CHRONIC TOTAL OCCULUSIONS

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Slide 1 : CHRONIC TOTAL OCCLUSION
Slide 2 : Prevalence of Total Occlusion(s) in Coronary Patients CTO 30% 70% Patients with Total Occlusions Patients without Total Occlusions Source: Cardiac Data Resources, The BLG Group 30% of patients have one or more total occlusions
Slide 3 : Chronic Total Occlusions Unmet Clinical Challenge Definition 100% blockage of coronary or peripheral artery (TIMI 0 Flow) Greater than 3 months old Duration of occlusion : the basis of history of angina, previous myocardial infarction (MI) in the same territory, or proven by previous angiogram
Slide 4 : Total Occlusion ; Pathophysiology Bidirectional thrombus formation “ends first” Suzuki et al. AJC 2001 Srivatsa et al. JACC 1997 Abbate et a. Circulation 2002 Gradual replacement of thrombus, cholesterol IP with collagen, calcium Fibrous tissue density greatest at prox and distal ends (“caps”)
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Slide 6 : Abbate et al, J Am Coll Cardiol 2008;51:956-64 IS ANY SYNTHESIS POSSIBLE?
Slide 7 : PCI Treatment of CTOs High restenosis rates PTCA - as high as 75% Stent - 20% to 35% Increased procedure time and costs (40% higher in Mayo Clinic Study) Increased radiation exposure time (Mayo Clinic Study) 95% of failed PTCA procedures are due to inability to cross the lesion with a guide wire or balloon (Manual of Interventional Cardiology) Lower success rates historically
Slide 8 : Classification “A” grading: Technical challenges of recanalizing CTOs A0” grade reflects a relatively higher possibility of technical success. The presence of the following features places the lesion at an “A0” grade: • A stem of patent vessel longer than 10 mm; • No branching vessels originating within 5 mm of the occlusion; • Tapering configuration or a visible track; • No evidence of calcification on fluoroscopy
Slide 9 : “A1” grade reflects a relatively lower possibility of reopening with a guidewire and subsequent angioplasty. Presence of any one of the following features places the lesion at an “A1” grade: • A stem of patent vessel shorter than 10 mm proximal to the occlusion; • Presence of branching vessels originating within 5 mm of the occlusion; • Blunt configuration of the leading edge with no visible track; • Evidence of some calcification on fluoroscopy.
Slide 10 : A2” grade indicates the highest technical difficulty in tackling CTOs, and rates of successful PCI are likely to be very low. The presence of any one of the following features places the lesion at an “A2” grade: • Ostial total occlusion; • Total occlusion precisely at a bifurcation point; • Significant calcification on fluoroscopy; • Long lesion as evidenced by retrograde filling of the distal segment
Slide 11 : Classification “B” grading: Risk associated with attempts at reopening “B0” grade denotes a relatively low risk of adverse outcomes and is characterized by the presence of any of the following features: • Absence of bridging collateral vessels; • Absence of an aneurysmal appearance at the point of occlusion or in close proximity; • Presence of good distal vasculature as seen by retrograde filling via collaterals from other arteries. On the contrary, the absence of the above-mentioned features (“B1” Grade) signify a high risk of adverse outcomes.
Slide 12 : Anatomic Descriptors of Procedural Success
Slide 13 : Dual injection documentation of collaterals serves to evaluate the segments of the artery, distal to the occlusion, which is essential to CTO success. The retrograde injection is done a few heartbeats before the antegrade injection, to allow optimal documentation of both sides of the occlusion segment’s adjacent branches and to evaluate its actual length, occasionally demonstrating an unsuspected lumen.
Slide 14 : collateral channels (CCs) CC0, no continuous connection between donor and recipient vessel; CC1, continuous thread-like connection; CC2, continuous, small sidebranch-like connection visible, the connection is visible on coronary angiography or on the selective collateral injection all the way extending from donor to recipient vessel.
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Slide 16 : APROACH ANTEGRADE RETROGRADE
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Slide 18 : CART controlled antegrade and retrograde subintimal tracking Sumerly et al.
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Slide 20 : Procedural Technique The patients were pretreated with aspirin and ticlopidine or clopidogrel and were administered weight-adjusted heparin to keep the activated clotting time (ACT) >250 seconds. The technique of retrograde approach has evolved over time with accumulating experience and emergence of dedicated devices. the use of septal CCs and technique of controlled antegrade and retrograde subintimal tracking (CART) to facilitate this procedure
Slide 21 : GUIDING CATHETERS extra support is usually needed in greater force for delivery of devices In the left coronary artery usually EBU (Medtronic, Minneapolis, Minnesota), XB (Cordis, Gaithersburg, Maryland), Voda (Boston Scientific, Natick, Massachusetts) will be sufficient, with rare cases requiring an Amplatz curve catheters
Slide 22 : In the right coronary artery Amplatz left family of catheters, usually AL1, with AL0.75 for small aortas and AL 1.5 or 2.0 for dilated roots very proximal occlusions, having an AL1 catheter may be counterproductive
Slide 23 : GUIDEWIRE Hydrophobic wires (Miracle Bros/Confianza, Abbott Vascular Inc, Abbott Park, IL) offer better tactile response when attempting to penetrate the CTO and are favored when blunt dissecting through a fibrocalcific cap or organized thrombotic core. Hydrophilic wires (Fielder/Whisper, Abbott Vascular Inc) are preferred when navigating microchannels or tortuous segments where increased tip lubricity is helpful in overcoming frictional forces.
