J’aborde toute les CTO - EDITO | · PDF fileJ’aborde toute les CTO ... Assess the...
Transcript of J’aborde toute les CTO - EDITO | · PDF fileJ’aborde toute les CTO ... Assess the...
Thierry Lefèvre
J’aborde toute les CTO ….
Quand le territoire est viable et ischémique
Prévalence des CTOs
Fefer P et al. J Am Coll Cardiol. 2012;59:991-
Patients
54%
10%
18%
What do we currently know?
1. 95% of patients with CTO have inadequate distal collateral supply (FFR <0.80)
2. Ischaemia is prognostically adverse
3. Successful CTO PCI cases have better prognosis than failed CTO PCI cases
Amélioration de l’angor
Amélioration de la capacité à l’effort
Amélioration de la qualité de vie
Amélioration de l’ischémie
Amélioration de la fonction VG
Diminution du risque rythmique
Diminution des indications de pontage
Amélioration de la survie
Succès vs Echec
Ischaemia
Shaw et al, Circulation 2008; 117; 1283-91
Residual ischaemia
Shaw et al, Circulation 2008; 117; 1283-91
Incomplete Revascularisation is associated with Poor Outcome
Kirschbaum Am J Cardiol 2008;101:179 –
IRM et Indication de Revascularisation
CTO-PCI Améliore la Qualité de Vie
N=42
N=83
Grantham JA et al. Circ Cardiovasc Qual Outcomes. 2010;3:284-290
Effectiveness of recanalization of CTO
Residual/recurrent angina during FU
Joyal Am Heart J 2010;160:179-87
All causes of Mortality
Khan et al. CCI 2013; 82: 95–1
Meta-Analysis (successfull vs Unsuccessfull)
Sudhakar et al. JACC 2014; 64: 235–
CTO-PCI in the UK central cardiac audit database
28% mortality
CTO data from SYNTAX
Farooq et al. JACC 2013; 61: 282-9
51% non revasc. 32% non pontée
Genereux et al. JACC 2012; 59: 2165-74
“Residual Syntax Score”, a new predictor of outcomes
Genereux et al. JACC 2012; 59: 2165 74
“Residual Syntax Score”, a new predictor of outcomes
Theoretical
• If the muscle subtended by the CTO is – Alive (> 50%)
– Ischemic (10-20%)
• Then the patient would be better off if that artery
were magically reopened (i.e.at zero risk)
To maximize potential benefit
Know the predictors of success
Assess the risk of the procedure
Start by treating the CTO in Pts with MV disease
Concentrate expertise
Minimise contrast use and radiation exposure
Adjust the difficulty to your level of expertise
Know when to stop and ask to an expert
Lesion morphology
Patient characteristics
Learning curve
The Success Rate of CTO
Guidewire Crossing < 30 min.
Morino et al. JACC Interv 2011; 4: 213-221
Successfull CTO PCI
Morino et al. JACC Interv 2011; 4: 213-221
CTO Success
No ad Hoc PCI !
Good CTO Angiography
No panning, large field
Optimal view of the distal run off
Optimal view of the donor vessel
Good views of the collaterals
Several views of the occluded vessel
At least 1 same view for both vessels
What are the Questions ? Proximal and/or distal ambiguity ? Lesion length ? Vessel course, Island ? Lesion calcification and tortuosity ? Distal run off ? Collaterals ? Good and safe support ?
What about the support ?
What about the support ?
What about the support ?
What about the support ?
What about the support ?
Fielder XT + Finecross
What about the support ?
3D right
Miracle 12 + Finecross
What about the support ?
Anchoring balloon
What about the support ?
What about the support ?
What about the support ?
Ostial and calcified lesion GC Support, Stability ?
Risk of ostial dissection ?
Which Approach ?
Which Approach ?
Which Approach ?
Which Approach ?
Which Approach ?
Which Approach ?
Which Approach ?
« Mother and Child Technique »
Which Approach ?
Which Approach ?
Vessel Course ?
Vessel Course ?
Vessel Course ?
Vessel Course ?
No Calcification Lesion length < 20 mm Proximal ambiguity ? No distal ambiguity Good distal run-off ?
Proximal ambiguity ?
Proximal Ambiguity
Proximal ambiguity ?
Proximal ambiguity ?
Proximal ambiguity ?
What about the support ?
Proximal ambiguity ?
Proximal ambiguity ?
Finecross + Fielder XT
Proximal ambiguity ?
Proximal ambiguity ?
Proximal ambiguity ?
Collaterals
Collaterals
Collaterals
Collaterals
Collaterals
Collaterals
Collaterals
Collaterals
Successful PCI of CTO’s improves symptoms, ischemia, quality of life, left ventricular function, reduce the need for CABG and even may improve survival.
The net benefit is strongly related to the amount of pre procedural myocardial ischemia.
Conclusions
PCI of CTO’s is not a high risk procedure in experience centers.
Conclusions
The success rate is relatively high in non selected cases (70-90%) in Europe, depending mainly on the operator’s and Team center experience.
The balance between benefit (amount of
ischemia) and risk (PCI attempt in a center x
or y) should always be assessed before
taking the decision.
Conclusions
It is time to build strong networks
between centers in order to treat better
more patients.
CTO et IDM
Claessen BE et al. Eur Heart J, 2012; 33 :768-775
8.6% des patients avec IDM
NCDR 2005-2008: BMS and DES in CTOs 92069 patients, of these 10766 with a CTO PCI and stent (BMS: 2043, DES: 8218)
Patel MR et al. JACC Interv 2012; 5: 1054-6
EURO-CTO Trial Evaluation of the Utilisation of Revascularisation vs Optimal medical therapy for CTOs
1200 patients 30-40 operators >80% success rate First patient enrolled March 2012 Primary efficacy endpoint: Improvement of QoL Safety endpoint: MACE
Conclusion
Take extra time during the diagnostic angiogram to obtain specific anatomic information that will guide strategy (ies) for the subsequent CTO PCI.
Study the film in detail (Team).
Educate refering physicians
Start the procedure with powerfull bilateral injection in the majority of cases