CTO-PCI. Evidens, indikation, teknik. Regionmöte Kalmar, Georgios Panayi, Kardiologiska Kliniken, US Linköping

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1 CTO-PCI Evidens, indikation, teknik Regionmöte Kalmar, Georgios Panayi, Kardiologiska Kliniken, US Linköping

2 CTO-PCI Evidens Indikationer Teknik 2

3 CTO-definition och prevalens ockluderat koronart segment, med TIMI flöde=0, >3mån 15-30% av patienter med CAD Sianos G. et al. EuroIntervention May 15;8(1): Carlino M. et al. Catheter Cardiovasc Interv Apr;85(5):

4 CTO området är ischemiskt trots välutvecklade kollateraler >90% av pat med CTO har inadekvat kollateral försörjning Coronary Flow Reserve (doppler) > 2, i endast 7% av pat mean FFR distalt om ocklusionen= 0,32 ± 0,13 motsvarar 95% stenos Werner et al, Eur Heart J Oct;27(20):

5 CTO området är ischemiskt trots välutvecklade kollateraler PET för myocardial blood flow (MBF) och Coronary Flow Reserve (CFR) MBF kvot (target/remote) <0,75 in 96% CFR < 2,0 in 91% Prevalence of ischaemia in patients with a chronic total occlusion and preserved left ventricular ejection fraction Stuijfzand WJ et al, Eur Heart J Cardiovasc Imaging Sep 5

6 Vad vet vi om klinisk effekt av CTO-PCI? Metanalyser av retrospektiva studier (lyckad vs misslyckad CTO-PCI) Mortalitets vinst? Minskad MACE? Minskat behov av CABG? Minskad angina pectoris? Förbättring av LVEF? Minskad risk för ventrikulära arytmier? 6

7 7

8 Mortalitet Meta-Analysis of Clinical Outcomes of Patients Who Underwent Percutaneous Coronary Interventions for Chronic Total Occlusions The American Journal of Cardiology, Volume 115, Issue 10, 2015,

9 Hjärtinfarkt Meta-Analysis of Clinical Outcomes of Patients Who Underwent Percutaneous Coronary Interventions for Chronic Total Occlusions The American Journal of Cardiology, Volume 115, Issue 10, 2015,

10 Behov av CABG Meta-Analysis of Clinical Outcomes of Patients Who Underwent Percutaneous Coronary Interventions for Chronic Total Occlusions The American Journal of Cardiology, Volume 115, Issue 10, 2015,

11 Angina Meta-Analysis of Clinical Outcomes of Patients Who Underwent Percutaneous Coronary Interventions for Chronic Total Occlusions The American Journal of Cardiology, Volume 115, Issue 10, 2015,

12 LVEF Meta-analysis on the impact of percutaneous coronary intervention of chronic total occlusions on left ventricular function and clinical outcome International Journal of Cardiology, Volume 187, 2015, 90 96

13 Kaplan-Meier survival curves for freedom from first appropriate device therapy in CTO and non-cto populations. Luis Nombela-Franco et al. Circ Arrhythm Electrophysiol. 2012;5: Copyright American Heart Association, Inc. All rights reserved.

14 Kaplan-Meier survival curves for all-cause mortality in patients with CTO and without CTO. CTO indicates chronic total coronary occlusion. Luis Nombela-Franco et al. Circ Arrhythm Electrophysiol. 2012;5: Copyright American Heart Association, Inc. All rights reserved.

15 3 randomiserade studier EXPLORE 304 STEMI pat CTO PCI within 7d vs OMT (LVEF + EDV on card MR 4m) DECISION-CTO (2023) 1284 pat CTO-PCI vs OMT (all-cause death, MI, stroke, and any revascularization at 3 years after randomization) slow enrollment-early termination, presented ACC2017 EuroCTO (2018) 450 pat CTO-PCI vs OMT (QoL - 12m, death+ MI - 36m) 20

16 DECISION-CTO 21

17 DECISION-CTO 22

18 DECISION-CTO 23

19 DECISION-CTO 24

20 DECISION-CTO 25

21 DECISION-CTO 26

22 DECISION-CTO 27

23 DECISION-CTO 28

24 DECISION-CTO 29

25 DECISION-CTO 30

26 DECISION-CTO As treated 31

27 EXPLORE Trial Left Ventricular Function at 4-Month Follow-Up in STEMI Patients Undergoing CTO PCI Versus no CTO PCI Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI : The EXPLORE Trial Journal of the American College of Cardiology, Volume 68, Issue 15, 2016,

28 EXPLORE Trial Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI : The EXPLORE Trial Journal of the American College of Cardiology, Volume 68, Issue 15, 2016,

29 Vilka pat ska vi behandla? Safley et al. Catheter. Cardiovasc. Interv. 78:

30 Vilka pat ska vi behandla? 1.symptomatiska trots OMT 2. asymptomatiska med betydande ischemi > 10% (speciellt om LAD CTO) 35

31 36 Vilka pat ska vi behandla?

32 37 Riktlinjer

33 Indikation indikation att behandla en CTO bör inte skilja sig från en icke-cto lesion när det finns symptom eller betydande ischemi det finns ingen evidens att CTO är mindre relevant vad gäller kliniska outcomes jmf med icke-cto lesioner 38

34 CTO-PCI teknik Antegrade wire escalation (AWE) Antegrade Dissection Re-entry (ADR) Retrograde dissection Re-entry (RDR) Retrograde wire escalation (RWE) 39

35 40 CTO-PCI teknik

36 41 CTO PCI teknik

37 Komplikationer Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions : A Weighted Meta-Analysis of 18,061 Patients From 65 Studies JACC: Cardiovascular Interventions, Volume 6, Issue 2, 2013,

38 CTO-PCI i Linköping ca dedicerade CTO-PCI per år ca ad hoc (enklare antegrada PCI) >80% success 43

39 44 TACK