Slide 24 : ADAPTED MATERIALS Stiffer wires Additional bend 1to 2mm from the tip Hydrophilic wires
Slide 25 : Support catheters Support catheters provide the ability to exchange guidewires easily or to change the shape of the wire tip Selective infusion catheters similar to the Transit Catheter (Cordis, Miami, Florida), the Spectronetics (Westbury, New York) Quick-Cross support catheter, the Intraluminal (Carlsbad, California) Therapeutics angled support catheter, St Jude’s (St. Paul, Minnesota) Venture catheter,
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Slide 28 : modification of the support catheter BridgePoint Medical Systems The system is comprised of 3 elements: the CrossBoss CTO catheter, the Stingray CTO orienting balloon catheter, and the Stingray reentry guidewire with a tapered tip
Slide 29 : LINK
Slide 30 : Intravascular ultrasound of the entry point to assess the exact entry point of the proximal edge of the CTO. any occlusion that takes place immediately after a bifurcating branch. IVUS will be less useful in cases of heavy calcification in the vessel wall at the CTO ostium or side branch.
Slide 31 : CROSSING THE LESION Balloon low profile 1.5-mm balloon is advanced through the lesion and inflated for first predilatation. This is followed by additional predilatations as needed, according to the vessel size.
Slide 32 : Tornus® The Tornus® device (Asahi, Japan) is a catheter made up of eight stainless steel strands woven together to enhance flexibility and strength in exchanging wires, delivering balloons, It is used after a wire has crossed a chronic occlusion where a balloon will not cross. The Tornus is advanced into the CTO by up to 20 counterclockwise rotations
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Slide 34 : Crossing the chronic total occlusion with special devices Safe-Cross Frontrunner™ XP CTO Catheter Crosser™ System
Slide 35 : DEDICATED TECHNIQUES Magnum ball tip wire Ultrasound recanalisation Safesteer/ safecross Frontrunner spreading forceps Parallel wire technique IVUS guided wire technique CART technique Tornus crossing catheter
Slide 36 : Safe-Cross a steerable 0.014 inch intermediate stiffness guidewire incorporating optical coherence reflectometry, which measures the reflection of near-infrared light ahead of the wire tip
Slide 37 : The Safe-Cross Technological Principle Forward-Looking Guidance System High Resolution (10-15 microns) Precise Control of RF Energy
Slide 38 : Radio Frequency Controlled RF Energy to effectively cross total occlusions Ease of use with simple pedal used to deliver RF energy Precise RF energy release at distal tip of wire
Slide 39 : Safe-Cross Console and Display Display Advancing Mechanism Crossing Wire Support Catheter Console
Slide 40 : OCR Waveform Displays Simple Display Feature
Slide 41 : Frontrunner catheter is a manually operated device incorporating a bilaterally hinged distal tip assembly that, when activated spreads tissue planes via the principle of blunt microdissection. This device may have a special role in refractory in-stent CTOs.
