Carlo Di Mario - Recent Publications & Research in CTO: 2015-16

Recent Publications & Research in CTO: 2015-16

Carlo Di Mario, MD, FESC, FACC, FRCPCarlotta Sorini Dini, MD

Univ. Florence & Careggi Hospital

Manuscripts Published on CTO

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• Epidemiology

• Physiology

• Outcome Data

• Predictors

• Technique

• Imaging

• Stents in CTO

CTO Published Manuscripts 2015-2016 : Rapid Review of the Recent CTO Literature

CTO in 20.3% of angiographies in 4140 patients

January-October 2014, single high volume centre (Quebec)

Exclusion criteria: history of coronary artery bypass graft (CABG)

Treatment: 9% PCI, 34% CABG, 57% medical therapy

NSTEMI41%

Stable CAD48%

STEMI8%

Other3%

Clinical presentation Viability testing

Viability68%

No viability6%No testing

26%

Azzalini et al In press Am J Cardiol 2016

Azzalini et al In press Am J Cardiol 2016

Indipendent predictors of PCI

Success PCI : 64.6%

ACCF/AHA/SCAI guidelines for PCI

European Heart Journal (2015)36, 3189–3198

IRCTO is a prospective real world multicentre registrya total of 1777 patients were enrolled for an overall CTO prevalence of 13.3%.12 high-volume Italian centresStrategies: MT(medical therapy) in 826 patients (46.5%), PCI in 776 patients (43.7%), and CABG in the remaining 175 patients (9.8%) 1-year follow-up: patients undergoing PCI showed:

A) lower rate of major adverse cardiac and cerebrovascular events (MACCE) (2.6% vs. 8.2% and vs. 6.9%;P.0.001 and P.0.01) and cardiac death (1.4% vs. 4.7% and vs. 6.3%; P.0.001 and P.0.001) in comparison with those treated with MT and CABG, respectively.

B) after propensity score matching analysis, patients treated with PCI showed lower incidence of cardiac death (1.5 vs. 4.4% P.0.001), acute myocardial infarction (1.1 vs. 2.9% P 0.03), and re-hospitalization (2.3 vs. 4.4% P 0.04) in comparison with those managed by MT

European Heart J: Sept 2015

Angiographic characteristics of CTO

Am J Cardiol. 2016 Apr 1;117(7):1031-8

2368 patients with coronary heart disease and diabetes mellitus enrolled in the BARI-2D trial

Revascularization + intensive medical therapy ( PR) vs intensive medical therapy alone (IMT)

CTO prevalence 41 % (972 patients)

482 patients (41%) in PR group and 490 patients (41%) in IMT group

In the PR group, patients with CTO were more likely to be selected for the coronary artery bypass grafting stratum (CABG 62% vs PCI 31%, p <0.001)

Single centre COMMIT-HF registry

January 2009-Dicember 2014

Follow-up: 12 months

consecutive nonselected patients hospitalized in cardiology wards and

intensive cardiac care units with a diagnosis of systolic HF

278 patients (41.2%) with CTO

The patients with CTO had a higher prevalence of previous MI (77% vs 66%)

and CABG (38% vs 26%)

Tajstra, Pyka et al J Am Coll Cardiol Intv 2016:9:1790-7

Tajstra, Pyka et al J Am Coll Cardiol Intv 2016:9:1790-7

PCI only in 4.4% patients

NO viability testing was performed

1212 patients with an EF of 35% or less and coronary artery disease amenable to CABG. Randomized to CABG plus medical therapy (n=610 ) or medical therapy alone (n=602 )

Velazquez, Kerry et al N Engl J Med 2016

European Heart Journal , Sept 2016

European Heart J , Sept 2016

• Epidemiology

• Physiology

• Outcome Data

• Predictors

• Technique

• Imaging

• Stents in CTO


Stuijfzand ,Eur Heart J Cardiovasc Imaging 2016 Sep 1

Even in the presence of angiographicallywell-developed collateral arteries, thevast majority of CTO patients with apreserved LVEF showed significantlyimpaired perfusion

