Experts "Live" CTO Workshop 2015 Septemper, 18th – 19th , 2014 in Istanbul, Turkey

1. Gerald S. Werner FESC FACC FSCAI
Medizinische Klinik I
Klinikum Darmstadt GmbH

2. Complication rates in expert hands with
advanced techniques
Rathore JACC Card Int 2009:2,6:489

3. ERCTO : retrograde complication rates
Galassi AR et al. EuroIntervention 2011; 7:472-479

4. How helpful is a Meta-analysis of CTO complications ?
Patel et al J ACC Intervention 2013; 6:128-36
-9A Weighted Meta-Analysis of 18,061 Patients From 65 Studies

6. TCT 21- Periprocedural Myocardial
Infarction And Increased Markers of Cardiac
Injury After Retrograde Recanalization of
Chronic Total Coronary Occlusions Via
Transseptal And Epicardial Pathways
G.S. Werner,
K.H. Tischer, S. Oehlmann, H. Moehlis
Medizinische Klinik I
Klinikum Darmstadt, Germany

7. Patients
• We applied the retrograde technique after a failed
antegrade approach or in case of unfavorable
morphology starting in March 2006.
• We studied a consecutive cohort of patients with
a CTO between 3/06 and 2/08 with the following
selection criteria:
 TIMI 0 flow and >3 months duration
 No left ventricular (LV) aneurysm
 Minimum vessel reference diameter 2.5 mm

8. Procedural characteristics
Antegrade Septal Septal dilated Epicardial
Patients 137 20 17 5
Procedure time (min) 89 ± 35 *) 125 ± 24 171 ± 41 144 ± 41
Fluoro time (min) 31 ± 16 *) 52 ± 15 78 ± 23 73 ± 21
Contrast use (ml) 236 ± 93 *) 297 ± 56 370 ± 98 310 ± 45
Balloons used 2.0 ± 1.0 2.4 ± 1.2 3.5 ± 0.8 *) 2.5 ± 0.7
Stents used 2.2 ± 1.0 2.4 ± 1.2 3.5 ± 0.7 *) 2.5 ± 0.7
Procedure success % 83 80 82 60
*) p<0.05 Per patient success rate 86%

9. CK and TnI after PCI
0
50
100
150
200
250
CK
Antegrade
No dil.
Septal dil.
0
0,5
1
1,5
2
2,5
3
TnI
0.5
1.5
2.5

10. Periprocedural Infarct(lets)
Antegrade Septal Septal dilated Epicardial
Patients 137 20 17 5
CK > 3 x ULN 3.1 7.1 12.5 20
TnI > 0.15 ng/ml 48 79 100 *) 100 *)
TnI > 1.0 ng/ml 14 21 69 *) 80 *)
*) p<0.01
Percent of procedures

11. Case example: Antegarde failure and second
retrograde attempt successful
K.R. 27.6.08
Procedure time 177 min
Contrast 390 ml
CK max 66 IU/L
TnI 0.21 ng/ml
K.R. 21.8.08
Procedure time 267 min
Contrast 600 ml
CK max 278 IU/L
TnI 4.36 ng/ml

12. Summary and conclusion
• The retrograde approach leads to an
increased release of markers of myocardial
injury after PCI.
• This is more pronounced after septal
pathway dilatation, and also with epicardial
procedures.
• The clinical significance remains to be
established, still, a sound indication for the
procedure should be established, and
patients should be informed about this risk.

13. Lo et al. JACC CI 2014; 7: 47-54

14. PMI: CK-MB >3 times
MACE: Death, MI,
Revascularization?
Lo et al. JACC CI 2014; 7: 47-54

15. No relation between
TnI increase and 30
day events:
1 death, 4 PE
Werner et al. EuroInt 2014; 10: 799-805

16. Werner et al. EuroInt 2014; 10: 799-805

17. Determinants of cTnI > 0.7
Werner et al. EuroInt 2014; 10: 799-805

18. Periprocedural ischemia in PCI for CTOs
• Frequently patients complain about pain
during CTO PCI, especially when the
retrograde approach is applied
• The increase in troponine after retrograde
procedures is rather common than
exceptional
• The clinical relevance of this periprocedural
ischemia remains unresolved
• For clinical studies and assessment of
procedural complications, we may need a
review of definitions of periprocedural MI

19. Are the markers too sensitive for complex PCI ?
Moussa et al. CCI 2013; 83: 27-36