Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany BSIC, Manchester, September 15, 2006.

Gerald S. Werner, MD, FESC, FACC

Klinikum Darmstadt, Germany

BSIC, Manchester, September 15, 2006

Chronic total occlusions updateChronic total occlusions update

A European perspectiveA European perspective

Chronic total occlusions updateChronic total occlusions update

A European perspectiveA European perspective

Gerald S. Werner, MD, FESC, FACC

Klinikum Darmstadt, Germany

BSIC, Manchester, September 15, 2006

CTO – The European perspectiveCTO – The European perspectiveCTO – The European perspectiveCTO – The European perspective

• What you may want to know about collaterals

• Why should we open a CTO ?

• The past and presence of CTO treatment

• CTOs in the DES era

• The remaining challenges in CTOs

Pathophysiology of collaterals in CTOsPathophysiology of collaterals in CTOsPathophysiology of collaterals in CTOsPathophysiology of collaterals in CTOs

• How to assess collaterals ?

• What happens to collaterals after PCI ?

• Can collaterals replace an open artery ?

Assessment of collaterals: pressure Assessment of collaterals: pressure andand flow flowAssessment of collaterals: pressure Assessment of collaterals: pressure andand flow flow

P A o

P O ccl APV O ccl

R C o ll

R P

P A o

P O ccl APV O ccl

R C o llP ressure/D oppler W ire

P ressure/D oppler W ire

Before recanalization R eocclusion after PTC A

TC O Balloon

RA RA

R P

Baseline collateral function

P A o

P O ccl APV O ccl

R C o ll

R P

P A o

P O ccl APV O ccl

R C o llP ressure/D oppler W ire

P ressure/D oppler W ire

Before recanalization R eocclusion after PTC A

TC O Balloon

RA RA

R P

Recruitable collateral function

Werner et al. Circulation 2001;104:2784-90

Collateral function in CTOsCollateral function in CTOsCollateral function in CTOsCollateral function in CTOs

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,70

5

10

15

20N

um

ber

of patie

nts

Collateral pressure index

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,70

5

10

15

20

Num

ber

of patie

nts


79%79% 46%46%


Before PCI After PCI

Loss of collateral function not due to Loss of collateral function not due to embolizationembolization

Loss of collateral function not due to Loss of collateral function not due to embolizationembolization

0 25 50 75

Rcoll [mmHg/(cm*sec)]

0,0

0,5

1,0

1,5

2,0

max

imal

e C

K [

µm

ol/(

L*s

ec)]

R-Quadrat = 0,01

Bahrmann et al. Z Kardiol 2002;91:937-945

Collateral function in CTOsCollateral function in CTOsCollateral function in CTOsCollateral function in CTOs

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,70

5

10

15

20N

um

ber

of patie

nts


0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,70

5

10

15

20

Num

ber

of patie

nts


79%79% 46%46%

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,70

5

10

15

20

Num

ber

of patie

nts


18%18%



6 mo FUP

Evidence for preformed collaterals in manEvidence for preformed collaterals in manEvidence for preformed collaterals in manEvidence for preformed collaterals in man

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,70

5

10

15

20N

um

ber

of patie

nts


0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,70

5

10

15

20

Num

ber

of patie

nts


79%79% 46%46%

0,0 0,1 0,2 0,3 0,4 0,5 0,6 0,70

5

10

15

20

Num

ber

of patie

nts


18%18%

20%20%

Wustmann et al. Circulation 2003;107:2213-20 Werner et al. Circulation 2003;108:2877-82


6 mo FUP

Can good collaterals replace an open artery Can good collaterals replace an open artery ??


Collateral function assessed as collateral flow reserveIn 98 Pat. with CTO during adenosine stress

Adapted from Werner et al. JACC 2006;48:51-8



95% of collaterals are no substitute for the open artery

CTOs – Should we treat them all ?CTOs – Should we treat them all ?CTOs – Should we treat them all ?CTOs – Should we treat them all ?

• Improvement of symptoms (angina, dyspnea)

• Improvement of LV function

• Improvement of prognosis

Benefit of recanalisation on LV functionBenefit of recanalisation on LV functionBenefit of recanalisation on LV functionBenefit of recanalisation on LV function

Werner et al. Am Heart J 2005;149:129-37

No improvement in case ofReocclusion !!!

