1. Nicolaus ReifartBad Soden imMain Taunus KlinikenTaunusBad Soden, GermanyCTO PCICurrent Concepts & TechniqueRole of DES

2. Important to know before: Will patient benefit from CTOrecanalisation ? Are patient and operator the rightcandidate for CTO-PCI ? Familiar with various proceduraltechniques and their outcomes ? 3. Whom should we open a CTO? Limiting symptoms most likelydue to CTO Or objective evidence of relevantviability/ischemia in the territoryof the occluded artery 4. Whom should we open a CTO? Limiting symptoms most likelydue to CTO Or objective evidence of relevantviability/ischemia (> 10% of LV)in the territory of the occludedartery 5. How are CTOs treated today? 27% of CAD patients have at least 1 CTOof these CTO Patients 7 % PCI (success about 50 %) * 19 % CABG (grafted about 68 %) * 74% Medical Treatment * SYNTAX G. Werner 2009; EuroCTO 2010 6. Total Occlusion Procedural characteristics Per lesion analysisCABG n=26612 were not treated with CABGCABG n=254Not Bypassed Bypassedn=81n=173Reason not bypassed:Not intended to treat (n=12) Overall 68.1 % of TODiseased (n=11)were bypassed Inadequate conduit (n=2)Too small (n=19)Unable to find (n=1) Early Patency ???Other (n=36)ITT, Per LesionSYNTAX: Total Occlusions SerruysCRT 2009 March 2009 Slide 8 7. 2010 8. Changes of Strategy and Results 9. Euro CTO Club membership454340 383533 293025212015 1310 5 0 2006 2007 2008 2009 2010 2011 10. 11481 CTO Procedures40003500 3591Online30003090Registry2500200019771500 16081000 12155000 2006 2007 2008 20092010 11. EuroIntervention 2011 12. Evidence of viable myocardium100% 90 80 70 60 50 40 306864 20 50 1002008 20092010 13. Previous STEMI (%)1900n1900ral1900n1900ral1900n1900ral17 17 181900n1900ral1900n1900ral1900n1900ral1900n1900ral1905n1905ral 1905n1905ral 1905n1905ral 14. Unlike OAT: > 80% of CTO patientshad no Q-Infarction 2008/10) 15. Success of CTO 11481 CTO Procedures100 90 82867780 80 75 70 60 50 40 30 20 1002006 (3591) 2007 (3090) 2008 (1215) 2009 (1608) 2010 (1977) 06/07: all members - since 2008 online registry 16. Success related to Volume 2008-10150/>200>300 CTO100 9593 90 8988 898384 83 85 79 81 81 83 80 75 70 67 65 60 55 50 200820092010 Remember: Syntax < 50% 17. Success Second Attempt (%)100 90 80 70 60 50 85 40 69 30 20 100Referral 636 2nd try 260 EuroCTO registry 2011 18. Dont start with level 3 or4 !!! Stepwise increase indifficulty important 19. Fluoroscopy & Procedure (min)200180160140120100 89 91 92 94 80 60 40 35 38 47 203302007 2008 2009 2010 20. Dye Consumption (ml)500450400350 278284279300250200150100 5001905n1905ral 1905n1905ral 1905n1905ral 21. CIN (GFR > 25%)54.543.532.521.50.7 11 0.40.502008 20092010 22. Complications (%) 54.5 AMI: QMI < 0.5 % 43.5 3 Bleeding AMI2.5 Em-CABG 2 Tamponade1.5Death 10.50.30.4 0.40.3 02007 20082009 2010 23. There are different strategies to successThe goal should be : Most simple aproach withoptimal outcome for the patient . 24. No Discussion: Referral is not a shame go and watch theexpert View of distal vessel 100% (contralateralinjection required in 70%) Start with OTW Limit dye to 4-6 x GFR Failures are worth a 2nd try (success >70%) 25. Use of hydrophylic wires (%) (polimer & non-polimer)100 90 80 70 60 5049 55 40 46 30 35 20 25 1002006200720082009 2010 26. Successful wire504540 * 39< 1g35 1-3g32 31 286-9g30272425 > 9g2522 201920 16 171510 5 0200820092010* mostly Fielder XT 27. Use of IVUS and MSCT (%)10 9 8 7 6 6 5 434 MSCT 32.6 2 121.5 IVUS 020082009 2010 28. Use of Tornus and Corsair20181614131210 Tornus 8 8 Corsair 65 5 4 20.08 0.08 02008 0.08 2010 29. Retrograde Aproach% of all CTO2018161412 10.69.8 10.810 8 6 4 2 0 200820092010 30. Ante - versus Retrograde450400 383350300268250ante (4299)200 154retro (501)150100 8187 5036 0Fluoro (min) Procedure (min) Dye (ml) 31. Success Antegrade vs Retrograde100 90 848781 79 80 7065 70 60 50 Antegrde 40 Retrograde 30 20 100 200820092010 32. 5075265CTO CX 26months2nd tryCorcescreworthogradeepicardialcollateral 33. 2Confianza 9 34. Externalisationwith RG3 andantegradedilation 35. Nobori3.0 x 282.5 x 18 36. Conclusion Antegrade should be turned intoretrograde before the distal vesselis ruined Retrograde with Corsair feasablevia orthograde corc-screw likecollaterals of the same vessel 37. 50753698 years oldvery calcifyedCTO of LAD 38. PCI failure5 years agoCCS 2 39. Confianza12Corsair 40. Allwayscheck 2ndview 41. Antegradeno chance 42. Retrogradetry viaseptalcollaterals 43. Wire inguiding butimpossible tofollow withCorsair(severecalcification) 44. AgainantegradeKissingwires 45. Failed withCorsair insituCorsairpulled back 46. Then wirecould beplaced throughexisting lumen 47. Andsuccessfullyfinished 48. Conclusion Severe calcification easier to penetrateretrogradely If retrograde fails, why not completeantegradely. Ante- and retrograde procedures are oftencomplimentary 49. Use of DES EuroCTO Club95 97100 85 90 80 72 66 70 60 50 40 30 20 100 2006 2007 2008 2009 2010 50. 14 comparative studies, 4394 patients 51. Conclusion DES definitely reduce TVR andReocclusion and should be 1st choice Suspiscion of more Late stent thrombosis atleast with 1st generation DES DES with bioabsorbable coating likely tobe superior but not yet proven 52. There are only 2 randomised trials with DES for CTO Prison II Coracto 53. The DES Coracto Rapamycin as an anti-restenotic drug and apoly(lactic co-glycolic acid) (PLGA)biodegradable polymer (3-4 m) Stent struts 80 m Crimped on semi-compliant ballooncatheter 54. CORACTO Randomised trial Constant Stent with Rapamycine in chronictotal occlusions (> 3 mos) or long (> 20mm) 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 mosEuroIntervention 2010 55. 6m Restenosis Reocclusion and TVR*(n= 91 pts; 249 stents)% 75