28-29 March 2014
CTO revascularization in Europe
Alfredo R. Galassi MD, FESC, FACC, FSCAI
Director of Cardiac Catheterization and
Interventional Cardiology Unit
Department of Medical Sciences and Pediatrics
Division of Cardiology, Cannizzaro Hospital,
University of Catania, Italy
15
September
1977
Andreas Gruntzieg
First Percutaneous Coronary
Angioplasty in humans
….therefore, the total closure is a real problem.
If we cannot solve the total closure problem, we will
probably never really address the question
of multivessel disease dilatation
Andreas Gruentzig, 1985
2 weeks before his death during airplane crash
Euro Cto Club
Founding Meeting
Carlo Di Mario was the
photographer
Paris 14.12.2006
Joachim Buettner
Gerald Werner
Dariusz Dudek
George Sianos
Alfredo Galassi
Nicolaus Reifart
Goals of the Euro CTO Club
Promote angioplasty for
treatment of CTO in Europe
• Exchange experience among the most
experienced
•
•
•
•
Test new technologies and strategies
Draw information from an own registry
Issue ”state of the art” recommendations
Teaching courses
CTOs are common and influence
management
Analysis of 6.581 consecutive patients undergoing
angiography (1990-2000), CTO was found in 52%
patients with significant (> 70% DS) coronary disease
Christofferson et al, Am J Cardiol 2005
12
CENTERS
2008-2009
The IRCTO Registry
1777 patients enrolled with 1968 CTO lesions
Christofferson et al,
AJC 2005
CTO
prevalence 12.3%
46%
44%
Optimal medical
therapy 826 pts
10%
CABG 175 pts
PCI 776 pts
Tomasello D et al, GIC 2012
The Canadian Multicenter CTO Registry
April 2008 - July 2009 (3 centers)
Patients with chronic total occlusion (CTO)
n=1697
CTO prevalence 18.4%
Christofferson et al, AJC 2005
PCI
n=515
30%
Medical Therapy
n=747
44%
Attempted CTO PCI
n=162
10%
Successful CTO PCI
n=123
7%
CABG
n=435
26%
CTO bypassed
n=388 (90% of operations)
23%
Overall, 30% of CTOs revascularized!
Fefer P et al, JACC 2012
Course Directors
Nicolaus Reifart
Main Taunus Kliniken
Bad Soden, Germany
Gerald S. Werner
Medizinische Klinik
Klinikum Darmstadt
Darmstadt, Germany
Co-Directors
Alfredo R. Galassi
Ferrarotto Hospital
University of Catania
Catania, Italy
George Sianos
AHEPA University Hospital
Thessaloniki, Greece
Hans Bonnier
University Hospital Brussels
Brussels, Belgium
Number of Total and Retrograde PCI
in the ERCTO Registry (~8000 patients)
Procedural Success Divided
According to Type of Approach
%
All p<0.05
%
Procedural Complications
3
All p=NS
2.5
2.5
2.3
2.2
2
1.9
1.5
1.5
1
1
0.5
1.1
1.2
1
0.8
0.8
0.5
0.5
0.5
1
0.9
0.6
0.6
0.3
0.7 0.7
0.8
0.5
0.03
0
0
2009
0.8
0.5
0.6
0.5
0.3 0.3 0.3
0.1
2008
1
2010
2011
0.0008
2012
Death
Cardiac tamponade
Myocardial infarction
Vascular complication
Coronary perforation
Collateral donor vessel
thrombus or dissection
2013
0.6
Procedural Success Divided
According to Skill of Operators
% 95
90
90.2
87.8
85
80
80.3
85.9
81.6
88
82.5
89.6
82.4
79.8
75
70
65
60
2008
2009
2010
2011
Retrograde Operator
Only Antegrade Operator
2012
Success Rate and Case Load
2008 - 2013
%100
88 89
84
Variance analysis p<0.001
92
91
88
87
84
82
82
96
90 91
90 90
85
78
80
72
60
40
20
0
2008
2009
>150/<200 procedures
2010
2011
2012
>200/<300 procedures
2013
>300 procedures
Retrograde experience in the Euro CTO Club
Retrograde CTO Revascularization
Types of collaterals used in
retrograde CTO revascularization
IVUS usage in CTO revascularization
Course Directors
Nicolaus Reifart
Main Taunus Kliniken
Bad Soden, Germany
Gerald S. Werner
Medizinische Klinik
Klinikum Darmstadt
Darmstadt, Germany
Co-Directors
Alfredo R. Galassi
Ferrarotto Hospital
University of Catania
Catania, Italy
George Sianos
AHEPA University Hospital
Thessaloniki, Greece
Hans Bonnier
University Hospital Brussels
Brussels, Belgium
Consensus on Indications and Strategy
from the EURO CTO CLub
Best treatment for CTO is the result of:
-
Careful review of clinical history
-
Sensitive non-invasive assessment of myocardial ischemia
and viability in CTO related territory
-
Life expectancy (younger and older youth)
-
Patient risk profile assessment (complete revascularization
in multivessel patient); patient selection is crucial
-
LAD CTO no more a problem!!!
Consider main vessel ischemic area related to CTO
Radiation, contrast load and complication risk assessment
(balance success vs failure)
Consensus of Euro CTO Club Eurointervent 2012
Conclusions from the Euro CTO club

Number of CTO recanalization increased from 2008 till 2013
from ~1000 to ~2.500 per/year

Overall success stable around ~85-90% in the last 5 years

Retrograde procedures increased significantly from 2010
onwards (up to ~30%); more complex CTO treated but retrograde
more complex in terms of radiation time and contrast volume

Retrograde operators shows higher success than antegrade only
operators (~90% vs ~80%)

Severe complications <1.5-2.0%
6th Experts “Live” Workshop 2014
September, 25th – 26th, 2014
Madrid, Spain
www.eurocto2014.com
Thank You
For Your Attention
www.alfredogalassi.com