Complex Coronary Cases

1. Complex Coronary Cases Supported by: Abbott Vascular Boston Scientific Corporation Medtronic, Inc. Astrazeneca

2. Disclosures Samin K. Sharma, MBBS, FACC Speaker’s Bureau – Boston Scientific Corporation, Abbott Vascular Inc, AngioScore, The Medicines Company, Daiichi Sankyo, Inc. and Lilly USA, LLC Annapoorna S. Kini, MBBS, FACC Nothing to disclose Sameer Mehta, MBBS, FACC Consulting Fees – The Medicines Company American College of Cardiology Foundation staff involved with this case have nothing to disclose

3. August 20th 2013 Case #14: SD, 62 yr M Presentation: Patient with new onset cresendo angina and positive stress echo for infero-lateral ischemia underwent cardiac cath on June 26, 2013 which revealed 3 V CAD (60% prox LAD, 80% distal LCx and 100% distal RCA) and normal LV function; SYNTAX score 22. CABG was recommended but declined and pt underwent Resolute Integrity (3.5/30mm) DES PCI of distal LCx. Pt continued to have class II angina on MMT. Prior History: Hypertension, NIDDM, +F/H Medications: All once daily dosage Atenolol 50mg, Amlodipine 5mg, Aspirin 81mg, Prasugrel 5mg, Metformin XR 1000mg, Glimeperide 2mg, Omeprazole 20mg

4. Case# 14: cont… Cardiac Cath 6/26/2013: Right Dominance 3 V CAD with LVEF 65% Left Main: No obstruction LAD: 60% prox LAD and 60% D1 non-bifurcation lesions LCx: 80% distal LCx, large vessel RCA: 80% mid and 100% distal RCA occlusion and distal vessel fills via bridge as well as retrograde collaterals Pt underwent successful DES PCI of distal LCx using 3.5/30mm Resolute Integrity DES. Pt did well but had class II angina despite MMT. Did not tolerate ISMN Plan Today: - PCI of distal RCA CTO using retrograde recanalization.

5. Appropriateness Criteria for Coronary Revascularization

6. Issues Involving The Case • Current status of CTO lesion success • Retrograde recanalization approach

7. Issues Involving The Case • Current status of CTO lesion success • Retrograde recanalization approach

8. Chronic Total Occlusion (CTO) From Randomized Trials to Daily Practice 1. CTO is present in 20-22% of cath cases but PCI is attempted only in 5-13% of these cases 2. From BARI trial (1994) to SYNTAX trial (2007) , the single most common reason for a patient to be referred to surgery and not randomized was a CTO with low success rate of recanalization 3. Even in the recent era of increasing success rate of CTO recanalization (60-85%), the PCI success rate for CTO lesions in the SYNTAX trial was only 53%

9. Current Perspective on Coronary CTOThe Canadian Multicenter CTO Registry Management of CTO Registry Patients by Treating Center Fefer et al, J Am Coll Cardiol 2012;59:991

10. Anatomic Descriptors of Procedural Success In the current ERA; Severe calcification

11. Predictors of CTO Procedural Success Multivariate analysis from TOAST-GISE Olivari et al., J Am Cardiol Coll 2003;41:1672

12. Incidence of Procedural Complications in Successful vs. Unsuccessful CTO PCI Complications Successful Unsuccessful p value Patel et al., JACC Cardiovasc Interv 2013;6:128

13. Temporal Trends in Cumulative Angiographic Success Rates and Major Procedural Complication Rates 80% 0.5% Patel et al., JACC Cardiovasc Interv 2013;6:128

14. Meta-Analysis of CTO Outcomes 13 Observational Studies, 7288 patients weighted averaged follow-up 6 years Joyal et al., Am Heart J 2010;160:179.

15. All-Cause Mortality for Successful and Failed Groups of CTO Duration >3 Months Khan et al., Cath & Cardiovasc Intervn 2013;82:95

16. Residual SYNTAX Score: 1-Year Outcomes According to the rSS rSS = 3-8 rSS = >8 rSS = 0 rSS = 0-2 P = 0.006 P =0.32 P = 0.007 (%) P = 0.001 P = 0.23 Stent Thrombosis uTVR MI Death MACE Généreux et al., JACC2012;59:2165

17. PCI: Four-Year Clinical Outcomes in Patients by Complete vs. Incomplete Revascularization Complete Revascularization (n=578) p=<0.001 Patients (%) Incomplete Revascularization (n=510) p=0.011 p=0.052 p=0.059 p=0.046 p=0.23 Farooq et . al., J Am Coll Cardiol 2013;61:282

18. Total Charges, Payments and Direct Costs per Patient Undergoing CTO and Non-CTO PCI p=<0.001 CTO (n=154) Cost (Dollars) Non-CTO (n=1,847) p=<0.001 p=0.58 Karmpaliotis et al., Cath & Cardiovasc Interv 2013;82:1

