This document discusses techniques for percutaneous coronary intervention (PCI) to treat chronic total occlusions (CTOs). It provides statistics on the number of CTO patients treated with PCI versus other options. Success rates for CTO-PCI have increased from around 50% in early studies to over 80% currently. Retrograde approaches and newer wires and devices have improved outcomes. Drug-eluting stents significantly reduce restenosis compared to bare metal stents for CTO-PCI. The Coracto randomized trial demonstrated the Coracto DES significantly reduced rates of restenosis and target vessel revascularization out to 6.5 years compared to a bare metal stent.
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Ct omin
1. Nicolaus Reifart
Bad Soden im
Main Taunus Kliniken
Taunus
Bad Soden, Germany
CTO PCI
Current Concepts & Technique
Role of DES
2. Important to know before:
• Will patient benefit from CTO
recanalisation ?
• Are patient and operator the right
candidate for CTO-PCI ?
• Familiar with various procedural
techniques and their outcomes ?
3. Whom should we open a CTO?
• Limiting symptoms most likely
due to CTO
• Or objective evidence of relevant
viability/ischemia in the territory
of the occluded artery
4. Whom should we open a CTO?
• Limiting symptoms most likely
due to CTO
• Or objective evidence of relevant
viability/ischemia (> 10% of LV)
in the territory of the occluded
artery
5.
6. How are CTOs treated today?
• 27% of CAD patients have at least 1 CTO
of these CTO Patients
• 7 % PCI (success about 50 %) *
• 19 % CABG (grafted about 68 %) *
• 74% Medical Treatment
• * SYNTAX G. Werner 2009; EuroCTO 2010
7.
8. Total Occlusion Procedural characteristics
Per lesion analysis
CABG
n=266
12 were not treated with CABG
CABG
n=254
Not Bypassed Bypassed
n=81 n=173
Reason not bypassed:
Not intended to treat (n=12) Overall 68.1 % of TO
Diseased (n=11) were bypassed
Inadequate conduit (n=2)
Too small (n=19)
Unable to find (n=1)
Early Patency ???
Other (n=36) ITT, Per Lesion
SYNTAX: Total Occlusions • Serruys CRT 2009 • March 2009 • Slide 8
26. There are different strategies to success…
The goal should be : Most simple aproach with
optimal outcome for the patient ….
27. No Discussion:
• Referral is not a shame – go and watch the
expert
• View of distal vessel 100% (contralateral
injection required in 70%)
• Start with OTW
• Limit dye to 4-6 x GFR
• Failures are worth a 2nd try (success >
70%)
44. Conclusion
• Antegrade should be turned into
retrograde before the distal vessel
is ruined
• Retrograde with Corsair feasable
via orthograde corc-screw like
collaterals of the same vessel
58. Conclusion
• Severe calcification easier to penetrate
retrogradely
• If retrograde fails, why not complete
antegradely….
• Ante- and retrograde procedures are often
complimentary
59. Use of DES EuroCTO Club
95 97
100
85
90
80 72
66
70
60
50
40
30
20
10
0
2006 2007 2008 2009 2010
64. Conclusion
• DES definitely reduce TVR and
Reocclusion and should be 1st choice
• Suspiscion of more Late stent thrombosis at
least with 1st generation DES
• DES with bioabsorbable coating likely to
be superior – but not yet proven
65. There are only 2 randomised
trials with DES for CTO
Prison II
Coracto
66. The DES Coracto ®
• Rapamycin as an anti-restenotic drug and a
poly(lactic co-glycolic acid) (PLGA)
biodegradable polymer (3-4 µm)
• Stent struts 80 µm
• Crimped on semi-compliant balloon
catheter
67. CORACTO Randomised trial
• Constant Stent with Rapamycine in chronic
total occlusions (> 3 mos) or long (> 20
mm) functional occlusions
• Bad Soden/Trier- trial 95 pts randomised
• PE: 6 mos late loss and restenosis
• SE: 6 mos TLR clinically driven
• Clinical Fu 12 mos - 24 mos – 78 mos
EuroIntervention 2010
68. 6m Restenosis Reocclusion and TVR*
(n= 91 pts; 249 stents)
% 75 <0.0001 p<0.0001 Constant
65 60 CORACTO
53.3
55
45
35
25 17.4 15.5
15 10.8
5 0
-5
in segment iS Reocclusion TVR
Restenosis
TVR if Restenosis + angina/ischemia or Stenosis > 70%
71. 6.5 Years Follow-up (20% lost)
Death and TVR
N= 95 N = 91 N = 78
80
68.8
70
60
60
Death 53.3 TVR ***
50
40 *** ***
30
20 17.8 17.4
15.2
10.8 10.8
10
2.5 4.5
0 0
0
1 year 2 years 6,5 years
72. Conclusion Coracto
• Superbe early and late results of Coracto ®
versus similar BMS for CTO-PCI namely:
• Sustained rel. reduction of TVR of 75%
• No Stent-Thrombosis despite only 6 mos
dual antiplatelet therapy
• No late catch-up
• The only available DES with evidence for
CTO-PCI