CTO Technique Evolution Insights from 20 Years of

CTO Technique Evolution: Insights from 20 Years of Experience Barry D. Rutherford, MD Saint Luke’s Mid America Heart Institute Kansas City, Missouri, USA L’enfant terrible

DISCLOSURES Barry D. Rutherford, MD Honoraria – Volcano Corporation, Abbott Vascular, Medtronic Cardio. Vascular, Inc.

L’enfant Terrible (Chronic Total Occlusion circa 1990) Management Requirements – Time and patience – Consultation from others – Persistent and consistent effort – Open to new ideas, variety of approaches – Multiple “new toys” (may not pacify) – Long-term outcome in doubt – “Tough love” (CABG) may be final solution – Can be most rewarding experience

Andreas Gruentzig

8 -6 -1980 LAD completely occluded Coronary Angiogram: June 1980 LCA: Severe 95% stenosis of LAD, LCX and RCA normal

G. R. 53 Year-Old Male • March 1982 • March 1985 • Feb 2, 1986 PTCA LAD & RCA-PL • March 1986 • Mar 7, 1986 Returned to USA PTCA of LADD, LCx, and RCA-PDA While on vacation in New Zealand sustained acute inferior infarct CPK 1000. No complication Received no thrombolytic agent, no PTCA Repeat Coronary Angio, MAHI

G. R. March 1986 Total occlusion RCA Successful PTCA RCA Patent RCA PDA & PL

JACC 1983; 1(2): 656

CTO RCA Manipulation of Guide for Backup Support

Documented 13 -Year-Old CTO . 014” STD wire 2. 0 x 20 mm balloon

Chronic Total Occlusion of LAD Double Guide Injections to Localize Distal Segment

Chronic Total Occlusion of LAD Double Guide Injections

CTO Technique (Circa 1985) • • 8 -Fr Guides, SL 4 left, JR 4 or L Amplatz, right Deep guide support Low profile over-the-wire balloon Wire progression – ACS 014 HT Floppy ACS 014 HT Intermediate ACS 014 Standard – USCI 016 or 018 wire Back end of wire!! • Advance balloon tip to proximal cap • Long balloon inflation time (2 -5 mins)

GW Stone et al. JACC 1990; 15: 819 -56

100 400 90 350 80 300 70 250 60 50 200 40 150 30 100 20 10 50 0 0 1981 1982 1983 1984 Year 1985 1986 1987 1988 No. of Total Occlusions Attempted Procedural Success Rate (%) Annual Procedural Success Rate for PTCA of Chronic Total Occlusions GW Stone et al. JACC 1990; 15: 819 -56

Effect of Occlusion Morphology on Procedural Success p = 0. 002 N = 37 p = 0. 07 N = 67 N = 24 N = 80

CTO Innovative Techniques • • “Smart” laser system Excimer laser guidewire (laserwire) Magnum wire Ultrasonic angioplasty Vibrational angioplasty ROTACS Frontrunner™ blunt dissection Percutaneous In-Situ Coronary Venous Arterialization (PICVA) • Optical Coherence Reflectometry (OCR) Safe. Cross™ (RF) Guide. Wire All either failed to be broadly accepted or caused unacceptable complications or restenosis

“Smart” Laser

“Smart” Laser

Management of Chronic Total Occlusion circa 1995 Choice of Guidewire • Traditional Wire Series – ACS H-T Intermediate® – Guidant Corp. – ACS H-T Standard® – Guidant Corp. – Choice PT Wire – Boston Scientific Corp. • “New” Generation Wires – Shinobi™ - Cordis Corp. – CROSS-IT™ - Guidant Corp. – Athlete Wire – Asahi Corp.

Suero et al. JACC 2001; 38: 409 -14

Procedural Outcomes and Long-Term Survival for PCI of Chronic Total Occlusion 2007 Patients, 20 -Year Experience CTO, n = 1486 1294 1065 806 582 Suero et al. JACC 2001; 38: 409 -14

The Japanese Connection • Patience and persistence • Careful evaluation of images • ASAHI wires • Anchoring balloon (circa 2000) • Parallel wire (circa 2000) • IVUS guidance (2001) • Tornus device (2004) • Retrograde (CART) (2005) • Channel Dilator (Corsair) (2009)

Toyohashi Heart Center Technical Success for CTO 2004 86. 3% 2009 96. 6%

Case 1 74 -yo Male CTO of LCX, short lesion, tapered pt of occlusion

Case 2 60 -yo Male CTO of LAD

Case 3 CTO of LAD Retrograde Approach

Extra slides

Case 3 CTO of LAD Retrograde Approach

7 Year-Old CTO of RCA Use of Left Amplatz Guide