In Stent CTO PCI

Jarosław Wójcik

Dept of Cardiology

Medical University of Lublin / Poland

R. Mehran

• Prevalence

• Pathophysiology

• Angiographic apperance

• Treatment Algorithm

PREVALENCE

1. Christopoulos G, Karmpaliotis D, Alaswad K, et al. The efficacy of“hybrid” percutaneous coronary intervention in chronic total occlusionscaused by in-stent restenosis: insights from a US multicenterregistry. Catheter Cardiovasc Interv. 2014;84:646–51. 10,9%2. Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’NeillWW. Success, safety, and mechanisms of failure of percutaneouscoronary intervention for occlusive non-drug-eluting in-stent restenosisversus native artery total occlusion. Am J Cardiol. 2005;95:1462–6. 25%3. Werner GS, Moehlis H, Tischer K. Management of total restenoticocclusions. EuroIntervention. 2009;5 Suppl D:D79–83. 5-10%4. Wilson WM, Walsh S, Hanratty C, et al. A novel approach to themanagement of occlusive in-stent restenosis (ISR). EuroIntervention.2014;9:1285–93. 14,9%

PREVALENCE

5 - 25%

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

2008 2009 2010 2011 2012 2013 2014 2015 2016 All

12641619

20292389 2369

2660 2475 2374

1549

18728

39 105 156 225 199 247 219 191 114

1495

In stent CTO (count)

de novo CTO

in stent CTO

PREVALENCE

7,39%

siology

In-Stent CTOIn-Stent CTO

In-stent restenosis - ISR

Stent thrombosis - ST

The Proportion ?

PATHOPHYSIOLOGY

STENT RECOIL, UNDERDEPLOYMENT,

FRACTURE

smooth muscle cells ingrowth (neointima

proliferation)

Christopoulos et al.

DM: 56,1% vs 39,6% (in-stent CTO vs de

novo CTO (p=0,02)

Occlusion length: 35mm vs 30 mm

(p=0,04)

Christopoulos G, Karmpaliotis D, Alaswad K, et al. The efficacy of“hybrid” percutaneous coronary intervention in chronic total occlusions

caused by in-stent restenosis: insights from a US multicenterregistry. Catheter Cardiovasc Interv. 2014;84:646–51.

- Less calcifications- Composed of a hypocellular matrix

made up of hard and resistantcollagenous material – relativeabsense of microchannels

- Less calcifications- Composed of a hypocellular matrix

made up of hard and resistantcollagenous material – relativeabsense of microchannels

Different angio appereance dependingon the restenosis or thrombotic

phenomenon and time of occlusion

Different angio appereance dependingon the restenosis or thrombotic

phenomenon and time of occlusion

Angiographic Appereance

Restenosis - Proximal cap tends to be more frequently tapered

Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’NeillWW. Success, safety, and mechanisms of failure of percutaneouscoronary intervention for occlusive non-drug-eluting in-stent restenosis versus native artery total occlusion.Am J Cardiol. 2005;95:1462–6

„ in-stent occlusions are more frequently blunt at the

proximal cap compared with de novo CTOs ”

Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’NeillWW. Success, safety, and mechanisms of failure of percutaneouscoronary intervention for occlusive non-drug-eluting in-stent restenosis versus native artery total occlusion.Am J Cardiol. 2005;95:1462–6

„ in-stent occlusions are more frequently blunt at the

proximal cap compared with de novo CTOs ”

Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’Neill

WW.Am J Cardiol. 2005;95:1462–6. 63%

Werner GS, Moehlis H, Tischer K. EuroIntervention. 2009;5 Suppl D:D79–83. 70 vs 85% (ISR vs de novo CTOs)

Abbas AE, Brewington SD, Dixon SR, Boura J, Grines CL, O’Neill

WW.Am J Cardiol. 2005;95:1462–6. 63%

Werner GS, Moehlis H, Tischer K. EuroIntervention. 2009;5 Suppl D:D79–83. 70 vs 85% (ISR vs de novo CTOs)

Treatment Algorithm- The Succes Rate

87,81%

0

200

400

600

800

1000

1200

1400

2008 2009 2010 2011 2012 2013 2014 2015 2016 All

35

91

136

187 175213 200

169

106

1312

414 20

3824 33 19 22

8

182

Successful

Not successful

Operation success (in stent CTO)

Failure: the inability to cross the lesion with a

guidewire

sub-stent wire tracking

stent-fractures, undersized stents, deformed &malapposed stents

Failure: the inability to cross the lesion with a

guidewire

sub-stent wire tracking

stent-fractures, undersized stents, deformed &malapposed stents

Treatment Algorithm

The efficacy of “hybrid” percutaneous coronary

intervention in chronic total occlusions caused by in-

stent restenosis: insights from a US multicenter

registry

Georgios Christopoulos et al, Catheter Cardiovasc Interv. 2014 1;

84(4): 646–651. doi:10.1002/ccd.25465.

Antegrade wire escalation:

Soft tip tapered polymer-jacketed(Fielder XT)

Stiffer polymer jacked Pilot 200 Hard tip wires Miracle 12 Confianza Pro 12 Gaia Family (3rd)

Antegrade wire escalation:

Soft tip tapered polymer-jacketed(Fielder XT)

Stiffer polymer jacked Pilot 200 Hard tip wires Miracle 12 Confianza Pro 12 Gaia Family (3rd)

Knuckled wires - avoided as a firststrategy: can track under the stent strutsor in the subintimal sub-stent space

Knuckled wires - avoided as a firststrategy: can track under the stent strutsor in the subintimal sub-stent space

EuroIntervention 2014;9:1285-1293

A novel approach to the management of occlusive in-stent restenosis (ISR)

CrossBoss alone:

Papayannins et al. 83% Wilson et al. 90% Christopoulos et al. 89,4%

CrossBoss alone:

Papayannins et al. 83% Wilson et al. 90% Christopoulos et al. 89,4%

Conclusions:

IS CTOs carry their own predictors of success and mechanism of failure that differfrom de novo CTOs. PCI of IS CTO is (was?) traditionally associated with lower successrate

The hybrid strategy, especially including the CrossBoss catheter seems to be associatedwith similarly high procedural success and low major complication rates as for pts with de novo CTOs.

Conclusions:

IS CTOs carry their own predictors of success and mechanism of failure that differfrom de novo CTOs. PCI of IS CTO is (was?) traditionally associated with lower successrate

The hybrid strategy, especially including the CrossBoss catheter seems to be associatedwith similarly high procedural success and low major complication rates as for pts with de novo CTOs.

44

• Female 67 yo.

• CCS II / III

• PCI RCA / 2x BMS in 1998

• Angio in 2011 – total in stent occlusion

• 2011 & 2012 – unseccsesful attempts of antegraderecanalization

• EF 50%

• SPECT +

• Risk factors: HT, DM (oral)

BVS implantation

1 st - 3.0/28 mm

2nd - 3.0/28

3rd - 3.5/28

The final shot

8 months f-up:

Patient – is very happy, CCS I

Doctor – is very happy, too

CONCLUSIONS:

• Retrograde approach for in-stent CTO couldbe succsesfull option

• Implantation of BVS in such clinical setting isvery promising solution, we need the longterm angio f-up