Total Occlusions PCI for Chronic Cardiovascular Research Foundation - PDF document

ANGIOPLASTY SUMMIT Total Occlusions PCI for Chronic Cardiovascular Research Foundation

Chronic Total Occlusions 20- -40% 40% of patients with CAD of patients with CAD 20 Why should we open ? Why should we open ? ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Rationale for CTO Revascularization Rationale for CTO Revascularization • Relief of symtomatic ischemia and angina • Increase long-term survival • Improve left ventricular function • Reduced predisposition to arrhythmic events • Improved tolerance of contralateral coronary occlusion ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

12-Month Clinical Outcome of PCI in CTO TOAST-GISE 25 25 % N=390, Success 73.3% 20 15.7 Success 15 11.3 No success 10 7.2 5 2.5 1.1 0 Death & MI CABG angina Olivari Z, et al. JACC 2003; 41:1672-1678 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Long-term Survival Success vs. Failure Trial Number of Success Duration of Mortality(%) Patients(n) (n) follow-up(y) Success failure P V alue British Columbia 1458 1118(74.4%) 1 10.0 19.0 <0.001 Cardiac Registry 1 2007 1491(76.7%) 10 26.6 35.0 0.001 Suero et al. 2 369 286(77.5%) 6 1.1 3.6 0.13 TOAST-GISE 3 1 Kandzari, et al. TCT 2003 2 Suero, et al. JACC 2001;38:409-414 3 Olivari Z, et al. JACC 2003; 41:1672-1678 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Reopening of CTO 20 Years Experience 100 P = 0.005 90 Percent surviving 80 73.5% 70 CTO-Success CTO-Failure 65% 60 50 0 2 4 6 8 10 Years Suero, et al. JACC 2001;38:409-414 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Effect on LV function PCI in CTO improves LV function Pre 89 (%) 6 Mo Post 82 *P < 0.05 57 49 46 35 19 14 LV EDVI ESVI EF PCWP Van Belle E, et al. AJC 1997;80:1150-1154 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Issues in CTO Intervention Issues in CTO Intervention • Very dangerous • Low procedural success • High restenosis rate ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Issues in CTO Intervention Issues in CTO Intervention • Very dangerous • Low procedural success • High restenosis rate ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Possibility of High Complication • Impairment of collateral flow - spasm, shearing off side-branches and collateral by dissection, distal embolization • Retrograde dissection with branch occlusion Perforation - intra-wall balloon expansion, side-branch dilatation, damage of neochannels connecting vasa vasorum • Guidewire entrapment • Subacute vessel reocclusion - 8% of total occlusion within 24hr Vs. 1.8% of non total occluson • Extensive contrast use and fluoresence time ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

In-Hospital Major Complication Not dangerous ! 4 CTO (n=2007) vs. Non-CTO (n=2007) % All p=NS 3 Non-CTO CTO 2 1 0 Death Q-MI Non-Q Urgent Urgent MACE MI CABG PCI Suero JA, et al. JACC 2001;38:409-414 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Issues in CTO Intervention Issues in CTO Intervention • Very dangerous • Low procedural success • High restenosis rate ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Reasons for PCI failure in CTO • Passage failure of guidewire 63% • Long intimal dissection 24% • Dye extravasation 11% • Balloon did not cross or dilate 2% • thrombus 1.2% Kinoshita I, et al. JACC 1995;26:409-411 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Predictors of Predictors of Procedural Success Procedural Success • Duration of occlusion • Length of occluded lesion • Presence of a non-tapered stump • Origin of a side branch at occlusion site • Vessel and lesion tortuosity and calcification • Absence of antegrade flow • Ostial occlusion • Bridging collateral ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Predictors of Predictors of Procedural Success Procedural Success Multivariate analysis from TOAST-GISE Hazard Variables P value Ratio Length ≥ 15 Vs. <8 mm 3.9 0.028 Length not measurable Vs. <8 mm 3.8 0.019 3.5 0.023 Moderate to severe calcification Duration ≥ 180 days 3.1 0.013 Multivessel disease 2.3 0.009 Stump morphology not discernable 2.2 0.048 Olivari z, et al. JACC 2003;41:1672-1678 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Procedural Success Procedural Success Favorable Unfavorable Tapered stump Stump absent Functional occlusion Total occlusion Pre or post occlusion Side branch(+) Bridging collateral (-) Bridging collateral (+) ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

