Debate: Is there a difference between RDR and reverse CART? – No

Debate: Is there a difference between RDR and reverse CART? – No
Dimitri Karmpaliotis, New York, USA

11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany

1. Debate: Is there a difference between RDR and reverse CART? – No Dimitri Karmpaliotis , MD,PhD FACC Associate Professor of Medicine Columbia University Medical Center Director of CTO, Complex and High Risk Angioplasty NYPH/Columbia Email: [email protected] EURO CTO CLUB, 11 th Experts Live CTO Berlin , Germany, September 13-14, 2019

2. Disclosures As a faculty member for this program, I disclose the following relationships with industry: Honoraria from Abbott Vascular, Abiomed and Boston Scientific

3. That’s What Paul Needs to Prove to You to Convince you that RCART is Better than ADR His Arguments Need to be Based on Data His Arguments Need to be Based on Common Sense

4. That’s What Paul Needs to Prove to You to Convince you that RCART is Better than ADR His Arguments Need to be Based on Data

5. That’s What Paul Needs to Prove to You to Convince you that RCART is Better than ADR ADR is not needed to achieve high success rates and that AWE and Retrograde CTO PCI can take care of all cases Even before he gets to perform his magic RACRT, he can get at the distal cap all the time Consistently requires less number of stents to complete( Which is used as a surrogated of more controlled dissections)

6. That’s What Paul Needs to Prove to You to Convince you that RCART is Better than ADR Retrograde PCI is: Easier, Faster, Requires less Contrast Safer than Antegrade PCI Easier to teach, adopt and disseminate among CTO Operators Associated with better periprocedural outcomes Associated with better long-term outcomes

7. If Paul Fails to Prove to You Convincingly at least most of these points, then he would have failed miserably in making his point that RCART is Better than ADR

8. Having said all this, I am Confident that Paul will Triumph in making his point that RCART is Better than ADR Because I set the bar too low for a man of his CALIBER

9. ADR is not needed to achieve high success rates and that AWE and Retrograde CTO PCI can take care of all cases

10. Multiple strategies may be necessary to succeed in CTO-PCI

11. 1/2012 to 2/2014 n=632 Technical success: 92.4% Major complications: 1.9% Appleton Cardiology, WI Dallas VAMC/UTSW, TX Peaceheath Bellingham, WA Piedmont Heart Institute, GA St Luke’s Mid America Heart Institute, MO Torrance Medical Center, CA Christopoulos , Karmpaliotis , Alaswad , Wyman, Lombardi, Grantham, Thompson, Brilakis et al Journal of Invasive Cardiology 2014;26: 427-432 Successful technique PRO spective G lobal RE gi S try for the S tudy of CTO interventions

12. Pre “Hybrid” era Michael, Karmpaliotis , Brilakis, Lombardi, Kandzari et al. Heart 2013;99:1515-8 Δ =9.1% P<0.001 Christopoulos , Menon, Karmpaliotis , Alaswad , Lombardi, Grantham, Brilakis et al. AJC 2014;113-1990-4 CTO PCI: success and prior CABG N= 1,363 3 US sites Prior CABG: 37% Complications: 1.5% vs. 2.1% Retrograde: 27.1% vs. 46.7% Δ =3.7% P=0.092 “Hybrid” era N= 630 6 US sites Prior CABG: 37% Complications: 2.5% vs. 0.8% Retrograde: 34% vs. 39%

13. Pre Hybrid era Δ =9.1% p<0.001 Effect of Prior CABG Michael, Karmpaliotis, Brilakis, Abdullah, Kirkland, Mishoe , Lembo , Kalynych , Carlson, Banerjee, Lombardi, Kandzari . Heart 2013;99:1515-8 1,363 lesions; 3 US sites Prior CABG : 37% Complications: 1.5% vs. 2.1% Retrograde: 27.1% vs. 46.7% Δ =4.6% p=0.001 Hybrid era Current available data in PROGRESS-CTO Registry 02/05/2018 2967 lesions; 20 international sites Prior CABG : 32% Complications: 2.9% vs. 3.5% Retrograde : 31% vs. 54%

