Trattamento delle CTO

Indicazioni e risultati Prof. Alfredo R. Galassi MD, FESC, FACC, FSCAI

Department of Medical Sciences and Pediatrics,

University of Catania, Italy

and University Heart Center,

University Hospital Zurich, Switzerland

Andreas Gruentzig

First Percutaneous Coronary

Angioplasty in humans

15

September

1977

…. pertanto le occlusioni totali sono un problema reale

Se non risolviamo il problema delle occlusioni totali,

probabilmente non saremo mai in grado di risolvere il

problema dell’angioplastica nel paziente multivascolare

Andreas Gruentzig

2 settimane prima della sua morte avvenuta in un

incidente aereo

(27, Ottobre 1985) quando aveva 46 anni

……30 anni dopo!!!!!!

Euro Cto Club

Founding Meeting

Paris 14.12.2006

Joachim Buettner

Gerald Werner

Dariusz Dudek

George Sianos

Alfredo R Galassi

Nicolaus Reifart

Carlo Di Mario was

the photographer

Christofferson et al, Am J Cardiol 2005

CTOs are common and influence

management

Analysis of 6.581 consecutive patients undergoing

angiography (1990-2000), CTO was found in 52%

patients with significant (> 70% DS) coronary disease

Patients with chronic total occlusion (CTO)

n=1697

CTO prevalence 18.4%

Medical Therapy

n=747

44%

PCI

n=515

30%

CABG

n=435

26%

CTO bypassed

n=388 (90% of operations)

23%

Attempted CTO PCI

n=162

10%

Successful CTO PCI

n=123

7%

The Canadian Multicenter CTO Registry April 2008 - July 2009 (3 centers)

Overall, 30% of CTOs revascularized!

Fefer P et al, JACC 2012 Christofferson et al, AJC 2005

1777 patients enrolled with 1968 CTO lesions

CTO prevalence 13.3%

Optimal medical

therapy 826 pts

PCI 776 pts CABG 175 pts

46%

44% 10%

Tomasello D et al, Eur Heart J 2015

Christofferson et al, AJC 2005

Galassi et al, Eur Heart J 2015

Indications of CTO revascularization according to

symptoms, ischemia and viability

Galassi et al, Eur Heart J 2015

Course Directors

Nicolaus Reifart

Main Taunus Kliniken

Bad Soden, Germany

Gerald S. Werner

Medizinische Klinik

Klinikum Darmstadt

Darmstadt, Germany

Co-Directors

Alfredo R. Galassi

Ferrarotto Hospital

University of Catania

Catania, Italy

George Sianos

AHEPA University Hospital

Thessaloniki, Greece

Hans Bonnier

University Hospital Brussels

Brussels, Belgium

Procedural complications

and in-hospital outcome

Galassi et al, EuroIntervention 2011

0

500

1000

1500

2000

2500

3000

2008 2009 2010 2011 2012 2013 2014

1303

1724

2189

2634 2603 2660 2615

Online Registry 2008-2014

0

20

40

60

80

100

2006 2007 2008 2009 2010 2011 2012 2013 2014

75 77 80 82

85.3 85 85.3 87 85.8

Angiographic Success

%

Course Directors

Nicolaus Reifart

Main Taunus Kliniken

Bad Soden, Germany

Gerald S. Werner

Medizinische Klinik

Klinikum Darmstadt

Darmstadt, Germany

Co-Directors

Alfredo R. Galassi

Ferrarotto Hospital

University of Catania

Catania, Italy

George Sianos

AHEPA University Hospital

Thessaloniki, Greece

Hans Bonnier

University Hospital Brussels

Brussels, Belgium

Course Directors

Nicolaus Reifart

Main Taunus Kliniken

Bad Soden, Germany

Gerald S. Werner

Medizinische Klinik

Klinikum Darmstadt

Darmstadt, Germany

Co-Directors

Alfredo R. Galassi

Ferrarotto Hospital

University of Catania

Catania, Italy

George Sianos

AHEPA University Hospital

Thessaloniki, Greece

Hans Bonnier

University Hospital Brussels

Brussels, Belgium

Antegrade Retrograde Overall

Galassi AR et al, on behalf of the Euro CTO Club

Course Directors

Nicolaus Reifart

Main Taunus Kliniken

Bad Soden, Germany

Gerald S. Werner

Medizinische Klinik

Klinikum Darmstadt

Darmstadt, Germany

Co-Directors

Alfredo R. Galassi

Ferrarotto Hospital

University of Catania

Catania, Italy

George Sianos

AHEPA University Hospital

Thessaloniki, Greece

Hans Bonnier

University Hospital Brussels

Brussels, Belgium

Galassi AR et al, on behalf of the Euro CTO Club

Course Directors

Nicolaus Reifart

Main Taunus Kliniken

Bad Soden, Germany

Gerald S. Werner

Medizinische Klinik

Klinikum Darmstadt

Darmstadt, Germany

Co-Directors

Alfredo R. Galassi

Ferrarotto Hospital

University of Catania

Catania, Italy

George Sianos

AHEPA University Hospital

Thessaloniki, Greece

Hans Bonnier

University Hospital Brussels

Brussels, Belgium

Galassi AR et al, on behalf of the Euro CTO Club

Tomasello D et al, Eur Heart J 2015

Survival free from MACCE and cardiac death

in pts (No: 619) treated with PCI or medical

therapy after propensity score adjustment

0

0,5

1

1,5

2

2,5

2008 2009 2010 2011 2012 2013 2014

0,5 0,5

0,3

0 0,03 0,08 0,07

0,8

1,1

0,9

1

0,8

0,5

0,4

2,2

1

2,5

1,5

1,9

2,3

2,5

0,1

0,6

0,3

0,6

0,5

0,6

0,5

1

0,8

0,3

0,7

1

0,5 0,5 0,5

1,2

0,3

0,7

0,8

0,6

0,5

Death

Myocardial infarction Vascular complication

Donor vessel dissection

Cardiac tamponade

Coronary perforation

Procedural Complications

Consensus on Indications and Strategy

Best treatment for CTO is the result of:

- Careful review of clinical history

- Sensitive non-invasive assessment of myocardial ischemia

and viability in CTO related territory

- Patient risk profile assessment (complete revascularization

in multivessel patient); patient selection is crucial

- Life expectancy (younger and older youth)

- LAD CTO

- Non-LAD CTO but main vessel ischemic area related CTO - Radiation, contrast load and complication risk assessment

(balance success vs failure)

Consensus of Euro CTO Club Eurointervent 2012

Conclusions

The European Strategy

1. Antegrade success (approx 85%) stable from 2010

onwards (last 5 years)

2. Retrograde procedures:

a) mostly staged

b) increased significantly from 2010 onwards (up

to 30% in 2014)

c) more complex lesions, more time consuming,

more fluoroscopy time, more dye to be used

3. Retrograde operators higher success than non

retrograde operators (90% vs 80%)

4. Severe complications <1.5-2.0%

Thank you

for your attention

argalassi@gmail.com