76 patients with CTO and preserved LVEF

PET to assess myocardial blood flow (MBF) and coronary flow reserve

MBF of the target area during hyperaemia was significantly lower when compared with the remote area (1.37+0.37 vs. 2.63+0.71 mL /min/g, P 0.001)

• Epidemiology

• Physiology

• Outcome Data

• Predictors

• Technique

• Imaging

• Stents in CTO


• 14,441 patients with CTO (16%) and 75,431 patients without CTO

• January 2005-January 2012

• CTO group vs non CTO group

• Follow-up mean: 3.1 years

Ramunddal, Hoebers et al J Am Coll Card Intv 2016;9: 1535-44

CTO indipendent predictor mortality



Risk long-term mortality Successful revascularisation

Successful revascularisation 54.4%

Long-term impact of CTO successful recanalization on mortality

LP. Hoebers et al IJC 2015

Thai, Catheter Cardiov Intv 85:781–794 (2015)

= failure PCI

= success PCI

LONG-TERM FOLLOW UP (median FU 30-month)

Coronary CTO in the nonculprit artery in patients presenting with ST- segment elevation myocardial infarction is associated with increased short- and long-term all-

cause mortality.

480 STEMI patients with a CTO in a non-infarct-related artery

Henriques , EuroIntervention 2016;12:423-430

Mortality in STEMI patients with a single CTO stratified according to culprit-related artery

Mortality in STEMI patients with a single CTO stratified according to CTO-related artery

http://www.exploretrial.com/background.html

José PS Henriques

http://www.exploretrial.com/background.html

Additional PCI of a CTO located

in the LAD may improve LVEF

and clinical outcome during

follow up.

Results

• Epidemiology

• Physiology

• Outcome Data

• Predictors

• Technique

• Imaging

• Stents in CTO


• Occlusion characteristics (stump/length/calcium/tortuosity)

J-CTO Score

Morino et al. JACC Cardiovasc Interv 2011

CL score- clinical and lesion related score

Alessandrino, JACC Interv 2015

Christopoulos, JACC Interv 2016

Karatasakis, Internat J Cardiol 2016

Data from 4 centers involving 240 consecutive

CTO lesions with pre-procedural coronary

computed tomography angiography were

analyzed.

Successful guidewire (GW) crossing ≤30 min

was set as an endpoint to eliminate operator bias

JACC Cardiovasc Interv. 2015 Feb;8(2):257-67

JACC Cardiovasc Interv. 2015 Feb;8(2):257-67

Conclusion: the CT-RECTORscore represents a simple andaccurate noninvasive tool forpredicting time-efficient GWcrossing that may aid in gradingCTO difficulty before PCI.

Suzuki, Cathet Cardiov Interv 2016

Crossing success: 77%

PCI success: 68%

• Epidemiology

• Physiology

• Outcome Data

• Predictors

• Technique

• Imaging

• Stents in CTO


Wilson WM, Walsh SJ, Yan AT, et al. Heart 2016;102:1486– 1493.

First attempt success rate by a hybrid-trained CTO operator was 79%.The success rate during the subsequent procedure was 87%

1,211 patients, 7 hospital in UK

Hybrid approach improves success of chronic totalocclusion angioplasty

Hybrid approach improves success of chronic totalocclusion angioplasty

1,211 patients, 7 hospital in UK

Adverse eventsFinal strategy adopted

AWE= anterograde wire escalationADR= anterograde dissection re-entryRWE= retrograde wire escalationRDR= retrograde dissection re-entry

Wilson WM, Walsh SJ, Yan AT, et al. Heart 2016;102:1486– 1493.