14. Author Year N (CTO lesions) Prior CABG Diabetes Retrograde Technical Success Major complications Death Tamponade Fluoroscopy time (minutes) Contrast use, (ml) Rathore 2009 904 12.6 40.0 17 87.5 1.9 0.6 0.6 NR NR Morino 2010 528 9.6 43.3 26 86.6 NR 0.4 0.4 45 (1-301)* 293 (53-1,097)* Galassi 2011 1983 14.6 28.8 14 82.9 1.8 0.3 0.5 42.3±47.4 313 ±184 U.S Registry* 2013 1361 37.0 40.0 34 85.5 1.8 0.22 0.6 42±29 294 ±158 * Median (range) Summary of Large Contemporary Registry Publications of Percutaneous Coronary Interventions of Chronic Total Occlusions * Tesfaldet, Karmpaliotis, Brilakis, Lembo, Lombardi, Kandzari. Am J Cardiol 2013

15. Author Year n Prior CABG (%) Septal collaterals used (%) Reverse CART (%) Technical Success (%) Major complications (%) Fluoroscopy time, min Contrast use, mL Sianos 2008 175 10.9 79.4 NR 83.4 4.6 59 ± 29 421 ± 167 Rathore 2009 157 17.8 67.5 NR 84.7 4.5 NR NR Kimura 2009 224 17.6 79 14 92.4 1.8 73 ± 42 457 ± 199 Tsuchikane 2010 93 10.8 82.8 60.9 98.9 60 ± 26 256 ± 169 Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR* Karmpaliotis* 2012 462 50.0 71 41 81.4 2.6 61 ± 40 345 ± 177 Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9. Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Procedural Outcomes from a Multicenter Registry in the United States

16. Technical approach

17. Successful crossing strategy stratified by J-CTO score p<0.0001

18. Even before he gets to perform his magic RACRT, he can get at the distal cap all the time

19. Limitations of Retrograde Approaches McEntegart et al. EuroIntervention. 2016;11:e1596-1603 Data from 481 patients with 519 CTOs Visible “interventional” collaterals only seen in 64% of lesions

20. Limitations of Retrograde Approaches Tsuchikane et al. CCI. 2013;82:e654-61 Data from 801 patients in J-PROCTOR registry

21. Reasons For Failure With Attempted Retrograde CTO PCI J Proctor CCI 2013.

22. Limitations of Retrograde Approaches Similar updated experience from Japan Examined 5984 CTO PCIs from 45 centres (2009-12) Retrograde attempt in 1656 cases Failed to cross with wire/micro-catheter in 23% Procedure success after collateral crossing 89% (~70% Overall) Suzuki et al. CCI. 2016;In Press doi: 10.1002/ccd.26785

23. Consistently requires less number of stents to complete( Which is used as a surrogated of more controlled dissections)

24. Retrograde PCI is: Easier, Faster, Requires less Contrast Easier to teach, adopt and disseminate among CTO Operators

25. Author Year n Prior CABG (%) Septal collaterals used (%) Reverse CART (%) Technical Success (%) Major complications (%) Fluoroscopy time, min Contrast use, mL Sianos 2008 175 10.9 79.4 NR 83.4 4.6 59 ± 29 421 ± 167 Rathore 2009 157 17.8 67.5 NR 84.7 4.5 NR NR Kimura 2009 224 17.6 79 14 92.4 1.8 73 ± 42 457 ± 199 Tsuchikane 2010 93 10.8 82.8 60.9 98.9 60 ± 26 256 ± 169 Morino 2010 136 9.6 63.9 NR 79.2 NR* NR* NR* Karmpaliotis* 2012 462 50.0 71 41 81.4 2.6 61 ± 40 345 ± 177 Karmpaliotis, Tesfaldet, Brilakkis, Lembo, Lombardi, Kandzari: JACC Cardiovasc Interv. 2012 Dec;5(12):1273-9. Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Procedural Outcomes from a Multicenter Registry in the United States

