CTO PCI in Post-CABG Patients

Dimitri Karmpaliotis, MD, PhD, FACC

Assistant Professor of Medicine

Columbia University Medical Center

Director of CTO, Complex and High Risk Angioplasty

CIVT/NYPH

Email: dk2787@columbia.edu

EURO CTO

Krakow, Poland, September 30-Oct 1, 2016

Disclosures

• As a faculty member for this program,

I disclose the following relationships

with industry:

• Speakers Bureau for Abbott Vascular,

MDT vascular, ASAHI Intel and Boston

Scientific

CTO PCI in post CABG Patients

• Despite declining rates of overall re-vascularization in

the U.S, more than 100,00 CABG operations are

performed every year

• 10,000 re-do CABG/year

• Hundreds of thousands of patients with

occluded/degenerated grafts and symptoms/ischemia

are under-treated

• CTO PCI is more technically challenging in post-

CABG patients

• Diffuse disease/Calcified vessels

• Progression of native vessel disease

• Distortion of anatomy due to vessel “tenting”

CABGn=266

Not Bypassed

n=81

ITT, Per Lesion

Bypassed

n=173

CABGn=254

12 were not treated with CABG

Overall 68.1 % of TO were

successfully bypassed

49.6% overall complete

revascularization in CTO subset

SYNTAX CTO Subset Procedural

Characteristics: Per Lesion Analysis

Serruys P, CRT 2009 [modified]; courtesy Prof Serruys and the SYNTAX investigators

• 26.2% patients with CTO

• CTO accounted for 266

lesions (7.4%)

Reason not bypassed:

Not intended to treat (n=12)

Diseased (n=11)

Inadequate conduit (n=2)

Too small (n=19)

Unable to find (n=1)

Other (n=36)

New CTOs After CABG Surgery338 patients with 1 yr angio in Radial Artery Patency Study (RAPS)

Pereg et al, JACC CV Intv 2014

169 pts (43.6%)

had at least 1 new

native CTO

CTOs were almost

5X more likely to

occur in vessel with

pre CABG visual

stenosis >90% and

bypassed by SVG

or radial graft

Drug-Eluting vs. Bare-Metal Stents in

Saphenous Vein Graft (SVG) Lesions

Conclusion: In high-risk SVG lesions, DES cut TLR rates almost in half, leading to an overall decrease in late outcomes.

ISAR-CABG: Randomized, superiority trial in 610 pts.

Mehilli J, et al. Lancet.

2011. Epub ahead of print.

DES reduced angiographic restenosis at 7 months (15% vs. 29%; P < 0.0001).

Author Year

N (CTO

lesions)

Prior

CABG Diabetes Retrograde

Technical

Success

Major

complicati

ons Death

Tampon

ade

Fluoroscopy

time

(minutes)

Contrast use,

(ml)

Rathore 2009 904 12.6 40.0 17 87.5 1.9 0.6 0.6 NR NR

Morino 2010 528 9.6 43.3 26 86.6 NR 0.4 0.4 45

(1-301)*

293

(53-1,097)*

Galassi 2011 1983 14.6 28.8 14 82.9 1.8 0.3 0.5 42.3±47.4 313 ±184

U.S

Registry*

2013 1361 37.0 40.0 3485.5

1.80.22 0.6 42±29 294 ±158

* Median (range)

Summary of Large Contemporary Registry Publications of

Percutaneous Coronary Interventions of Chronic Total Occlusions

* Tesfaldet, Karmpaliotis, Brilakis, Lembo,

Lombardi, Kandzari. Am J Cardiol 2013

Author Year n

Prior

CABG

(%)

Septal

collaterals

used (%)

Reverse

CART

(%)

Technical

Success

(%)

Major

complications

(%)

Fluoroscopy

time, min

Contrast

use, mL

Sianos 2008 175 10.9 79.4 NR 83.4 4.6 59 ± 29 421 ± 167

Rathore 2009 157 17.8 67.5 NR 84.7 4.5 NR NR

Kimura 2009 224 17.6 79 14 92.4 1.8 73 ± 42 457 ± 199

Tsuchikane 2010 93 10.8 82.8 60.9 98.9 0 60 ± 26 256 ± 169

Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR*

Karmpaliotis* 2012 462 50.0 71 41 81.4 2.661 ± 40 345 ± 177

Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari:

JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.

