Complications of Retrograde CTOPCI J Aaron Grantham MD

Complications of Retrograde CTO-PCI J. Aaron Grantham, MD, FACC, FSCAI Associate Professor of Medicine University of Missouri Kansas City Saint Luke’s Mid America Heart Institute, Kansas City, MO

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company • • Grant/Research Support Consulting Fees/Honoraria • • Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Employment/Director • • • Boston Scientific BSCI, ABT, Asahi-Intecc, Vascular Solutions Company Names CTOfundamentals. org Company Names Corindus Vascular Robotics

Retrograde Complications Karmpaliotis et al J Am Coll Cardiol Intv. 2012; 5(12): 1273 -1279

75% Galassi et al J Am Coll Cardiol 2015

OPEN CTO Design • DESIGN: Prospective, nonrandomized, single-arm, multi-center clinical evaluation of the Hybrid CTO -PCI 1000 consecutive patients enrolled between Feb 2014 and July 2015 at 12 clinical sites in the US Comprehensive baseline clinical, angiographic, and HS assessment • OBJECTIVE: To evaluate the Success, safety, efficiency, health status outcomes, appropriateness, and costs of hybrid CTO-PCI. • PRINCIPAL INVESTIGATOR • J. Aaron Grantham, MD, FACC Saint Luke’s MAHI • Co. PIs Bill Lombardi and James Sapontis Clinical follow-up at 1, 6, 12 months Success Failure Angina Dyspnea Efficient inefficient Complicated Uncomplicated

Predictors of MACCE

(9. 0% vs 2. 6%) (4. 0% vs 2. 6%) (2. 4% vs 0%) (2. 3% vs 0. 4%) (0. 3% vs 0%) Retro vs all CTO-PCI (2. 0% vs 0. 2%) (0% vs 0%) (1. 6% vs 0. 05%) (1. 2% vs 0. 2%) Retrograde complications in OPEN CTO (N=514) OPEN vs Prior Retro reports

OPEN CTO • • Audited Angiographic core lab adjudicated Events committee adjudicated Central call center follow up Operator Reported Adjudicated Technical success 89% 86% MACE 4. 4% 7. 0% Perforation 6. 0% 8. 8% Clinical perforation 3. 9% 4. 8%

Case Example

Tip Injection

Crossing

LP crossed Resistance at Lesion

Knuckle retro

LP won’t go

Finecross

Retro balloon

Back with LP

Injection

Antegrade

Scratch and go

Anchor Boss

Stick with Ray

Swap enters downstream

Investment procedure

Final

6 weeks later-Axillary Impella

Investment pays off

RCA final

Collateral crossing

Overlapping gear

Wire into ramus

Snaring in ramus

Externalize

Edge dissection

POBA

Ministar sidebranch

Final

Success-Safety Matrix Frequency of Event Futility? Success MACE Success Patient and Procedural Complexity

Conclusions • Complications in retrograde CTO-PCI are higher than reported in general CTO-PCI • Perforations remain the most common and potentially catastrophic complications in CTO-PCI • Collateral perforations aren’t always catastrophic • We must get better • Devices must be continually improved

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• retrograde cases were significantly more complex, both clinically (previous coronary artery bypass graft surgery prevalence, 48% versus 24%; P<0. 001) and angiographically (mean Japan-chronic total occlusion score, 3. 1+/-1. 0 versus 2. 1+/1. 2; P<0. 001) and had lower technical success (85% versus 94%; P<0. 001) and higher major adverse cardiovascular events (4. 3% versus 1. 1%; P<0. 001) rates. Karmpaliotis Circ CI 2016