Debate: Is there a difference between RDR and reverse CART? – No

Dimitri Karmpaliotis, MD,PhD FACCAssociate Professor of Medicine

Columbia University Medical CenterDirector of CTO, Complex and High Risk Angioplasty

NYPH/Columbia

Email: dk2787@columbia.eduEURO CTO CLUB, 11th Experts Live CTOBerlin, Germany, September 13-14, 2019

Disclosures

• As a faculty member for this program, I disclose the following relationships with industry:

• Honoraria from Abbott Vascular, Abiomed and Boston Scientific

That’s What Paul Needs to Prove to You

to Convince you that RCART is Better than ADR

• His Arguments Need to be Based on Data

• His Arguments Need to be Based on Common Sense

That’s What Paul Needs to Prove to You

to Convince you that RCART is Better than ADR

• His Arguments Need to be Based on Data

That’s What Paul Needs to Prove to You

to Convince you that RCART is Better than ADR

• ADR is not needed to achieve high success rates and that AWE and Retrograde CTO PCI can take care of all cases

• Even before he gets to perform his magic RACRT, he can get at the distal cap all the time

• Consistently requires less number of stents to complete( Which is used as a surrogated of more controlled dissections)

That’s What Paul Needs to Prove to You

to Convince you that RCART is Better than ADR

• Retrograde PCI is:• Easier, Faster, Requires less Contrast• Safer than Antegrade PCI• Easier to teach, adopt and disseminate

among CTO Operators• Associated with better periprocedural

outcomes• Associated with better long-term

outcomes

If Paul Fails to Prove to You Convincingly at least most of these points, then he would have failed miserably in making his point that

RCART is Better than ADR

Having said all this, I am Confident that Paul will Triumph in making his point

that RCART is Better than ADRBecause I set the bar too low for a man

of his CALIBER

• ADR is not needed to achieve high success rates and that AWE and Retrograde CTO PCI can take care of all cases

Multiple strategies may be necessary to succeed in

CTO-PCI

1/2012 to 2/2014n=632Technical success: 92.4%Major complications: 1.9%

•Appleton Cardiology, WI•Dallas VAMC/UTSW, TX•Peaceheath Bellingham, WA •Piedmont Heart Institute, GA•St Luke’s Mid America Heart

Institute, MO•Torrance Medical Center, CA

Christopoulos, Karmpaliotis, Alaswad, Wyman, Lombardi, Grantham, Thompson, Brilakis et alJournal of Invasive Cardiology 2014;26:427-432

42

27

31

Antegrade

Antegrade dissection/re-entry

Retrograde

65

37 44

0

20

40

60

80

100

Techniques Used

%

AntegradeAntegrade DRRetrograde

Successful technique

PROspective Global REgiStry for the Study of CTO interventions

87.2

93.7

78.1

90.0

70

80

90

100

2006-2011 2012-2013

%

No prior CABG

Prior CABG

Pre “Hybrid” era

Michael, Karmpaliotis, Brilakis, Lombardi, Kandzari et al. Heart 2013;99:1515-8

Δ=9.1%P<0.001

Christopoulos, Menon, Karmpaliotis, Alaswad, Lombardi, Grantham, Brilakis et al. AJC 2014;113-1990-4

CTO PCI: success and prior CABG

N=1,3633 US sitesPrior CABG: 37%Complications: 1.5% vs. 2.1%Retrograde: 27.1% vs. 46.7%

Δ=3.7%P=0.092

“Hybrid” era

N=6306 US sitesPrior CABG: 37%Complications: 2.5% vs. 0.8%Retrograde: 34% vs. 39%

87.2% 86.5%

78.1%81.9%

70%

80%

90%

100%

2006-2011 2012-2017

No priorCABGPrior CABG

Pre Hybrid era

Δ=9.1%p<0.001

Effect of Prior CABG

Michael, Karmpaliotis, Brilakis, Abdullah, Kirkland, Mishoe, Lembo, Kalynych, Carlson, Banerjee, Lombardi, Kandzari.