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Slide 43 : Actuation, Retraction, and Torque Firm engagement before actuation Feel for resistance, and look for slow opening Retract after every actuation and confirm jaw closure Torque back into position before next actuation Assures closure Improves engagement Frontrunner Technique
Slide 44 : Equipment Selection Guiding Catheters 6F vs 8F Left Coronary JL4 vs XB vs Left Amplatz Right Coronary JR4 vs HS vs Left Amplatz (.75 vs 1) Frontrunners Curved vs Straight jaws Curved 25 degree vs 36 degree Small vs Large jaws New devices Bottlenose, FR 4.0, FR 2.8
Slide 45 : Frontrunner engaged in CTO: True Lumen FR2.5 can apply up to 7 – 10 atm pressure to tissue
Slide 46 : Comparison of CTO tissues Adventitia Fibrous Plaque
Slide 47 : Comparison of CTO tissues P = 0.002 P = 0.043 Yield Stress Ultimate Stress Adventitia is generally stiffer and stronger than fibrous plaque
Slide 48 : Computer modeling of Frontrunner: Transverse View Centered – true lumen Note higher stresses in plaque only Offset – probably subintimal Note high focal stress in plaque only
Slide 49 : Computer modeling of Frontrunner Longitudinal view Centered – true lumen Offset – probably subintimal
Slide 50 : Frontrunner Technique When do stop with Frontrunner and go with a wire? Instent CTO - -stop at end of stent Large distal sidebranch - -stop early Poor distal visualization - -stop early Hard distal cap – -go distal
Slide 51 : Guidewire Placement after Frontrunner Guidewire technique Subintimal vs True Lumen Frontrunner proximal vs distal to end cap Confirmation of Distal True Lumen (Nirvana) Antegrade flow (gold standard) Wire Movement in distal branches Visualization via collaterals Distal injection (pros and cons) IVUS (pros and cons) Guidewire selection Terumo Gold 18 Choice PT, PT Graphix, Shinobi Standard wires, Cross-It series
Slide 52 : Frontrunner Multicenter Study Results Frontrunner: delivered to lesion 95% advanced distal to lesion 61% Frontrunner Time 32min. Intraluminal Guide Wire Placement Beyond CTO 56% Stents Successfully Deployed 54% P. Whitlow, MD- The Cleveland Clinic Foundation: ACC2002
Slide 53 : The Crosser CTO recanalization system is comprised of a generator, transducer, foot switch, and a disposable catheter. The generator applies alternating current to piezoelectric crystals, resulting in their expansion and contraction within the transducer. The transducer then converts, amplifies, and transmits this energy to the catheter, which results in vibration of the tip at a rate of 21 000 cycles/second. This vibration provides mechanical impact and cavitational effects, which supposedly aid in the recanalization of the occluded artery
Slide 54 : When the CROSSER Catheter is activated using the foot switch, the Nitinol core wire transmits the vibrational energy to the metal tip of the Catheter. The high frequency mechanical vibration facilitates guidewire passage of the CTO
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Slide 80 : Complication Management Perforations Reverse Heparin – frequently all that is needed 2. Determine size and location Small vs Large Side branch vs adventitial disruption 3. Stop extravasation with balloon if possible 4. Echocardiogram 5. Right heart cath to r/o tamponade physiology 6. Confirm perforation has stopped for at least 30 min. Pericardiocentesis for Tamponade ? Coil embolization (try to avoid) Covered stent (Jomed) if needed
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Slide 83 : Procedural success Procedural success was defined as successful guide wire and balloon crossing with residual stenosis >50% and Thrombolysis in Myocardial Infarction grade 3 flow.
Slide 84 : Angiographic assessment Angiographic assessment of the collaterals was performed after bilateral simultaneous coronary injection performed in 2 perpendicular projections. Visibility of the CC was assessed after selective injections in the CC, if the coronary angiography was inadequate
Slide 85 : Total Occlusion ; Pathophysiology Bidirectional thrombus formation “ends first” Suzuki et al. AJC 2001 Srivatsa et al. JACC 1997 Abbate et a. Circulation 2002 Gradual replacement of thrombus, cholesterol IP with collagen, calcium Fibrous tissue density greatest at prox and distal ends (“caps”)
Slide 86 : PCI Treatment of CTOs High restenosis rates PTCA - as high as 75% Stent - 20% to 35% Increased procedure time and costs (40% higher in Mayo Clinic Study) Increased radiation exposure time (Mayo Clinic Study) 95% of failed PTCA procedures are due to inability to cross the lesion with a guide wire or balloon (Manual of Interventional Cardiology) Lower success rates historically
Slide 87 : Rationale for Opening CTO’s Outcomes “Improved global and regional ventricular function after angioplasty for chronic coronary occlusion” Engelstein E; et. al., Clin Investig, 72 (6): 442-7 1994 Jun Contrast Echocardiography in 49 patients before and 10 weeks after CTO PTCA 12 patients (24%) with reocclusion by angiography 37 patients - patent EF improved from 55.8% to 62.5% (p<.001) and regional wall motion improved from -1.7 to -0.6 (p<.001) In patients with reocclusion EF and RWM were unchanged Change in global and regional wall motion were unrelated to other parameters (Hx MI, collaterals, baseline LV function, severity of angina)
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Slide 91 : DEDICATED TECHNIQUES Magnum ball tip wire Ultrasound recanalisation Safesteer/ safecross Frontrunner spreading forceps Parallel wire technique IVUS guided wire technique CART technique Tornus crossing catheter
Slide 92 : Procedural Technique The decision and technique to perform retrograde attempt is completely on operator’s discretion. The patients were pretreated with aspirin and ticlopidine or clopidogrel and were administered weight-adjusted heparin to keep the activated clotting time (ACT) >250 seconds. The technique of retrograde approach has evolved over time with accumulating experience and emergence of dedicated devices. the use of septal CCs and technique of controlled antegrade and retrograde subintimal tracking (CART) to facilitate this procedure

 


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