Indication for revascularization: MRI Indication for revascularization: MRI function and vitalityfunction and vitality

Indication for revascularization: MRI Indication for revascularization: MRI function and vitalityfunction and vitality

LV recovery after recanalization of CTOs - LV recovery after recanalization of CTOs - MRIMRI

LV recovery after recanalization of CTOs - LV recovery after recanalization of CTOs - MRIMRI

Baks T et al. JACC 2006;47:721-5

PCI success and PCI success and survivalsurvival

PCI success and PCI success and survivalsurvival

Suero et al. JACC 2001;38:409-14

Ramanathan & Buller, ACC 2003

2000 Pat, 74% successful

1458 Pat, 77% successful

871 Pat, 65% successfulHoye et al. Eur Heart J 2005;26:2630-6

If PCI fails … at least consider CABGIf PCI fails … at least consider CABGIf PCI fails … at least consider CABGIf PCI fails … at least consider CABG

Suero et al. JACC 2001;38:409-14

But CABG seems to be only the second best option

A CTO left occluded makes life more A CTO left occluded makes life more dangerousdangerous

A CTO left occluded makes life more A CTO left occluded makes life more dangerousdangerous

Leaving a CTO alone means taking risks in low Leaving a CTO alone means taking risks in low risk patientsrisk patients

Leaving a CTO alone means taking risks in low Leaving a CTO alone means taking risks in low risk patientsrisk patients

0

1

2

3

4

5

6

7

8

PeriproceduralMACE

Death within 12months

CTO (n=122)Non-CTO (n=88)No PCI (n=451)

STAR Registry, Institute for infarct research, Ludwigshafen

PCI of

CTOs in the cathlab routine in 2003CTOs in the cathlab routine in 2003CTOs in the cathlab routine in 2003CTOs in the cathlab routine in 2003

• In a German registry (STAR – Stable Angina pectoris Registry - IHF, Ludwigshafen) 2002 consecutive diagnostic angiographies were evaluated:• 33% had at least one CTO• CTO pts had more severe symptoms, and LV

dysfunction• the 1-year mortality with CTOs was 5.5% vs. 3.1%

• Only one third of CTOs underwent PCI• Half of all CTOs were referred to CABG

Why bother, you can‘t open it … most timesWhy bother, you can‘t open it … most timesCTO success rates – historical perspectiveCTO success rates – historical perspective

Why bother, you can‘t open it … most timesWhy bother, you can‘t open it … most timesCTO success rates – historical perspectiveCTO success rates – historical perspective

Why bother with PCI – you can‘t keep it Why bother with PCI – you can‘t keep it open anyhowopen anyhow

Binary angiographic restenosis with balloon vs BMSBinary angiographic restenosis with balloon vs BMS

Why bother with PCI – you can‘t keep it Why bother with PCI – you can‘t keep it open anyhowopen anyhow

Binary angiographic restenosis with balloon vs BMSBinary angiographic restenosis with balloon vs BMS

Woehrle CTO Workshop Munich 2005

Stenting in CTOs: long and multiple stents Stenting in CTOs: long and multiple stents requiredrequired

Stenting in CTOs: long and multiple stents Stenting in CTOs: long and multiple stents requiredrequired

Werner et al. J Am Coll Cardiol 2003;42:219-25

1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tient

s [%

]

Number of implanted stents

No TVF Restenosis Reocclusion

1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tient

s [%

]



1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tient

s [%

]



1 2 >20

10

20

30

40

50

60

70

80

90

100

4

11

9

17

5

10

61628

Pa

tient

s [%

]



Published studies using DES in CTOsPublished studies using DES in CTOsPublished studies using DES in CTOsPublished studies using DES in CTOs

Hoye Ge Nakamura Prison II PACTO

Stent Cypher Cypher Cypher Cypher Taxus

Patients 56 122 60 100 95

Reference diameter [mm] 2.35 2.67 3.12 3.38 2.65

Stent length 24 42 36.5 32 40

Stents per lesion 2.0 1.4 1.4 ? 1.4 1.7

TVF 9 % 9 % 3 % 8 % 10 %

Reocclusion 3 % 2.5 % 0 % 4 % 1 %

Follow-up 59 % 83 % 75 % 94 % 100 %

Events in PRISON II: BMS vs. CypherEvents in PRISON II: BMS vs. CypherEvents in PRISON II: BMS vs. CypherEvents in PRISON II: BMS vs. Cypher

Suttorp et al. TCT 2005

30 90 1500 60 120 210180 240 270

Days Since Index Procedure

300 330 360

100%

90%

80%

70%

Fre

edom

of

TLR

TAXUS MRControl

9 mos. 12 mos.