How to improve procedural How to improve procedural success ? success ? • Better guiding support • Smart guidewire • New device • Technical advancement ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Improved Success Rate Improved Success Rate We can improve ! We can improve ! 100 % 1039 lesions, 934 patients P=0.029 90 87.7 P<0.001 81.0 Double wire 80 technique New guidewire: 70 Conquest etc 67.9 64.6 Stepwise guidewire technique 60 No tapered tip 50 1995-1996 -1998 -2001 -2004 Hiroyuki tanaka, et al. ACC 2005 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

How to improve procedural How to improve procedural success ? success ? • Better guiding support • Smart guidewire • New device • Technical advancement ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Guiding Catheter for RCA Guiding Catheter for RCA ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Two Guiding Catheter for RCA Guiding Catheter for RCA Two ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Guiding Catheter for LCA Guiding Catheter for LCA ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Position of Support Catheter Position of Support Catheter ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

How to improve procedural How to improve procedural success ? success ? • Better guiding support • Smart guidewire • New device • Technical advancement ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

New Technologies for CTO • Dedicated guidewires - Hydrophilic guidewire - Tapered-tip guidewire: Cross-IT, Conquest, Miracle - Guidewire manipulation by microchannel guidance - Re-entry technique • New devices - FrontRunner TM Catheter - OCR SafeSteer TM System - Flow Cardia Crosser TM System • Biological approach - Prolonged urokinase/tPA infusion - Collagenase plaque digestion ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Ability to Cross CTO Hydrophilic- -coated coated Guidewire Guidewire Hydrophilic Conventional Crosswire P (n=46) (n=42) 0.001 1 st GW success(%) 35 74 0.009 Crossover(%) 26 59 <0.001 GW success 0 37 after crossover(%) <0.001 1.3 ± 0.5 1.7 ± 0.6 Total GW No. 0.013 42 ± 20 84 ± 33 Procedure(min) Lefevre et al, Am J Cardiol 2000;85:1144-7 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Ability to Cross CTO Tapered guidewire guidewire Tapered • Technical success: 76% • Success rate in visible microchannel - incomplete micro-channel: 81% - micro-channels with distal filling: 100% Buettner HJ, et al. JACC 2002;39:30A ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

New CTO Wires for CTO Lesions • Miracle 12g is more controllable to penetrate proximal cap, to advance in the tight CTO with bending, to puncture from pseudo to true lumen. • Conquest should be used only when the appropriate direction can be seen to penetrate distal cap, to puncture from pseudo to true lumen. • Conquest should not be used to seek the true lumen or advance for long distance. ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

Special Device for CTO recanalization • Failed special device - Magum/Magnarail system - Kensey Catheter - ROTACS Low Speed Rotational Atherectomy Catheter - Excimer Laser Wire • CTO device in current use - OCR SafeSteer TM System (Optical Coherence Reflectometry) - FrontRunner TM Catheter - Flow Cardia Crosser System ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

OCR SafeSteer System OCR SafeSteer System • Forward looking guidance system , using OCR to determine tissue types (plaque vs arterial wall). • Designed to navigate through total occlusion. ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

OCR SafeSteer System OCR Waveform Displays OCR Waveform Displays ANGIOPLASTY SUMMIT Cardiovascular Research Foundation

GREAT Registry 116 Lesions 21 centers with CTO “failure to cross” median occlusion duration: 22montths Median lesion length: 25mm(>30mm long in 25%) • Device Success 63(54.3%) • Complication MACE 8 (6.9%) -Non-Q MI 5 (5.2%) Clinical perforation 3 (2.6%) - Device related 1 (0.9%) Baim DS et al. Am J Cardiol 2004;94:853-858 ANGIOPLASTY SUMMIT Cardiovascular Research Foundation