Dr. Thierry Lefevre,
Chronic total occlusion (CTO) remains the most difficult procedure in interventional cardiology. However, in the last 10 years, we have seen an explosion in technology, technical refinement, expertise and clinical experience in this field. It was time in 2013 to have a dedicated session in this field at the ESC meeting.On Saturday 31st August, we had a very educative, well attended and well balanced session with 3 interventional experts in this field and one very experienced cardiac surgeon and the learning objectives were reached.Pr G. Werner, from Germany, President of the Euro CTO club nicely explained when we should propose CTO percutaneous coronary revascularisation. He showed that even big collateral vessels are not enough to avoid ischemia and “are not an excuse to avoid revascularisation”. Indication for PCI should be discussed only when there is viability and a significant amount of ischemia in the CTO territory. According to many studies, a 10% ischemic territory and > 50% viability seems to be the right cut-off point for improvement of ischemia, symptoms and quality of life after PCI success. This is the main objective of CTO PCI, he said, and MRI is probably the best tool for patient screening.Furthermore, many studies have shown that success in reopening a CTO is associated with an improvement in ejection fraction, a reduced need for CABG and, according to the recent meta-analysis by Joyal (Am Heart J 2010), a reduction in death. The limitation of these observational data is that we are comparing success to failure of CTO, not to optimal medical treatment (OMT).Ongoing randomized studies comparing OMT to PCI (including one from the Euro CTO club) will give a final answer to this important question. Several studies (Dr Claessen and the HORIZON study, Eur Heart J 2012) have shown that the presence of a CTO in AMI patients is associated with higher 30-day and long term mortality rates and he suggested that after treatment of the AMI vessel, the CTO should be reopened (if the territory is viable) within 4 weeks. Finally he showed in a recent paper by Migliorini (JACC 2011) that left main PCI is associated with worse outcome when an occlusion of the right coronary artery remains. More recently, 4 papers have shown that leaving a residual Syntax score > 8 after revascularisation by PCI or CABG is associated with poor outcome and that these untreated lesions were mainly CTOs.Dr Y. Louvard from France described nicely the up-to-date techniques for an antegrade approach, which is the most common approach, pointing out the importance of good catheter selection for optimal support, which can be improved by the “anchoring balloon technique” or mother and child technique. He showed how important the selection is and the shape of the wire, and today the default wire is a soft dedicated wire. He also showed good examples of the “parallel wire technique” and IVUS guided penetration in case of invisible stump.A retrograde approach as a first attempt is rarely used in his experience, only when the origin of the CTO is ambiguous and IVUS guided penetration cannot be used or in case of ostial occlusion of the right coronary artery. He also explained that he uses the radial approach and 6-French guides in the vast majority of cases. Finally, he showed that the success rate is high (> 80%) and the complication rate very low.Dr S. Rinfret from Quebec described when and how we should use a retrograde approach, or a “cook book for retrograde approach”. He showed an algorithm of what he called the hybrid approach, using the retrograde approach when there is ambiguity of the proximal or distal cap, long lesion or bifurcation at the level of the distal cap and failure to reach the distal lumen with the antegrade approach, using the crossbow/stingray technique in about 25% of cases. He recommend to use septal branches for retrograde connection using “septal surfing” (trial and error technique, he said), with a dedicated wire like the Sion wire. Epicardial connections are used only in case of failure with septal connections with very gentle progression of the wire because of a higher risk of pericardial effusion, except in patients with previous CABG. He showed that he uses the radial approach in the majority of cases, but more frequently 8 French guiding catheters. He concluded that the Hybrid approach is associated with a high rate of success (90%) and is very safe, but that this technique is very demanding and needs dedicated physicians doing more than 50 CTOs per year.Dr P Davierwala from Germany concluded the session with the surgical approach in patients with CTOs. He showed that the rate of success is similar in patients with or without CTO and that arterial grafts (as opposed to saphenous vein grafts) have a very good long term patency. He showed that the up-to-date approach with surgery today is “minimally invasive” and presented a large series of MIDCAB surgery with excellent results. During the discussion, Prof Werner pointed out that this technique is excellent for the left anterior descending artery, but unfortunately many right coronary arteries are still treated with saphenous vein grafts as shown in the Syntax study.
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