Angioplasty in Total Coronary Artery Occlusion

1
Angioplasty in Total Coronary Artery Occlusion

• PTCA performed for total occlusion in 24 patients
  without acute MI, 5 of which were occluded for
  more than 12 weeks.
• Success was 54 (LAD 59, RCA 50, Circumflex
  33)
• In the 5 patients occluded for more than 12 weeks
  there was no success.
• Holmes et al. J Am Coll Cardiol 1984
  Mar3(3)845-9.

2
Why Attempt PCI on CTOs?

• Presence of symptoms
• Improve left ventricular function
• Improve prognosis
• Complete revascularization (CABG to PCI)
• Because of the challenge
• Radiation badge had low reading last month

3
PCI for CTO in Stable Angina

• Class IIa Level of evidence C. Be aware of
  possible side branch occlusion and perforation.
  Eur Soc Cardiol Eur Heart J 200526804
• CTO (gt3 months and/or bridging collaterals)
  considered high risk lesion type (for technical
  failure/restenosis). Would qualify as type IV
  lesion. ACC/AHA/SCAI Circulation 2006113e166

4
Indications for CTO PCI

• CTO sole significant lesion
• 1. Objective ischemia responsible for
  symptoms
• 2. Viable myocardial region of
  significant size
• 3. Reasonable chance for success (gt60)
  risk of major complication (lt1 death, lt5 MI)
• MVD with CTO
• 1. Aim for total revascularization (as
  good as CABG)
• 2. Culprit lesion first unless failure of
  CTO would lead to surgery.
• 3. Absence of factors favoring CABG
• LM
• Complex TVD diabetic, LV
  dysfunction, CKD
• CTO of proximal LAD not favorable
  for PCI
• Multiple CTOs with low likelihood of
  success.
• Stone et al Circ
  20051122530

5
Rentrop Classification of Collateralization

• Grade 0 No visible collateral vessels
• Grade 1 Faintly visible collaterals to branches
  but no filling of the recipient parent epicardial
  artery
• Grade 2 Collaterals with partial filling of the
  recipient artery
• Grade 3 Complete filling of the recipient
  artery.

6
Location of CTO

• Proximal RCA 30.4
• Distal RCA 16.0
• Obtuse Marginal 12.8
• Distal LAD 8.6
• Proximal LAD 8.4
• Distal Cx 8.4
• Proximal Cx 7.4
• LADD 5.0
• PDA/PLV/AMARG 3.0
• Christofferson et al AJC
  2005951088

7
More CTO Factoids

• Prevalence of CTO increases with age for RCA and
  LAD
• CTO post STEMI
• No PCI/thrombolysis 45 at 1 month
• Thrombolysis 30 at 3-6 months
• PCI 5-10 at 7
  months
• May have little or no symptoms but stress
  imaging.
• Stone et al Circ
  20051122364

8
Is CTO PCI Risk Free?

• CTO N-CTO
  
• Death 1.3 0.8
  
• MI 2.4 3.0
• Q 0.5 0.6
• Non-Q 1.9 2.4
  ALL P NS
• Urgent CABG 0.7 1.1
• Urgent PCI 1.5 2.0
• MACE 3.8 3.7
• Stroke 0.01 0.1
• Vascular Comp 1.7 2.5
• 
  Stone et al. Circ 20051122530

9
Treatment of CTO Native Artery vs In-Stent
Occlusion

• Predictors of Success
• Overall Success 68 no difference NA vs ISO
• All lt15 mm tapering morphology SVD
• NA Taper SVD No bridging collaterals
• ISO Smaller stent diameter
• Mechanism of Failure NA ISO
• pass wire 93 69
• pass balloon 7 21
• fully dilate balloon 0
  10
• 
  Abbas et al AJC 2005

10
Coronary Steal in CTO

• Pts with CTO and collateral dependent circulation
  are subject to coronary steal during
  microvascular vasodilatation.
• Usually accompanies donor arterial obstruction
  but may also result from lack of vasodilatory
  reserve of distal recipent circulation.
• This may result in left ventricular dysfunction.
• 
  Werner et al. JACC 20064851