Retrograde Coronary Chronic Total Occlusion Revascularization:

Procedural and In-Hospital Procedural Outcomes from a Multicenter

Registry in the United States

Study Retrograde PCI,

n (%)

Primary

Retrograde, %*

Previous Failed

CTO PCI in

Retrograde

Group, %

Overall

Technical

Success in

Retrograde

Group, %†

MACE in

Retrograde

Group, %†

Kimura et al22 224 100 65 92 1.8

Galassi et al23 234 (12) 76 U 65 3.0

Karmpaliotis et

al12 462 (34) 46 18 81 2.6

Yamane et al24 378 (25) 75 32 84 0.5

Tsuchikane et

al25 801 (27) 67 29 85 1.6

Galassi et al7 1582 (16) 76 43 75 0.8

Karmpaliotis, et

al539 (41) 46 21 85 4.3

Circ Cardiovasc Interv. 2016;9:

Author Year

N

(CTO

lesions)

Prior

CABG,

(%)

Prior

CABG in

successful

PCI group

(%)

Prior

CABG in

unsuccessf

ul PCI

group (%)

Overall,

retrograde

(%)

Overall,

technical

Success

(%)

Overall,

major

comp-

lications

(%)

Overall,

fluoroscopy

time, min

Overall, contrast

use,

ml

Olivari 2003 376 5.0 4.5 6.9 NR 77.2 5.1 NR NR

Rathore 2009 904 12.6 11.9 17.7 17 87.5 1.9 NR NR

Morino 2010 528 9.6 NR NR 26 86.6 NR 45 (1-301)* 293 (53-1,097)‡

Mehran 2011 1791 15.9 13.6 20.9 NR 68.0 NR NR 448±229

Galassi 2011 1983 14.6 NR NR 14 82.9 1.8 42.3±47.4 313 ±184

Jones 2012 836 10.2 16.5 7.4 NR 69.6 2.3 NR NR

U.S

Registry*

2012 1363 37.0 35.0 50.8 3485.5

1.842±29 294 ±158

Summary of Large Contemporary CTO PCI Registry Publications that

Reported Outcomes for the Subgroup of Patients with Prior CABG

* Tesfaldet, Karmpaliotis, Brilakis, Lembo,

Lombardi, Kandzari. Am J Cardiol 2013

87.2

93.7

78.1

90.0

70

80

90

100

2006-2011 2012-2013

%

No prior CABG

Prior CABG

Pre “Hybrid” era

Michael, Karmpaliotis, Brilakis, Lombardi,

Kandzari et al. Heart 2013;99:1515-8

Δ=9.1%

P<0.001

Christopoulos, Menon, Karmpaliotis, Alaswad, Lombardi,

Grantham, Brilakis et al, AJC 2014;113-1990-4

CTO PCI: success and prior CABG

N= 1,363

3 US sites

Prior CABG: 37%

Complications: 1.5% vs. 2.1%

Retrograde: 27.1% vs. 46.7%

Δ=3.7%

P=0.092

“Hybrid” era

N= 630

6 US sites

Prior CABG: 37%

Complications: 2.5% vs. 0.8%

Retrograde: 34% vs. 39%

N= 21 - 4 US centers/14% OF RETROGRADE CASES)

The most common re-entry technique was rCART.

Technical success: 86%

Procedural success: 81%

Retrograde failure due to inability to wire the SVG or collaterals

Major complications: 2 patients (periprocedural MI, tamponade resulting in death)

Nguyen-Trong PKJ, Alaswad K, Karmpaliotis D, Lombardi W, Grantham J, Lembo N, Kandzari D, Karatasakis

A, Rangan B, Ayers CR, Thompson C, Banerjee S, Brilakis ES. J Invasive Cardiol. 2016 Jun;28:218-24

Native CTO PCI through retrograde SVG

PROspective Global REgiStry for the Study of CTO interventions

Case 1

Case 2

Case 3

Case 4

CTO PCI in post CABG Patients:

Conclusions

• Despite declining rates of overall re-vascularization in

the U.S, more than 100,00 CABG operations are

performed every year

• 10,000 re-do CABG/year

• Hundreds of thousands of patients with

occluded/degenerated grafts and symptoms/ischemia

are under-treated

• Re-Do CABG especially with patent LIMA is ill advised

• Great opportunity exists to benefit public health by

expanding CTO revascularization

Thank You

Thank You