Diapositiva 1

Trattamento delle CTO
Indicazioni e risultati
Prof. Alfredo R. Galassi MD, FESC, FACC, FSCAI
Department of Medical Sciences and Pediatrics,
University of Catania, Italy
and University Heart Center,
University Hospital Zurich, Switzerland
15
September
1977
Andreas Gruentzig
First Percutaneous Coronary
Angioplasty in humans
…. pertanto le occlusioni totali sono un problema reale
Se non risolviamo il problema delle occlusioni totali,
probabilmente non saremo mai in grado di risolvere il
problema dell’angioplastica nel paziente multivascolare
Andreas Gruentzig
2 settimane prima della sua morte avvenuta in un
incidente aereo
(27, Ottobre 1985) quando aveva 46 anni
……30 anni dopo!!!!!!
Euro Cto Club
Founding Meeting
Carlo Di Mario was
the photographer
Paris 14.12.2006
Joachim Buettner
Gerald Werner
Dariusz Dudek
George Sianos
Alfredo R Galassi
Nicolaus Reifart
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
The Canadian Multicenter CTO Registry
April 2008 - July 2009 (3 centers)
Patients with chronic total occlusion (CTO)
n=1697
CTO prevalence 18.4%
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!
Christofferson et al, AJC
2005
Fefer
P et al, JACC 2012
1777 patients enrolled with 1968 CTO lesions
Christofferson et al, CTO
AJC 2005
prevalence 13.3%
46%
44%
Optimal medical
therapy 826 pts
10%
CABG 175 pts
PCI 776 pts
Tomasello D et al, Eur Heart J 2015
Galassi et al, Eur Heart J 2015
Indications of CTO revascularization according to
symptoms, ischemia and viability
Galassi et al, Eur Heart J 2015
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
Procedural complications
and in-hospital outcome
Galassi et al, EuroIntervention 2011
Online Registry 2008-2014
3000
2634
2500
2660
2615
2189
2000
1500
2603
1724
1303
1000
500
0
2008
2009
2010
2011
2012
2013
2014
Angiographic Success
%
100
80
75
77
80
82
85.3
85
85.3
87
85.8
60
40
20
0
2006 2007 2008 2009 2010 2011 2012 2013 2014
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
Galassi AR et al, on behalf of the Euro CTO Club
Course Directors
Nicolaus Reifart
Main Taunus Kliniken
Bad Soden, Germany
Gerald S. Werner
Medizinische Klinik
Klinikum Darmstadt
Darmstadt, Germany
Overall
Antegrade
Co-Directors
Alfredo R. Galassi
Ferrarotto Hospital
University of Catania
Catania, Italy
Retrograde
George Sianos
AHEPA University Hospital
Thessaloniki, Greece
Hans Bonnier
University Hospital Brussels
Brussels, Belgium
Galassi AR et al, on behalf of the Euro CTO Club
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
Galassi AR et al, on behalf of the Euro CTO Club
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
Survival free from MACCE and cardiac death
in pts (No: 619) treated with PCI or medical
therapy after propensity score adjustment
Tomasello D et al, Eur Heart J 2015
Procedural Complications
2,5
2,5
2,5
2,3
2,2
2
1,9
1,5
1,5
1,2
1,1
1
1
1
1
1
0,9
0,8
0,8
0,8
0,6
0,5
0,5
0,8
0,70,7
0,6
0,5
0,5
0,5
0,6 0,6
0,5
0,5
0,50,50,5
0,4
0,3
0,30,30,3
0,1
0,08
0,03
0
0,07
0
2008
2009
2010
2011
2012
2013
2014
Death
Cardiac tamponade
Myocardial infarction
Vascular complication
Coronary perforation
Donor vessel dissection
Consensus on Indications and Strategy

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
- Patient risk profile assessment (complete revascularization
in multivessel patient); patient selection is crucial
- Life expectancy (younger and older youth)
- LAD CTO
- Non-LAD CTO but main vessel ischemic area related CTO
- Radiation, contrast load and complication risk assessment
(balance success vs failure)
Consensus of Euro CTO Club Eurointervent 2012
Conclusions
The European Strategy
1. Antegrade success (approx 85%) stable from 2010
onwards (last 5 years)
2. Retrograde procedures:
a) mostly staged
b) increased significantly from 2010 onwards (up
to 30% in 2014)
c) more complex lesions, more time consuming,
more fluoroscopy time, more dye to be used
3. Retrograde operators higher success than non
retrograde operators (90% vs 80%)
4. Severe complications <1.5-2.0%
Thank you
for your attention
[email protected]