Heart 2013;99:1515-8

1,363 lesions; 3 US sitesPrior CABG: 37%

Complications: 1.5% vs. 2.1%Retrograde: 27.1% vs. 46.7%

Δ=4.6%p=0.001

Hybrid era

Current available data in PROGRESS-CTO Registry 02/05/2018

2967 lesions; 20 international sitesPrior CABG: 32%

Complications: 2.9% vs. 3.5%Retrograde: 31% vs. 54%

Author YearN (CTO lesions)

Prior CABG Diabetes Retrograde

Technical Success

Major complicati

ons DeathTampon

ade

Fluoroscopy time

(minutes)

Contrast use,

(ml)

Rathore 2009 904 12.6 40.0 17 87.5 1.9 0.6 0.6 NR NR

Morino 2010 528 9.6 43.3 26 86.6 NR 0.4 0.4 45

(1-301)*

293

(53-1,097)*

Galassi 2011 1983 14.6 28.8 14 82.9 1.8 0.3 0.5 42.3±47.4 313 ±184

U.S

Registry*

2013 1361 37.0 40.0 3485.5

1.80.22 0.6 42±29 294 ±158

* Median (range)

Summary of Large Contemporary Registry Publications of Percutaneous Coronary Interventions of Chronic Total Occlusions

* Tesfaldet, Karmpaliotis, Brilakis, Lembo, Lombardi, Kandzari. Am J Cardiol 2013

Author Year n

Prior CABG

(%)

Septal collaterals used (%)

Reverse CART (%)

Technical Success

(%)

Major complications

(%)Fluoroscopy

time, minContrast use, mL

Sianos 2008 175 10.9 79.4 NR 83.4 4.6 59 ± 29 421 ± 167

Rathore 2009 157 17.8 67.5 NR 84.7 4.5 NR NR

Kimura 2009 224 17.6 79 14 92.4 1.8 73 ± 42 457 ± 199

Tsuchikane 2010 93 10.8 82.8 60.9 98.9 0 60 ± 26 256 ± 169

Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR*

Karmpaliotis* 2012 462 50.0 71 41 81.4 2.661 ± 40 345 ± 177

Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.

Retrograde Coronary Chronic Total Occlusion Revascularization:Procedural and In-Hospital Procedural Outcomes from a Multicenter

Registry in the United States

Technical approach

PROspective Global REgiStry for the Study of CTOinterventions

www.progresscto.org

Successful crossing strategy stratified by J-CTO score

88.3%71.6%

50.6%31.9%

17.3% 16.9%

5.8%

14.7%

20.5%

24.1%

21.6% 20.2%

3.1%9.0%

19.7%35.3%

41.5% 43.6%

0%

20%

40%

60%

80%

100%

J-CTO Score 0 J-CTO Score 1 J-CTO Score 2 J-CTO Score 3 J-CTO Score 4 J-CTO Score 5

RetrogradeADRAWE

p<0.0001

• Even before he gets to perform his magic RACRT, he can get at the distal cap all the time

Limitations of Retrograde Approaches

McEntegart et al. EuroIntervention. 2016;11:e1596-1603

Data from 481 patients with 519 CTOs

• Visible “interventional” collaterals only seen in

64% of lesions

Limitations of Retrograde Approaches

Tsuchikane et al. CCI. 2013;82:e654-61

Data from 801 patients in J-PROCTOR registry

Reasons For Failure With Attempted Retrograde CTO PCI

J Proctor CCI 2013.

Limitations of Retrograde Approaches

• Similar updated experience from Japan

• Examined 5984 CTO PCIs from 45 centres (2009-12)

• Retrograde attempt in 1656 cases

• Failed to cross with wire/micro-catheter in 23%

Suzuki et al. CCI. 2016;In Press doi: 10.1002/ccd.26785

• Consistently requires less number of stents to complete( Which is used as a surrogated of more controlled dissections)

• Retrograde PCI is:• Easier, Faster, Requires less Contrast• Easier to teach, adopt and disseminate

among CTO Operators

Author Year n

Prior CABG

(%)

Septal collaterals used (%)

Reverse CART (%)

Technical Success

(%)

Major complications

(%)Fluoroscopy

time, minContrast use, mL

Sianos 2008 175 10.9 79.4 NR 83.4 4.6 59 ± 29 421 ± 167

Rathore 2009 157 17.8 67.5 NR 84.7 4.5 NR NR

Kimura 2009 224 17.6 79 14 92.4 1.8 73 ± 42 457 ± 199

Tsuchikane 2010 93 10.8 82.8 60.9 98.9 0 60 ± 26 256 ± 169

Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR*

Karmpaliotis* 2012 462 50.0 71 41 81.4 2.661 ± 40 345 ± 177

Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9.