11
Opening the CTO

• Rapid de-recruitment of collaterals after
  stenting such that ischemia brought on by
  subsequent balloon occlusions is less well
  tolerated.
• This may place the patient at risk if there is
  sudden re-occlusion of the intervened upon
  artery.
• Zimarino et al JACC
  20064859

12
Approach

• Pre-procedure clopidogrel and ASA
• Access site(s) number sheath size
• Anticoagulation half-dose heparin
• Hold GP IIb/IIIa until lesion crossed
• Post Procedure Same as usual PCI

13
Using MDCT to Define CTO
14
Microvessel as a Pathway

• CTO created by Ruptured Plaque
• Thrombus
• Replacement of clot and cholesterol esters
• Deposition of collagen and calcium deposits
• Tissue most resistent at ends of CTO (fibrous
  caps)
• Strauss et al J Intervent Cardiol 2005

15
Support Catheters
Tornus 2.12.6 fr
Maverick 1.5 mm
16
Wire Support
17
Choice of CTO Guidewire

• Considerations
• Torque
• Stiffness
• Feel (tactile response)
• Tip shaping
• Hydrophobic Wires
• Better tactile response
• Good for older, fibro-calcific lesions
• Good for initial piercing of fibrous cap
• Hydrophilic Wires
• Good for less chronic TO softer
• May find microchannels easier (especially
  with tapered tip)
• Follow path of least resistance easier to
  go extra-luminal

18
STIFF STIFFER STIFFEST

• Guidant High Torque Intermediate 0.014
  2-3 g
• High Torque Standard
  4
• Cross-It 100-400
  0.014/0.010 2,3,4,6
• Whisper
  0.014 1
• Pilot 50, 150, 200
  0.014 2,4,6
• BSC Choice PT and P2 0.014
  2
• PT Graphix and Graphix P2
  3,4
• Magnum 0.014
  0.014/0.7 mm 2
• Asahi Miracle Bros
  0.014 3,4.5,6,12
• Confianza 9
  0.014/.009 9
• Confianza Pro 9
  0.014/.009 9
• Confianza Pro 12
  0.014/.009 12
  
• Stone et al.
  CCI200566217

19
This looks a little more complicated than usual
20
Once Wire Crosses

• Confirm by angiography.
• Pass balloon or support catheter.
• If not successful
• Consider
• Laser catheter X80 0.9mm catheter may enlarge
  lumen enough for balloon and stents.

21
New Technology

• Mechanical vibration (Crosser)
• Success 76 no MACE no perforation
• Grube
  et al. J Invasiv Cardiol 20061885
• Radiofrequency ablation (Safe-Cross)
• Success 54 of 116 pts with prior failed
  PCI. Uses optical coherence reflectometry
  guidance. MACE in 6.9. Perforation in 2.6. Baim
  et al. AJC 200494853
• Laser wire (Primo?Superwire)
• TOTAL Initial success 53 (vs 48) for
  standard wires. Crossover of failures laser 46
  (vs 27) success. No significant difference.
  Serruys et al. Eur Heart J 2000211797

22
CTO When Is Enough Enough?

• Futility what is it? Fluoro time gt 45 minutes
• Procedure gt 2
  hours
• Contrast gt 500 cc
• Need for
  bio-break
• Bad signals Perforation with stain
• Device/wire exit
• Risk of side
  branch
• Patient tolerance
  ?
• You Can (almost) Always come back!

23
CTO Degree of Difficulty

• Level 1
  Level 2 Level 3
• 3-6 months occlusion duration 6-12
  months gt12 months
• Defined entry point straight Mod
  tortuosity 10- Ostial occlusion
• segment short occlusion 20 mm
  moderate Ca no entry pt take
• distal vessel seen no bridging bridging
  collaterals of at side branch
• collaterals
  gt 80 y.o. ISR CTO gt angulated gt20mm
• 
  20 mm severe
  Ca
• 
  
  tandem CTO, prior
• 
  
  failure by expert
• 300-500 prior PCI
  1,000-2,500 gt2,500
• gt 40 CTO
  gt75 level 1 CTO gt100 level 2 CTO
• 80-90 estimated success
  70-80 50-70
• moderate stiff wire, buddy wire All
  wires parallel-wire technique exchange
• deep GC intubation, contralateral
  technique for rotational atherectomy. Advanced
• injections
  equipment.
• 
  Stone et al. CCI 200566217