26. Retrograde PCI is: Safer than Antegrade PCI Associated with better periprocedural outcomes Associated with better long-term outcomes

27. Insights from the Progress CTO Registry

28. Retrograde vs. antegrade-only: outcomes 2012-2015 11 centers, 1,301 lesions Retrograde utilization : 41% Δ = 8.9% p<0.001 Δ =11.4% p<0.001 Karmpaliotis D, Karatasakis A, Alaswad K, Jaffer FA, Yeh RW, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Patel M, Bahadorani J, Moses JW, Kirtane AJ, Parikh M, Ali Z, Kalra S, Nguyen- Trong PJ, Danek BA, Karacsonyi J, Rangan BV, Roesle M, Thompson CA, Banerjee S, Brilakis ES. Circ Cardiovasc Interv 2016 Jun;9(6)

29. Retrograde vs. antegrade-only: in-hospital MACE p<0.001 p=0.003 p=0.999 p=0.039 p=0.314 p=0.167 Karmpaliotis D, Karatasakis A, Alaswad K, Jaffer FA, Yeh RW, Wyman RM, Lombardi W, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Patel M, Bahadorani J, Moses JW, Kirtane AJ, Parikh M, Ali Z, Kalra S, Nguyen- Trong PJ, Danek BA, Karacsonyi J, Rangan BV, Roesle M, Thompson CA, Banerjee S, Brilakis ES. Circ Cardiovasc Interv 2016 Jun;9(6)

30. Co PIs James Sapontis, Bill Lombardi Manager Karen Nugent Statistician Kensey Gosch Core Lab Federico Gallegos Publications Spertus, Cohen, Marso, Yeh, McCabe, Grantham, Karmpaliotis

31. That’s What Paul Needs to Prove to You to Convince you that RCART is Better than ADR His Arguments Need to be Based on Common Sense

32. CASE EXAMPLE CTO-RCA

33. CTO-RCA Dual Injections 7Fr Slender Sheaths Right Radial Artery 7Fr EBU 3.5 90cm Left Radial Artery 7Fr AL0.75 SH 90cm

34. CTO-RCA Dual Injections 7Fr Slender Sheaths Right Radial Artery 7Fr EBU 3.5 90cm Left Radial Artery 7Fr AL0.75 SH 90cm

35. Retrograde via LAD septal TurnPike 150cm Sion wire

36. Setting up for Reverse CART Antegrade TurnPike 135cm Retrograde TurnPike 150cm Antegrade Pilot 200 Retrograde Pilot 200 Very Hard to get into vessel structure because of tortuous and ectatic vessel added to proximal bridging collaterals and ambiguous proximal cap

37. “Move the Cap” Technique Antegrade 4.0 x 12 Balloon inflated in pRCA On looped BMW wire Antegrade TurnPike 135cm With Knuckled Fielder XT Wire NEXT to the Balloon “Move the Cap” by entering the sub-intimal place (with your knuckle) more proximally that the proximal CTO cap

38. ADR-StingRay StingRay LP StingRay Wire Fenestrations

39. ADR-StingRay StingRay LP Pilot 200 rapidly advanced with wiring of the distal true lumen Into a smaller branch Retrograde Distal Tip Injections with Medallion Syringe for visualization

40. After 6Fr Guideliner supported PCI DES 3.5 x 38 mm DES 4.0 x 38 mm DES 4.0 x 18 mm DES 4.0 x 28 mm

41. Having said all this, I am Confident that Paul will Triumph in making his point that RCART is Better than ADR Because I set the bar too low for a man of his CALIBER So, Good Luck Paul……

42. THANK YOU

43. THANK YOU