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Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany

BSIC, Manchester, September 15, 2006. Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany. BSIC, Manchester, September 15, 2006. Chronic total occlusions update A European perspective. Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany. CTO – The European perspective.

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Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany

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  1. BSIC, Manchester, September 15, 2006 Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany

  2. BSIC, Manchester, September 15, 2006 Chronic total occlusions updateA European perspective Gerald S. Werner, MD, FESC, FACC Klinikum Darmstadt, Germany

  3. CTO – The European perspective • What you may want to know about collaterals • Why should we open a CTO ? • The past and presence of CTO treatment • CTOs in the DES era • The remaining challenges in CTOs

  4. Pathophysiology of collaterals in CTOs • How to assess collaterals ? • What happens to collaterals after PCI ? • Can collaterals replace an open artery ?

  5. Assessment of collaterals: pressure and flow Baseline collateral function Recruitable collateral function Werner et al. Circulation 2001;104:2784-90

  6. Collateral function in CTOs Before PCI After PCI 79% 46% Werner et al. Circulation 2003;108:2877-82

  7. Loss of collateral function not due to embolization Bahrmann et al. Z Kardiol 2002;91:937-945

  8. Collateral function in CTOs Before PCI After PCI 79% 46% 6 mo FUP 18% Werner et al. Circulation 2003;108:2877-82

  9. 20% Wustmann et al. Circulation 2003;107:2213-20 Evidence for preformed collaterals in man Before PCI After PCI 79% 46% 6 mo FUP 18% Werner et al. Circulation 2003;108:2877-82

  10. Can good collaterals replace an open artery ? Collateral function assessed as collateral flow reserve In 98 Pat. with CTO during adenosine stress Adapted from Werner et al. JACC 2006;48:51-8

  11. Can good collaterals replace an open artery ? 95% of collaterals are no substitute for the open artery

  12. CTO – The European perspective • What you may want to know about collaterals • Why should we open a CTO ? • The past and presence of CTO treatment • CTOs in the DES era • The remaining challenges in CTOs

  13. CTOs – Should we treat them all ? • Improvement of symptoms (angina, dyspnea) • Improvement of LV function • Improvement of prognosis

  14. Benefit of recanalisation on LV function No improvement in case of Reocclusion !!! Werner et al. Am Heart J 2005;149:129-37

  15. Indication for revascularization: MRI function and vitality

  16. LV recovery after recanalization of CTOs - MRI Baks T et al. JACC 2006;47:721-5

  17. PCI success and survival 2000 Pat, 74% successful Suero et al. JACC 2001;38:409-14 1458 Pat, 77% successful 871 Pat, 65% successful Hoye et al. Eur Heart J 2005;26:2630-6 Ramanathan & Buller, ACC 2003

  18. If PCI fails … at least consider CABG But CABG seems to be only the second best option Suero et al. JACC 2001;38:409-14

  19. A CTO left occluded makes life more dangerous

  20. Leaving a CTO alone means taking risks in low risk patients PCI of STAR Registry, Institute for infarct research, Ludwigshafen

  21. CTO – The European perspective • What you may want to know about collaterals • Why should we open a CTO ? • The past and presence of CTO treatment • CTOs in the DES era • The remaining challenges in CTOs

  22. CTOs in the cathlab routine in 2003 • In a German registry (STAR – Stable Angina pectoris Registry - IHF, Ludwigshafen) 2002 consecutive diagnostic angiographies were evaluated: • 33% had at least one CTO • CTO pts had more severe symptoms, and LV dysfunction • the 1-year mortality with CTOs was 5.5% vs. 3.1% • Only one third of CTOs underwent PCI • Half of all CTOs were referred to CABG

  23. Why bother, you can‘t open it … most timesCTO success rates – historical perspective

  24. Why bother with PCI – you can‘t keep it open anyhowBinary angiographic restenosis with balloon vs BMS Woehrle CTO Workshop Munich 2005

  25. Stenting in CTOs: long and multiple stents required Werner et al. J Am Coll Cardiol 2003;42:219-25

  26. CTO – The European perspective • What you may want to know about collaterals • Why should we open a CTO ? • The past and presence of CTO treatment • CTOs in the DES era • The remaining challenges in CTOs

  27. Published studies using DES in CTOs

  28. Events in PRISON II: BMS vs. Cypher Suttorp et al. TCT 2005

  29. CTO vs. Complex Nonocclusive Lesions (Taxus VI) 100% 12 mos. 9 mos. 91.3 % 90% P=0.0003 12% NNT 8 35% NNT 3 Freedom of TLR TAXUS MR 80% Control 79.4 % 70% 0 30 60 90 120 150 180 210 240 270 300 330 360 Days Since Index Procedure TAXUSTM MR stent is not available for sale TAXUS= TAXUSTM stent Control=bare metal stent Werner et al. J Am Coll Cardiol 2004;44:2301-6

  30. 3.5x8 3.0x32 3.0x28 3.0x32 2.75x32 Long stenting no longer a problem for recurrence 6 months later 2214/05 471/05

  31. Taxus restenosis in CTOs: focal All nonocclusive restenosis were focal at the edges and successfully treated with another Taxus stent ->99 % patency

  32. Longterm patency 95 pts 10 pts. TVF 85 pts. No TVF 6 months 9 pts. Repeat PCI 1 pt. Reoccl. No PCI 9 pts. *) No TVF 12 months 1 pt. Late Reoccl. 93 pts. Werner GS et al; ACC 2006

  33. WISDOM 12-Month TAXUS Related Cardiac Events: Total Occlusions N = 65/778 Patients Only 8.4% !!! 6.7% n=4 Incidence (%) 3.3% n=2 1.7%n=1 1.7% n=1 Cardiac Death Overall MI TLR

  34. MILESTONE II 12-Month TAXUS Related Cardiac Events: Total Occlusions N = 186/3688 Patients Only 5% !!! 4.3% n=8 Incidence (%) 2.2%n=4 1.6% n=3 1.1% n=2 Cardiac Death Treated Vessel Re-intervention Overall MI Stent thrombosis = 1.0% (2/186)

  35. Opening a CTO … • Improves symptoms (angina, dyspnea) • Improves LV function • Improves prognosis • Can be kept open with DES • Why are they still undertreated ?

  36. 1995/96 1997/98 1999/01 2001/03 CTO success rates

  37. Penetration power of dedicated wires

  38. New wire techniques Mitsudo; www.tctmd.com

  39. Parallel wire technique - example Parallel wire technique with ASAHI Miracle Bros and Conquest wires 230/05

  40. Case example: Double blunt occlusion Blunt proximal cap with 2 large sidebranches and blunt distal cap with one large side branch. 12/05/06

  41. Case example: Double blunt occlusion Bilateral approach: Confianza Pro over Spectranetics versus Miracle 3G over Transit 12/05/06

  42. Case example: Double blunt occlusion Bilateral approach: A major new option for 2nd attempts But the majority of CTOs are not treated in live courses 12/05/06

  43. Determinants of procedural success • Experience, dedication and patience of interventionist • Duration of occlusion • < > 2 weeks • < > 3 months • < > 12 months • Angiographic criteria … not many • Heavy calcification • Vessel tortuosity

  44. PCI of CTOs is dangerous … really ? Bahrmann et al. EuroInterv 2006;2:231-7

  45. 2006 1995/96 1997/98 1999/01 Why do we not apply what is possible ?

  46. CTO – The European reality • Opening a CTO … • Costs a lot of lab time • Costs a lot of work time • Costs a lot of material • Costs a lot of radiation exposure • Requires a lot of patience • Does not pay in our reimbursement system

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