Retrograde Coronary Chronic Total Occlusion Revascularization:Procedural and In-Hospital Procedural Outcomes from a Multicenter

Registry in the United States

• Retrograde PCI is:• Safer than Antegrade PCI• Associated with better periprocedural

outcomes• Associated with better long-term

outcomes

Insights from the Progress CTO Registry

Retrograde vs. antegrade-only: outcomes

2012-201511 centers, 1,301 lesionsRetrograde utilization: 41%

84.8 81.993.7 93.3

0

50

100

Technical Success Procedural Success

Succ

ess

rate

(%)

RetrogradeAntegrade-only

Δ= 8.9%p<0.001

Δ=11.4%p<0.001

Karmpaliotis D, Karatasakis A, Alaswad K, Jaffer FA, Yeh RW, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Patel M, BahadoraniJ, Moses JW, Kirtane AJ, Parikh M, Ali Z, Kalra S, Nguyen-Trong PJ, Danek BA, Karacsonyi J, Rangan BV, Roesle M, Thompson CA, Banerjee S, Brilakis ES.

Circ Cardiovasc Interv 2016 Jun;9(6)

4.3

2.1

0.4

1.3

0.60.8

1.1

0.3 0.3 0.30.1 0.1

0

1

2

3

4

5

MACE MI Stroke Pericardiocentesis Re-PCI Death

Com

plica

tion

rate

(%) Retrograde

Antegrade-only

Retrograde vs. antegrade-only: in-hospital MACEp<0.001

p=0.003

p=0.999

p=0.039

p=0.314

p=0.167

Karmpaliotis D, Karatasakis A, Alaswad K, Jaffer FA, Yeh RW, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Patel M, BahadoraniJ, Moses JW, Kirtane AJ, Parikh M, Ali Z, Kalra S, Nguyen-Trong PJ, Danek BA, Karacsonyi J, Rangan BV, Roesle M, Thompson CA, Banerjee S, Brilakis ES.

Circ Cardiovasc Interv 2016 Jun;9(6)

• Co PIs James Sapontis, Bill Lombardi• Manager Karen Nugent• Statistician Kensey Gosch• Core Lab Federico Gallegos• Publications Spertus, Cohen, Marso, Yeh,

McCabe, Grantham, Karmpaliotis

That’s What Paul Needs to Prove to You

to Convince you that RCART is Better than ADR

• His Arguments Need to be Based on Common Sense

CASE EXAMPLECTO-RCA

CTO-RCA Dual Injections

7Fr Slender Sheaths

Right Radial Artery7Fr EBU 3.5 90cm

Left Radial Artery7Fr AL0.75 SH 90cm

CTO-RCA Dual Injections

7Fr Slender Sheaths

Right Radial Artery7Fr EBU 3.5 90cm

Left Radial Artery7Fr AL0.75 SH 90cm

Retrograde via LAD septal

TurnPike 150cm

Sion wire

Setting up for Reverse CART

Antegrade TurnPike 135cm

Retrograde TurnPike 150cm

Antegrade Pilot 200Retrograde Pilot 200

Very Hard to get into vessel structure because of tortuous

and ectatic vessel added to proximal bridging collaterals and

ambiguous proximal cap

“Move the Cap” Technique

Antegrade4.0 x 12 Balloon inflated

in pRCA On looped BMW wire

Antegrade TurnPike 135cmWith

Knuckled Fielder XT WireNEXT to the Balloon

“Move the Cap” by entering the

sub-intimal place (with your knuckle) more proximally that the

proximal CTO cap

ADR-StingRay

StingRay LP

StingRay Wire Fenestrations

ADR-StingRay

StingRay LP

Pilot 200 rapidly advanced with wiring of the distal true lumen

Into a smaller branch

Retrograde Distal Tip Injections with Medallion Syringe for

visualization

After 6Fr Guideliner supported PCI

DES 3.5 x 38 mmDES 4.0 x 38 mm DES 4.0 x 18 mmDES 4.0 x 28 mm

Having said all this, I am Confident that Paul will Triumph in making his point

that RCART is Better than ADRBecause I set the bar too low for a man

of his CALIBER

So, Good Luck Paul……

THANK YOU

THANK YOU