CTO Corner

A Challenging Case of Failed CTO PCI: Was It Worth It?

It was 9 p.m. when the case ended. It was a 3-hour chronic total occlusion attempt that failed, fortunately without any complications. Returning home tired, both physically and emotionally, the question, “Was it worth it?” kept returning to my mind.

The Patient

The patient was a young woman who previously underwent CABG and presented with refractory angina despite massive doses of antianginal medications. Her grafts were open and the culprit appeared to be a CTO of a diagonal branch. It was a challenging CTO: The left main was occluded at its ostium. The diagonal was a small, diffusely diseased vessel that was filling via small, tortuous, epicardial collaterals from the left anterior descending (LAD) artery, which was in turn filling via the left internal mammary artery (LIMA). A CT angiogram showed significant calcification with the diagonal originating from the occluded segment of the LAD. This CTO had multiple layers of complexity: ostial occlusion, ambiguous proximal cap, long length, calcification, small-size distal vessel, poor collateral circulation and prior CABG.

Emmanouil S. Brilakis

The patient was turned down for CTO PCI several times in the past. However, she continued to be hospitalized with refractory angina. We knew that this was going to be a challenging procedure with low likelihood of success, but given the patient’s insistence we decided to give it a try. We decided upfront that we would not attempt retrograde through the LIMA, given significant tortuosity and risk for severe ischemia and hemodynamic collapse.

Femoral access was used for engaging the left main and left radial access was used for engaging the LIMA and visualizing the target vessel. Obtaining enough support to penetrate the flush left main occlusion was challenging, but after lengthy efforts using various guidewires and a Twin-Pass catheter (Vascular Solutions), we were able to make progress, crossing subintimally into the proximal LAD. The next challenge was making the turn for the diagonal, the origin of which was unclear. We decided that using a knuckled guidewire would be the safest approach to minimize the risk for perforation. Once again, after multiple attempts with various guidewires and after looking at multiple angles, we were able to advance a knuckled Fielder XT (Asahi Intecc) subintimally into the diagonal branch.

For the first time since the beginning of the case, optimism kicked in, a sense that this might actually work out in the end. Alas, despite numerous re-entry attempts using every technique possible, we failed to re-enter into the diagonal. We stuck to our decision to not attempt retrograde through the LIMA and the procedure was stopped. The patient remained stable throughout the case and was dismissed the following day without complications. Despite the failure, she was still thankful for the attempt.

Was It Worth It?

Despite the disappointment associated with failure, the attempt was worth it for four reasons.

First and foremost, the indication was strong. The patient had severe, debilitating symptoms despite extremely aggressive antianginal management, leading to multiple hospitalizations. Recanalizing the CTO could significantly improve her quality of life and decrease the likelihood of repeat hospitalizations. Hence, she had a strong desire to attempt the procedure and was OK with the possibility of failure.

Second, was the attempt truly futile and destined to fail? We knew that the likelihood of success was low, based on high angiographic complexity. However, several similarly “impossible” cases have been successfully completed in the past. Had we not tried, many of those successful cases and the resultant benefits would not have taken place.

Third, nothing was lost from the patient’s perspective; she did not have a complication and remained at her baseline condition. The technique that would have offered the best likelihood of successful recanalization in this highly complex lesion would have been retrograde crossing. However, a retrograde attempt through the LIMA would carry significant risks for hemodynamic collapse and even death. That is why, during the planning phase, we had made the decision to not attempt retrograde via LIMA. This could potentially have been attempted using hemodynamic support, but the patient’s femoral and subclavian arteries were too small. The CTO operator should never forget that “winning the battle” (opening the CTO), but “losing the war” (major complication or death of the patient) makes no sense.

Fourth, the procedure was costly, as we used a lot of equipment, including guidewires, microcatheters and balloons, as well as personnel, laboratory and hospitalization time. The hospital might lose money, given the low reimbursement for failed procedures. However, the patient has had multiple hospitalizations for angina, all of which carry significant cost as well, and which could potentially have been prevented — with the associated cost benefits — if the procedure was successful.

Controversial Decision

Not everyone will agree with this assessment. Some may argue that the patient was not facing a lethal disease, and that improving quality of life may not be a strong enough indication for embarking on procedures that are complex and have a relatively low likelihood of success, or that the patient should have to pay out of pocket for such procedures and not burden the health care system with additional costs. Perhaps we should have discouraged the patient and excluded the possibility of CTO PCI attempt because many patients “will do what their physicians advise them to do.” Did we truly make 100% certain that the patient was fully informed? Or that she had full decision-making capacity?

In the end, the failed CTO PCI attempt was worthwhile in the eyes of this particular patient. And we, as the treatment team, were privileged to be able to carry on what the patient deemed a worthwhile attempt, even though we failed. Hopefully, in the future, patients will remain able to ask for the care they deem worthwhile and physicians will remain able to provide it.

Disclosure: Brilakis reports he has received consultant/speaker honoraria from Abbott Vascular, Acist, Amgen, Asahi, Cardiovascular Systems Inc., Elsevier, GE Healthcare, Medicure, Medtronic and Nitiloop; research support from Boston Scientific and Osprey; and he has served on the board of directors of the Cardiovascular Innovations Foundation and the board of trustees of the Society for Cardiovascular Angiography and Interventions.