19. Issues Involving The Case • Current status of CTO lesion success • Retrograde recanalization approach

20. Retrograde Wire Technique of CTO Recanalization

21. Retrograde Techniques for CTO Recanalization • Typically reserved for LAD or RCA CTOs via septal collaterals; avoid using epicardial collaterals • Four techniques: • Direct retrograde crossing • Kissing wire crossing • Controlled Antegrade and Retrograde Subintimal Tracking (CART); balloon dilatation or knuckle wire • Reverse CART

22. Retrograde Wire Technique for Chronic Total Occlusion Recanalization Four Patterns of Success in Retrograde CTO Recanalization Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.

23. Increased Use of Retrograde Approach and Technical Success Rate Over Time 2006 2007 2008 2009 2010 2011 30% % Michael et al., Am J Cardiol 2013;112:488

24. Summary of Published Retrograde CTO PCI Series Karmpaliotis et al., JACC Cardio Interv 2012;5:1273

25. Retrograde PCI: 5 Steps • Retrograde PCI for recanalization of CTOs has gained acceptance as a necessary technique to improve success • The procedure involves five key steps: • Wiring of the collateral from the donor artery into the distal bed of the recipient artery, usually with the use of hydrophilic jacketed guidewires • Delivery of over-the-wire microcatheters especially Corsair channel dilator to allow an exchange for a CTO-specific guidewire • Crossing the total occlusion with the CTO guidewire and dilating the CTO with the retrograde small balloon (1.25-1.5/8-10mmsize) • Placing an antegrade guidewire into the distal bed through the recanalized CTO. Rarely exteriorization of the long retrograde guidewire (Viper wire 360cm) is needed to advance antegrade monorail or over-the-wire small balloon • 5. Stenting the lesion over the antegrade guidewire

26. Retrograde Wire Technique for CTO Recanalization • When to do Retrograde technique? • Minimum 200 CTO cases via antegrade technique • Dedicated setup, equipments and ability to handle compl. • Usually after failed antegrade (once or twice) approach • Ostial stump occlusion (RCA, LAD, LCx)

27. Fundamental Wire Technique and Current Strategy for Chronic Total Occlusion PCI Procedural Steps of Current CTO-PCI Cotralateral Dual Injection CTO - PCI Single Wire Technique Antegrade approach x2 Parallel Wire Technique Retrograde approach (ostial) Retrograde Wire Cross Kissing Wire Cross IVUS guide re-entry CART Reverse CART Success Failure

28. Take Home Message:Status of CTO lesion PCI and Retrograde recanalization approach • Improvement in the procedural techniques and devices has resulted in increasing success of CTO PCI. A successful CTO PCI is associated with better long-term outcome, decreased cost & lower mortality. • Technique of retrograde recanalization is gaining increasing momentum and adds to the already increasing technical success rates. Every advanced CTO PCI center should dedicated experienced operators for the retrograde approach.

29. Question # 1 • Which one of the angiographic lesion morphology is associated with the highest rates of unsuccessful CTO recanalization : • Blunt stump • Side branch at the site of occlusion • Short occlusion length • Severe calcification • Bridge collaterals

30. Question # 2 • A successful CTO recanalization is associated with following except : • Lower MACE • Lower mortality • Lower stent thrombosis • Lower incidence of long-term CABG • Lower angina

31. Question # 3 • Following are the techniques for retrograde recanalization except : • A. Kissing wire approach • B. Retrograde wire cross • C. Controlled antegrade and retrograde tracking (CART) • D. Reverse CART • E. Parallel wire technique

32. Question # 1 • Which one of the angiographic lesion morphology is associated with the highest rates of unsuccessful CTO recanalization : • Blunt stump • Side branch at the site of occlusion • Short occlusion length • Severe calcification • Bridge collaterals The correct answer is D as of these unfavorable factors severe calcification still is associated with highest failure Olivari et al., J Am Cardiol Coll 2003;41:1672.

33. Question # 2 • A successful CTO recanalization is associated with following except : • Lower MACE • Lower mortality • Lower stent thrombosis • Lower incidence of long-term CABG • Lower angina The correct answer is C as stent thrombosis may even be higher in successful vs. unsuccessful CTO recanalization Joyal et al., Am Heart J 2010;160:179.

34. Question # 3 • Following are the techniques for retrograde recanalization except : • A. Kissing wire approach • B. Retrograde wire cross • C. Controlled antegrade and retrograde tracking (CART) • D. Reverse CART • E. Parallel wire technique The correct answer is E as all others are the techniques of retrograde CTO recanalization while the parallel wire technique is for antegrade recanalization Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.