P=0.0003

91.3 %

79.4 %

Control=bare metal stent

TAXUS= TAXUSTM stent

TAXUSTM MR stent is not available for sale

CTO vs. Complex Nonocclusive Lesions CTO vs. Complex Nonocclusive Lesions (Taxus VI)(Taxus VI)

CTO vs. Complex Nonocclusive Lesions CTO vs. Complex Nonocclusive Lesions (Taxus VI)(Taxus VI)

12%NNT 8

Werner et al. J Am Coll Cardiol 2004;44:2301-6

35%NNT 3

Long stenting no longer a problem for Long stenting no longer a problem for recurrencerecurrence

Long stenting no longer a problem for Long stenting no longer a problem for recurrencerecurrence

2.75x32

3.0x32

3.0x28

3.0x323.5x8

2214/05 471/05

6 months later

Taxus restenosis in CTOs: focalTaxus restenosis in CTOs: focalTaxus restenosis in CTOs: focalTaxus restenosis in CTOs: focal

All nonocclusive restenosis were focal at the edges andsuccessfully treated with another Taxus stent ->99 % patency

95 pts

85 pts.No TVF

10 pts.TVF

93 pts.

9 pts.Repeat PCI

6 months

1 pt. Reoccl.No PCI

9 pts. *)No TVF12 months

1 pt. LateReoccl.

Longterm patencyLongterm patencyLongterm patencyLongterm patency

Werner GS et al; ACC 2006

0

2

4

6

8

10

12

Overall Cardiac Death

TLRMI

1.7% n=1

1.7%n=1

6.7%n=4

Inci

den

ce

(%

)

N = 65/778 Patients

WISDOM 12-Month TAXUS Related WISDOM 12-Month TAXUS Related Cardiac Events: Total OcclusionsCardiac Events: Total Occlusions

WISDOM 12-Month TAXUS Related WISDOM 12-Month TAXUS Related Cardiac Events: Total OcclusionsCardiac Events: Total Occlusions

3.3% n=2

Only 8.4% !!!

0

2

4

6

8

10

Overall Cardiac Death

Treated Vessel Re-intervention

MI

2.2% n=41.1%

n=2

4.3%n=8

Inci

den

ce

(%

)

N = 186/3688 Patients

MILESTONE II 12-Month TAXUS Related MILESTONE II 12-Month TAXUS Related Cardiac Events: Total OcclusionsCardiac Events: Total Occlusions

MILESTONE II 12-Month TAXUS Related MILESTONE II 12-Month TAXUS Related Cardiac Events: Total OcclusionsCardiac Events: Total Occlusions

1.6% n=3

Stent thrombosis = 1.0% (2/186)

Only 5% !!!

Opening a CTO …Opening a CTO …Opening a CTO …Opening a CTO …

• Improves symptoms (angina, dyspnea)

• Improves LV function

• Improves prognosis

• Can be kept open with DES

• Why are they still undertreated ?

CTO success ratesCTO success ratesCTO success ratesCTO success rates

1995/96 1997/98 1999/01 2001/03

Penetration power of dedicated wiresPenetration power of dedicated wiresPenetration power of dedicated wiresPenetration power of dedicated wires

New wire techniquesNew wire techniquesNew wire techniquesNew wire techniques

Mitsudo; www.tctmd.com

Parallel wire technique - exampleParallel wire technique - exampleParallel wire technique - exampleParallel wire technique - example

230/05

Parallel wire technique with ASAHIMiracle Bros and Conquest wires

Case example: Double blunt occlusionCase example: Double blunt occlusionCase example: Double blunt occlusionCase example: Double blunt occlusion

12/05/06

Blunt proximal cap with 2 large sidebranches and blunt distal cap with one large side branch.


12/05/06

Bilateral approach: Confianza Pro over Spectranetics versus Miracle 3G over Transit


12/05/06

Bilateral approach: A major new option for 2nd attempts But the majority of CTOs are not treated in live courses

Determinants of procedural successDeterminants of procedural successDeterminants of procedural successDeterminants of procedural success

• Experience, dedication and patience of interventionist

• Duration of occlusion• < > 2 weeks• < > 3 months• < > 12 months

• Angiographic criteria … not many• Heavy calcification• Vessel tortuosity

PCI of CTOs is dangerous … really ?PCI of CTOs is dangerous … really ?PCI of CTOs is dangerous … really ?PCI of CTOs is dangerous … really ?

Bahrmann et al. EuroInterv 2006;2:231-7

Why do we not apply what is possible ?Why do we not apply what is possible ?Why do we not apply what is possible ?Why do we not apply what is possible ?

1995/961997/981999/012006

CTO – The European realityCTO – The European realityCTO – The European realityCTO – The European reality

• Opening a CTO …

• Costs a lot of lab time• Costs a lot of work time• Costs a lot of material• Costs a lot of radiation exposure• Requires a lot of patience

• Does not pay in our reimbursement system

Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany BSIC, Manchester, September 15, 2006.

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Transcript of Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany BSIC, Manchester, September 15, 2006.