The Detrimental Impact of Chronic Renal Insufficiency

David Antoniucci, MD

Madrid, September 25, 2014

Stenting in CTO

Disclosure Statement of Financial InterestI, David Antoniucci, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

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Large registries have shown a survival benefit in patients with successful CTO PCI. Intuitively, sustained vessel patency may be considered as a main variable related to long-term survival and stent performance plays a key role in this setting. Very few data exist about the angiographic outcome after successful CTO PCI.

Danzi GB et al, Am J Cardiol 2013

Florence CTO RegistryAngiographic OutcomeDesign: Prospective single-center registry of CTO- PCI treated with DES.

End points: Angiographic outcome. Predictors of reocclusion

Methods: Forward stepwise Logistic Regression Analysis. Freedom from MACE assessed by Kaplan-Meier estimation.

Successful CTO-PCI n=802 (77%)233 Fail CTO-PCI 6-9 months Angio FU (82%)n=61629 Deaths20 Renal InsufficiencyFrom 2003 to 2011 1035 pts underwent CTO-PCI Valenti R et al, JACC 2013;61:545

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n=802 Age (yrs)68 11> 75 years, n (%)233 (29) Male, n (%)680 (85) Hypertension, n(%)485 (60) Hypercholesterolemia, n (%)458 (57) Diabetes mellitus, n (%)200 (25) Previous myocardial infarction, n (%)405 (50) Previous PCI, n (%) 289 (36) Previous coronary surgery, n (%)91 (11) ACS, n (%)55 (32) LVEF, (%) 44 12LVEF < 40 %, n (%)298 (37)Baseline Characteristics in Successful CTO PCI PatientsValenti R et al, JACC 2013;61:545

n=802 Multivessel disease, n (%) 660 (82) 3-vessel disease, n (%)393 (49) CTO vessel, n (%) LAD248 (31) LCx177 (22) RCA329 (41) Others48 (6) Occlusion length, mm 38 21 Lenght > 20 mm, n (%)597 (74) Reference CTO vessel diameter, mm2.63 0.53 Ref. Diameter 2.5 mm, (%)190 (24)Angiographic CharacteristicsValenti R et al, JACC 2013;61:545

n=802 Adjunctive Rotactional atherectomy, n (%)37 (4.6) STAR technique, n (%) 34 (4.2) CTO stent implanted, n1509 Mean stents / patient1.88 First generation DES (PES and SES) 66% EES 34% CTO stent length, mm52 30 Post-PCI minimum lesion diameter, mm2.74 0.49 Fluoroscopic time, min Median [IQ range] 24 [15 36] Contrast, ml Median [IQ range] 300 [200 400] Multivessel PCI, n (%) 540 (67) Completeness of revascularization, n (%)675 (84)Procedural CharacteristicsValenti R et al, JACC 2013;61:545

6-9 months Angiographic OutcomeCTO Reocclusion

1st generation DES10%EES 3%STAR 57%% p=0.001

CTO Rest./Reoccl.

1st generation DES25%EES13%STAR64%F-U rate 82%Valenti R et al, JACC 2013;61:545

Predictors of Angiographic Outcome Logistic Regression AnalysisReocclusionOR95% CIp value STAR technique29.511.9-73.2< 0.001 EES0.220.09-0.54 0.001Nonocclusive Restenosis RCA-CTO1.641.02-2.62 0.040Valenti R et al, JACC 2013;61:545

Conclusions The use of EES is associated with a 5-fold decrease in CTO vessel reocclusion rate as compared to 1st generation sirolimus-eluting stent and paclitaxel-eluting stent.The use of the STAR technique, even successful, is associated with a very high rate of target vessel reocclusion. The use of EES and conventional antegrade or retrograde approaches to CTO are associated with a very high sustained patency rate that links with prognosis.

One-year Clinical OutcomeCTO vessel re-PCI

1st generation DES14.1%EES10.5%STAR 32%%MACE

1st generation DES19%EES11.6% p=0.005

Valenti R et al, JACC 2013;61:545

Predictors of Clinical Outcome Multivariate Cox Regression AnalysisCardiac DeathHR CI p value Age >75 yrs4.642.19-9.83< 0.001 LVEF < 40%7.252.77-1975 yrs1.641.17-2.310.004 STAR technique2.261.21-4.220.010 LVEF < 40%1.471.06-2.060.023 LAD-CTO1.421.02-2.010.046Valenti R et al, JACC 2013;61:545

60123624183010.90.80.70.60.50.4Time (months)Event Free Survival77 2%55 14%nonSTARSTARp = 0.014Kaplan-Meier Analysis of Freedom from MACEValenti R et al, JACC 2013;61:545