•44 european hospitals•8647 patients ,mean age was 62.0 ± 10.4 years,men 88.5%•Mean clinical follow-up duration was 24.7 ± 15.0 months

Galassi, Sianos et al JACC 2015, vol 65, n 22

Galassi, Sianos et al JACC 2015, vol 65, n 22

Changes in angina and dyspnea status after retrograde CTO PCI

• Epidemiology

• Physiology

• Outcome Data

• Predictors

• Technique

• Imaging

• Stents in CTO


J Am Heart Assoc. 2016;5

619 CTO PCI performed in 7 US centers

In 38 % patients was used intravascular imaging (IVUS in 36%, OCT in 3%, and both in 1.45%)

Morphological assessment of CTO:coronary CTangiography and IVUS

128 patients, 130 lesions analyzed with coronary CT angiography and IVUS

Positive remodelling

(33.8%)

Negative remodelling

(56.9%)

Collapse(9.2%)

Yamamoto et al Eur Heart CardiovascImaging. 2016 Apr

Yamamoto et al Eur Heart J Cardiovasc Imaging. 2016 Apr 20

Positive remodelling(n=44)

Negative remodelling(n=74)

Collapse(n=12)

P value

Median age (years) 64.5 (51.3-71) 67 (58-75.3) 55 (49.5-61.8) 0.005

Occlusion length (mm) 10.4 (5.5-17.4) 10.7 (6.0, 20.5) 46.3 (19.0, 61.0) <0.001

IVUS remodelling index 1.24 (1.14, 1.33) 0.97 (0.80, 1.02) 0.89 (0.53, 0.95) <0.001

Proximal plaque burden 53.1 (46.2, 62.6) 59.1 (50.6, 65.0) 40.5 (31.5, 47.5) 0.001

Distal plaque burden 51.2 (38.9, 58.0) 57.1 (47.0, 65.6) 34.1 (21.4, 39.1) <0.001

Stent expansion (%) 96.2 94.8 91.3 0.76

Retrograde approach (%) 25 36.5 66 0.03

34%57%

9%

29%

40% 29% 41%

33%

25%Plaque type

= non-calcified= mixed = calcified

Am J Cardiol. 2016 Mar 1;117(5):727-34

serial follow-up intravascular ultrasound (baseline and follow-up at 9 ± 2 months)

after DES implantation into 40 CTOs.

anterograde approach (82.5%), retrograde approach (17.5%)

Late-acquired stent malapposition

was seen in 17 patients (42.5%)

In 8 CTOs (20%), a part of the stent

was implanted into a subintimal

space; in these 8 patients, maximum

percent neointimal hyperplasia and

minimum lumen area was similar in

the subintimal segment compared

with the adjacent intraplaque

segment. The frequency of late-

acquired stent malapposition was

similar

The distal reference, but not theproximal reference lumen CSA,increased significantly at follow-up(3.8 ± 2.0 to 5.1 ± 2.3 mm(2), p =0.0004)

Conclusion: after CTO treatment with DES, distal vessel enlargement was detected.Subintimal stenting after recanalization of CTO was not inferior compared withstenting within the plaque in terms of long-term morphologic impact

Am J Cardiol. 2016 Mar 1;117(5):727-34

230 pts with CTO randomized 1:1 IVUS+angiography vs angiography

EuroIntervention 2015;10:1409-1417

The primary endpoint was in-stent late lumen loss (LLL) at one-year follow-up.

Follow-up with office visits or telephone contact to 24 months

In-stent LLL in the IVUS-guided group was significantly lower compared to the angiography-guided group at one-year follow-up (0.28±0.48 mm vs. 0.46±0.68 mm, p=0.025), with a significant difference in restenosis of the "in-true-lumen" stent between the two groups (3.9% vs.13.7%, p=0.021)

The minimal lumen diameter and minimal stent cross-section area significantly and negatively correlated with LLL (all p<0.001).

The rates of adverse clinical events were comparable between the IVUS- and angiography-guided groups at two-year follow-up (21.7% vs. 25.2%, p=0.641).