It was 9 p.m. when the case ended. It was a 3-hour chronic total occlusion attempt that failed, fortunately without any complications. Returning home tired, both physically and emotionally, the question, “Was it worth it?” kept returning to my mind.

The Patient

The patient was a young woman who previously underwent CABG and presented with refractory angina despite massive doses of antianginal medications. Her grafts were open and the culprit appeared to be a CTO of a diagonal branch. It was a challenging CTO: The left main was occluded at its ostium. The diagonal was a small, diffusely diseased vessel that was filling via small, tortuous, epicardial collaterals from the left anterior descending (LAD) artery, which was in turn filling via the left internal mammary artery (LIMA). A CT angiogram showed significant calcification with the diagonal originating from the occluded segment of the LAD. This CTO had multiple layers of complexity: ostial occlusion, ambiguous proximal cap, long length, calcification, small-size distal vessel, poor collateral circulation and prior CABG.

Emmanouil S. Brilakis

The patient was turned down for CTO PCI several times in the past. However, she continued to be hospitalized with refractory angina. We knew that this was going to be a challenging procedure with low likelihood of success, but given the patient’s insistence we decided to give it a try. We decided upfront that we would not attempt retrograde through the LIMA, given significant tortuosity and risk for severe ischemia and hemodynamic collapse.

Femoral access was used for engaging the left main and left radial access was used for engaging the LIMA and visualizing the target vessel. Obtaining enough support to penetrate the flush left main occlusion was challenging, but after lengthy efforts using various guidewires and a Twin-Pass catheter (Vascular Solutions), we were able to make progress, crossing subintimally into the proximal LAD. The next challenge was making the turn for the diagonal, the origin of which was unclear. We decided that using a knuckled guidewire would be the safest approach to minimize the risk for perforation. Once again, after multiple attempts with various guidewires and after looking at multiple angles, we were able to advance a knuckled Fielder XT (Asahi Intecc) subintimally into the diagonal branch.

For the first time since the beginning of the case, optimism kicked in, a sense that this might actually work out in the end. Alas, despite numerous re-entry attempts using every technique possible, we failed to re-enter into the diagonal. We stuck to our decision to not attempt retrograde through the LIMA and the procedure was stopped. The patient remained stable throughout the case and was dismissed the following day without complications. Despite the failure, she was still thankful for the attempt.

Was It Worth It?

Despite the disappointment associated with failure, the attempt was worth it for four reasons.

First and foremost, the indication was strong. The patient had severe, debilitating symptoms despite extremely aggressive antianginal management, leading to multiple hospitalizations. Recanalizing the CTO could significantly improve her quality of life and decrease the likelihood of repeat hospitalizations. Hence, she had a strong desire to attempt the procedure and was OK with the possibility of failure.

Second, was the attempt truly futile and destined to fail? We knew that the likelihood of success was low, based on high angiographic complexity. However, several similarly “impossible” cases have been successfully completed in the past. Had we not tried, many of those successful cases and the resultant benefits would not have taken place.

Third, nothing was lost from the patient’s perspective; she did not have a complication and remained at her baseline condition. The technique that would have offered the best likelihood of successful recanalization in this highly complex lesion would have been retrograde crossing. However, a retrograde attempt through the LIMA would carry significant risks for hemodynamic collapse and even death. That is why, during the planning phase, we had made the decision to not attempt retrograde via LIMA. This could potentially have been attempted using hemodynamic support, but the patient’s femoral and subclavian arteries were too small. The CTO operator should never forget that “winning the battle” (opening the CTO), but “losing the war” (major complication or death of the patient) makes no sense.

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Fourth, the procedure was costly, as we used a lot of equipment, including guidewires, microcatheters and balloons, as well as personnel, laboratory and hospitalization time. The hospital might lose money, given the low reimbursement for failed procedures. However, the patient has had multiple hospitalizations for angina, all of which carry significant cost as well, and which could potentially have been prevented — with the associated cost benefits — if the procedure was successful.

Controversial Decision

Not everyone will agree with this assessment. Some may argue that the patient was not facing a lethal disease, and that improving quality of life may not be a strong enough indication for embarking on procedures that are complex and have a relatively low likelihood of success, or that the patient should have to pay out of pocket for such procedures and not burden the health care system with additional costs. Perhaps we should have discouraged the patient and excluded the possibility of CTO PCI attempt because many patients “will do what their physicians advise them to do.” Did we truly make 100% certain that the patient was fully informed? Or that she had full decision-making capacity?

In the end, the failed CTO PCI attempt was worthwhile in the eyes of this particular patient. And we, as the treatment team, were privileged to be able to carry on what the patient deemed a worthwhile attempt, even though we failed. Hopefully, in the future, patients will remain able to ask for the care they deem worthwhile and physicians will remain able to provide it.

Disclosure: Brilakis reports he has received consultant/speaker honoraria from Abbott Vascular, Acist, Amgen, Asahi, Cardiovascular Systems Inc., Elsevier, GE Healthcare, Medicure, Medtronic and Nitiloop; research support from Boston Scientific and Osprey; and he has served on the board of directors of the Cardiovascular Innovations Foundation and the board of trustees of the Society for Cardiovascular Angiography and Interventions.