CTO-PCI Evidens, indikation, teknik Regionmöte Kalmar, 2017-03-22 Georgios Panayi, Kardiologiska Kliniken, US Linköping
CTO-PCI Evidens Indikationer Teknik 2
CTO-definition och prevalens ockluderat koronart segment, med TIMI flöde=0, >3mån 15-30% av patienter med CAD Sianos G. et al. EuroIntervention. 2012 May 15;8(1):139-45 Carlino M. et al. Catheter Cardiovasc Interv. 2015 Apr;85(5):771-8 3
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. 2006 Oct;27(20):2406-12 4
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. 2016 Sep 5
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
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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, 1367 1375
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, 1367 1375
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, 1367 1375
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, 1367 1375
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
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;5:147-154 Copyright American Heart Association, Inc. All rights reserved.
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;5:147-154 Copyright American Heart Association, Inc. All rights reserved.
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
DECISION-CTO 21
DECISION-CTO 22
DECISION-CTO 23
DECISION-CTO 24
DECISION-CTO 25
DECISION-CTO 26
DECISION-CTO 27
DECISION-CTO 28
DECISION-CTO 29
DECISION-CTO 30
DECISION-CTO As treated 31
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, 1622 1632
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, 1622 1632
Vilka pat ska vi behandla? Safley et al. Catheter. Cardiovasc. Interv. 78:337 343. 34
Vilka pat ska vi behandla? 1.symptomatiska trots OMT 2. asymptomatiska med betydande ischemi > 10% (speciellt om LAD CTO) 35
36 Vilka pat ska vi behandla?
37 Riktlinjer
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
CTO-PCI teknik Antegrade wire escalation (AWE) Antegrade Dissection Re-entry (ADR) Retrograde dissection Re-entry (RDR) Retrograde wire escalation (RWE) 39
40 CTO-PCI teknik
41 CTO PCI teknik
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, 128 136
CTO-PCI i Linköping ca 50-60 dedicerade CTO-PCI per år ca 30-40 ad hoc (enklare antegrada PCI) >80% success 43
44 TACK