EuroIntervention 2015;10:1409-1417

Circ Cardiovasc Interv. 2015 Jul;8(7):

N-BES, Nobori biolimus

eluting stent;

R-ZES,Resolute

zotarolimus-eluting

stent

Circ Cardiovasc Interv. 2015 Jul;8(7):

IVUS-guided CTO intervention significantly improved MACE rate during the

12 months after DES implantation when compared with conventional

No significant differences zotarolimus and biolimus eluting stents

• Epidemiology

• Physiology

• Outcome Data

• Predictors

• Technique

• Imaging

• Stents in CTO


Kelbæk et al, EuroIntervention 2015;11:650-657

3 groups: - chronic TO (CTO; n=256)- non-chronic TO (n=292) - no occlusion (n=2.941)

Resolute zotarolimus-eluting stent (R-ZES)

The rate of TLF at two years was not significantly different among patients in the

CTO (9.1%), TO (9.8%), and no occlusion (10.4%) groups (log-rank p=0.800);

neither were the components of TLF

Definite or probable stent thrombosis occurred more frequently in the TO group

(2.8% vs. 1.2% in the CTO and 1.1% in the group with no occlusion, p=0.027).

There were 10 late and six very late stent thrombosis events

Conclusions

Apart from a higher rate of stent thrombosis in patients with TO, patients with

totally occluded coronary arteries who receive revascularisation with an R-ZES

have clinical outcomes comparable to those who receive a similar stent in non-

occluded lesions

Kelbæk et al, EuroIntervention 2015;11:650-657

Teewen et al Eurointervention 2014

First phase : randomized 51 pts SES vs 46 pts Endeavor (zotarolimus)Second phase: randomized 103 patients SES vs 104 patients Resolute (zotarolimus)

First phase NO significative differencestarget lesion revascularisation 12.2% vs. 19.6%, p=0.4target vessel failure 14.3% vs. 19.6%, p=0.68 definite or probable stent thrombosis 4.1% vs. 2.2%

Second phase NO significative differencestarget lesion revascularisation 10% vs. 5.9%, p=0.42target vessel failure 10% vs. 7.9 %, p=0.78 definite or probable stent thrombosis 1% vs. 0%

Target vessel failure

First-Generation Versus Second-Generation DES in CTO: Two-Year Results of a Multicenter Registry

Ahn …Choi, August 2016

Efficacy of second-generation DES is similar tothat of first-generation DES for patients with CTO

Everolimus- Versus Sirolimus- Versus Paclitaxel-Eluting Stents in OCT

National Korean registry

Primary endpoint: MACE (composite of cardiac death, nonfatal myocardial infarction, and target lesion revascularization)

Each component of MACE was also comparableamong the 3 stents.Independent predictors of MACE were diabetesmellitus, previous congestive heart failure, andleft circumflex CTO.

• 40 consecutive patients with CTO treated with BVS• Population : male 78%, mean age 59.9±8.3 years, diabetics 30% • Mean J-CTO score was 1.6. • Results: a total of 63 BVS were implanted with an average number of

1.6 per patient, and an average scaffold length of 42.4±21.5 mm. • No device-related complications. • At follow-up (median time 556 days): no deaths, one late scaffold

thrombosis , one focal restenosis

EuroIntervention 2016;12:e144-e151

• CTO Prevalence is increasing in the sicker, older patients studiedangiographically nowadays and depends on patientcharacteristics: it may reach up to 40% in diabetes/ischemic HFwith low EF

• New comparisons of successful and failed CTO revascularizationsuggest improvement of long term prognosis

• New predicting scores for estimating technical success in CTOPCI offer limited advantage over J-CTO

• Standardization of modern CTO recanalization techniques,achieves success rates approaching 90%

• Intravascular image can facilitate CTO PCI but is rarely used

• Type of DES have limited influence in MACE post CTOrecanalisation, with insufficient data to recommend BVS

Conclusions

EuroCTO Course 2015-2016 : Rapid Review of the Recent CTO Literature

Health & Medicine

Carlo Di Mario - Recent Publications & Research in CTO: 2015-16