Valeri Gelev - Ostial CTO Lesions

Ostial CTO Lesions

Valeri GelevTokuda Hospital Sofia

Ostial Lesions

Definition Ostial disease is defined as a lesion

arising within 3 mm of the vessel origin

Classification– Aorto-ostial – involving the ostia of the RCA, LMS, and ACB grafts.

– Non-aorto-ostial – involving the ostiaof the major coronary arteriesnot arising directly from the aorta; i.e., the LAD, Cx and RIM.

– Branch ostial – involving the ostia of branches of the major coronary vessels; (diagonals, marginals, PL and PD)

Percy Eurointerverntion 2009

Ostial Lesions - Incidence

33%12%

32%

18%

Overall Incidence around 3%

Patel CCI 2016

CTO - Ostial Lesions Incidence

Limited data

Galassi Coron Artery Dis 2015

CTO - Ostial Lesions Incidence

Limited dataEuro CTO Registry 2012-07.2015

Mayer-Gessner EuroCTO meeting 2015

RCA Ostial Other Lesions

n 378 (4%) 9030 (96%)

lesion length(mm) 43,4 30,7

J CTO score (men) 3,2 2,3

antegrade only (%) 38 73

retrograde only (%) 37 11

antegradea and

retrograde (%)

25 16

stent length (mm) 78,4 62,3

procedural time 140,1 106,2

fluoro time 62,5 41,2

Contrast (ml) 317,5 292,2

Success rate (%) 78 87

CTO - Ostial Lesions Incidence

Limited data

Chun Luo JACC – Cardiovascula Imaging 2015

Independent predictor of Failure

CTO - Ostial Lesions Incidence

Non Aorto-ostial Lesions

Side Branch at Proximal

Cap

=

Increasing the Proximal Cap Ambiguity

Angiographic Predictors of Unsuccesful CTO

CUMC experience

Odds Ratio 95% CI p-value

CTO length 1.06 per 1mm increase

1.03-1.09 <0.01

Blunt stump 1.35 0.68-2.66 0.39

Side Branches 2.81 1.45-4.96 <0.01

Bridging collaterals 0.60 0.32-1.15 0.12

>1 CTO in vessel 3.22 1.13-9.19 0.03

Vessel calcification 4.54 2.40-8.56 <0.01

Diffuse disease 0.85 0.34-2.12 0.73

Prior CABG 1.03 0.53-2.03 0.93

Obunal K: ACC 2008

1 1,5 2 2,5 3 3,5

Proximal v distal vessel

Length <15, 16-30, >30

Absent proximal tortuosity

Less calcification

Unambiguous proximal cap

No previous CABG

BMI < 30

Adjusted OR for success

Predictors of success – UK HYBRID

Multivariate analysis: C statistic = 0.72

All p<0.01

Wilson CTO summit 2016

PROspective Global REgiStry for the Study of CTO interventions

Proximal cap ambiguity

Brilakis CTO summit 2016

CTO - Ostial Lesions - Management

– Microchannels

– Bridging Collaterals

– Calcium in the vessel course

– Additional imaging modalities

• IVUS

• CT angio of CTO

– Utility of Retrograde Approach

Non Ao-ostial Ao - ostial

+ +/-

++ +/-

++ ++

+++ -

+/- +/-

++ +++

Meticulous attention should be paid to prevent retrograde wire going subintimally in the proximal vessel, LM respectively.

How to predict the vessel origin in the absence of stump

CTO - Ostial Lesions Case presentation

CTO - Ostial Lesions Case presentation

CTO - Ostial Lesions Case presentation

CTO - Ostial Lesions Case presentation

CTO - Ostial Lesions Case presentation

CTO - Ostial Lesions Case presentation

Final Result

CTO – Ao-Ostial Lesions - Case presentation

CTO – Ao-Ostial Lesions - Case presentation

CTO – Ao - Ostial Lesions - Case presentation

CTO – Ao - Ostial Lesions - Case presentation

Final Result

CTO - Ostial Lesions

• Ostial CTO lesions represent an inhomogeneous subsetof chronically occluded coronaries.

• There is a paucity of data about their incidence,treatment options and longstanding results.

• PCIs in Ao-ostila CTOs are complex, procedures,demanding high expertise of the operator and a lot ofresources.

• Reported success rates are lower compared with theconventional CTO PCI.