by Emmanouil S. Brilakis, MD, PhD
Chronic total occlusion PCI is one of the “last frontiers” of
interventional cardiology and has experienced significant growth in the last
few years with the adaptation and refinement of advanced techniques, including
retrograde and dissection/re-entry (see Figure).
As a result of this expansion, there has been a significant increase in
the attempt and success rates of CTO PCI in specialized centers in the United
States and abroad, inspiring many interventional cardiologists to explore this
cutting-edge field.
Why Should We Learn How to Do CTO Interventions?
First and foremost, it can provide significant benefits to our patients,
many of whom are currently told they have no revascularization options (ie,
patients with previous CABG who present with graft failure) or may be referred
for surgery because PCI is not considered to be feasible (ie, patients with
isolated right coronary artery CTO and medically refractory angina). Although
there are no randomized controlled clinical trials of CTO PCI vs. either
medical therapy or CABG, there are increasing data that suggest successful CTO
PCI can alleviate angina, improve left ventricular systolic function and
possibly reduce the impact of future ACS or even improve survival. Moreover,
CTO PCI can be accomplished safely with low complication rates.
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Emmanouil S.
Brilakis |
Second, it is good for interventionalists: CTO PCI requires refinement
of our skills, by forcing us to look critically at the angiograms, create
detailed procedural plans, apply advanced techniques of wire manipulation and
equipment delivery, and pay particular attention to preventing complications,
such as radiation injury or contrast-induced nephropathy. These skills are
applicable to the entire spectrum of PCI and can significantly improve our
efficiency and success rates.
And third, it is good for our institutions. In an era of plateauing or
decreasing PCI volume, centers with successful CTO PCI programs may attract
additional referrals and build reputations. Interestingly, although CTO
interventions can be intensive in equipment utilization and lab time, they
still appear to be financially attractive, as shown by data from Piedmont
Hospital (Atlanta) presented at TCT 2011. Despite higher direct costs, the
contribution margin per patient for CTO revascularization remained positive due
to increased total charges and reimbursement and did not statistically vary
compared with non-CTO PCI.
How Can an Interventionalist Learn to Proficiently Perform CTO
Interventions?
The first step is the interventionalist must be willing to commit the
time and energy required. As William Lombardi, MD, one of the fathers of
CTO interventions in North America, loves to say, “You either do CTO PCI,
or you don’t — there is no such thing as trying.” In other
words, CTO interventions are likely to be challenging and demanding, but the
key to success is persistence. With increasing experience, the procedures
become faster and success rates increase.
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Figure.
Examples of the three basic CTO crossing strategies. In panel A, dual coronary
injection reveals that the wire (arrow) is advanced into the distal true lumen.
In panel B, antegrade crossing is achieved by forming a knuckle (arrow) that is
advanced subintimally through the CTO, followed by re-entry into the true
lumen. In panel C, a retrograde guidewire (arrow) is advanced from the left
anterior descending artery into the right posterior descending artery via a
septal collateral, followed by retrograde true lumen crossing.
Images: Emmanouil S. Brilakis, MD,
PhD |
Secondly, an enthusiastic desire to learn via all possible avenues is
necessary: reading the CTO literature, attending CTO courses both live or
taped, talking to other interventionalists with the same interest, and
eventually being taught by experienced CTO operators. All North American
high-volume CTO operators are extremely keen in sharing all the “secrets
of the trade” and helping anyone interested to build a CTO program
And lastly, the interventionalist needs to establish local guidelines
and policies on how CTO interventions should be done. This includes
establishing limits for radiation and contrast exposure; creating “CTO
days” to allow for uninterrupted and concentrated focus on these
procedures; and obtaining and training the cath lab staff on the use of
specialized CTO-related equipment (such as stiff guidewires, specialized
microcatheters and devices for subintimal crossing and re-entry) and
techniques.
What to Expect From CTO Corner
The goal of this column will be to provide updates on the current status
of CTO interventions, describe technical “tips and tricks,” review
the relevant literature and hopefully encourage interventionalists to become
immersed in this area. It is my belief that performing CTO interventions is one
of the main reasons why it is so exciting to be an interventionalist in 2012.
Emmanouil S. Brilakis, MD, PhD, is the director of the cardiac
catheterization laboratory at the VA North Texas Health Care System, Dallas,
and is associate professor of medicine at the University of Texas Southwestern
Medical Center, Dallas. He is also a Cardiology Today Intervention
Editorial Board member.
Disclosure: Dr. Brilakis receives speaker
honoraria from St. Jude Medical and Terumo; research support from Abbott
Vascular and InfraReDx; and his spouse is an employee of Medtronic.