re-entry zone for ADR • CC 0 septal collaterals 150 Corsair/Sion via SP1 to PDA • Guideliner reverse CART Externalized wire, balloon, 3 successful stents • TIMI III antegrade flow • IVUS • To Recovery 12:40pm ◆ CTO Procedure Septal Surfing to PDA • Bilateral Femoral access • RCA: 8F 90cm AL1 + GL • LM: 6F EBU3.5 • NATO algorithm /Hybrid approach Algorithm nodes • Initial AWE 135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL) • Poor re-entry zone for ADR • CC 0 septal collaterals 150 Corsair/Sion via SP1 to PDA • Guideliner reverse CART Externalized wire, balloon, 3 successful stents • TIMI III antegrade flow • IVUS • To Recovery 12:40pm ◆ 7
◆ 12/2/17 Redirecting wire Adjacent wires ReverseCART LCA Corsair into RCA GC ◆ 8
◆ 12/2/17 ◆ CTO Procedure Positioning stent #1 • Bilateral Femoral access • RCA: 8F 90cm AL1 + GL • LM: 6F EBU3.5 • NATO algorithm /Hybrid approach Algorithm nodes • Initial AWE 135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL) • Poor re-entry zone for ADR • CC 0 septal collaterals 150 Corsair/Sion via SP1 to PDA • Guideliner reverse CART Externalized wire, balloon, 3 successful stents • TIMI III antegrade flow • IVUS • To Recovery 12:40pm Final LAO/Cranial Final RAO ◆ 9
◆ 12/2/17 ◆ CTO Procedure • Bilateral Femoral access • RCA: 8F 90cm AL1 + GL • LM: 6F EBU3.5 • NATO algorithm /Hybrid approach Algorithm nodes • Initial AWE 135cm Corsair, FXT, P200, CP12 to distal subintimal space (no DTL) • Poor re-entry zone for ADR • CC 0 septal collaterals 150 Corsair/Sion via SP1 to PDA • Guideliner reverse CART Externalized wire, balloon, 3 successful stents • TIMI III antegrade flow Eur Heart J. 2015;37(35):2692-2700 • IVUS • To Recovery 12:40pm CTO Appropriateness Summary I CTO Appropriateness Summary II ■ CTO are commonly seen on coronary ■ Revascularization modality and angiography. risk/benefit must be individualized. (elderly, comorbidities, post CABG, ■ European and American guidelines: impaired EF, operator’s experience.) Class IIa (Level B) for CTO PCI. ■ CTO PCI should be performed by ■ QOL is an important measure of expert operators in labs equipped for utility: significant improvement in management of potential physical limitation, anginal episodes, complications. and treatment satisfaction in successful versus failed CTO PCI ■ Current Guidelines do not address patients. discordance of recommendations for CTO vs non-CTO PCI with respect to operator expertise or outcomes. ◆ 10
◆ 12/2/17 Thank you. Questions? ◆ 11
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