1. The study evaluated subintimal tracking that occurred during chronic total occlusion percutaneous coronary intervention (CTO PCI) using antegrade and retrograde approaches.
2. Subintimal tracking was more common in the retrograde approach and in lesions with longer occlusion lengths.
3. No significant differences were found in 12-month target vessel revascularization rates or major adverse cardiac events between the intimal and subintimal tracking groups for either approach.
1. Try to Stay Intimal
Etsuo Tsuchikane, MD, PhD
Toyohashi Heart Center
Nagoya Heart Center
Gifu Heart Center
2. Disclosure
Within the past 12 months, the presenter or their
spouse/partner have had a financial interest/arrangement or
affiliation with the organizations listed below.
Physician Name
Etsuo Tsuchikane, MD, PhD
Company/Relationship
Abbott Vascular, Japan Consultant
Boston Scientific, Japan Consultant
Asahi Intecc, Japan Consultant
3. a = IVUS catheter , b = Sub-Intimal space, c = the Intimal Plaque
Sub-Intimal TrackingIntimal Plaque Tracking
4. 26 CTO lesions successfully treated by a single operator
4 lesions by retrograde approach
Subintimal tracking in 45% (12/26)
Subintimal tracking was more common in reattempted case (42% vs. 7%), associated
with longer stent length (71 vs. 50 mm), procedural time (122 vs. 69 min), fluoroscopy
time (47 vs. 22 min), and contrast dose (300 vs. 199 mL).
No long-term data available (CCI 2012;79:43-48)
5. 48 CTO lesions successfully treated by a single operator
25 lesions by retrograde approach
Subintimal tracking in more common in retrograde approach (40 vs. 9%)
No long-term data available (JACC Intv 2009;2:846-54)
6. 1. How often in the contemporary CTO-PCI?
2. Any effect of short subintimal tracking on long-
term outcomes after DES?
7. J-PROCTOR REGISTRY
PROMUS STENT TREATMENT OF
CHRONIC TOTAL OCCLUSIONS
USING TWO DIFFERENT RECANALIZATION
TECHNIQUES IN JAPAN
(EuroIntervention 2014;10:681)
8. Study Design
Flow Chart
CTO Cases
Antegrade Retrograde
IVUS Check for GW penetration position
PROMUS Stent Implantation
12 mo. Clinical FU
Study Enrollment
Antegrade 50 : Retrograde 100
GW Cross Lesion Success
9 mo. Angiogram FU
Primary Endpoint: 12 mo. TVR
Secondary Endpoint: 12 mo. MACE
and Fu QCA parameters
15. Acute QCA Results
Intimal vs. Sub-Intimal
Intimal
(125)
Sub-Intimal
(31)
p value
Pre Procedure
RVD, mm 2.82±0.42 3.02±0.44 0.020
Occlusion Length, mm 18.5±14.8 23.9±20.5 0.14
Post Procedure( In stent)
RVD, mm 3.09±0.48 3.17±0.44 0.38
MLD, mm 2.60±0.46 2.61±0.37 0.91
Stent Length, mm 50.5±23.8 60.5±23.0 0.040
Acute Gain, mm 2.6 ±0.5 2.6 ±0.4 0.91
16. 9-month QCA Results
Intimal vs. Sub-Intimal
Intimal
(100)
Sub-Intimal
(22)
p value
In Stent
RVD, mm 3.00±0.46 2.95±0.41 0.87
MLD, mm 2.41±0.66 2.03±0.79 0.021
% DS, % 19.8±19.1 30.4±25.9 0.031
Late Loss, mm 0.21±0.52 0.57±0.93 0.016
Loss Index, % 7.8±22.6 19.7±30.3 0.038
Reocclusion 3.0% (3) 4.5% (1) 0.55
Aneurysm 1.0% (1) 9.1% (2) 0.08
Aneurysm (from QCA core lab) = an expansion of the lumen by at least 20% compared with the normal lumen dimensions in the
treatment region (analysis segment) that extends with a wide or narrow mouth beyond the apparent normal contour
17. Acute QCA Results
Retrograde: Intimal vs. Sub-Intimal
Intimal
(75)
Sub-Intimal
(24)
p value
Pre Procedure
RVD, mm 2.89±0.41 3.08±0.43 0.06
Occlusion Length, mm 21.5±15.5 28.1±21.1 0.14
Post Procedure( In stent)
RVD, mm 3.11±0.51 3.21±0.41 0.39
MLD, mm 2.60±0.48 2.63±0.41 0.74
Stent Length, mm 56.4±23.7 66.7±20.9 0.06
Acute Gain, mm 2.6±0.5 2.6±0.4 0.74
18. 9-month QCA Results
Retrograde: Intimal vs. Sub-Intimal
Intimal
77.3% (58)
Sub-Intimal
75.0% (18)
p value
In Stent
RVD, mm 3.02±0.49 3.00±0.43 0.86
MLD, mm 2.32±0.73 1.92±0.83 0.05
% DS, % 23.2±20.3 34.8±26.7 0.05
Late Loss, mm 0.29±0.63 0.71±0.98 0.037
Loss Index, % 10.8±24.9 24.6±31.4 0.06
Reocclusion 3.4% (2) 5.6% (1) 0.56
Aneurysm 1.7% (1) 11.1% (2) 0.14
Aneurysm (from QCA core lab) = an expansion of the lumen by at least 20% compared with the normal lumen dimensions in the
treatment region (analysis segment) that extends with a wide or narrow mouth beyond the apparent normal contour
19. J-PROCTOR Summary
• According to IVUS analysis, Sub-intimal tracking tended to be higher
in retrograde approach than antegrade.
• Lesion characteristics were more severe in Sub-intimal tracking group.
• No significant difference was observed in 1year TVR rate (primary
endpoint) between Intimal and Sub-intimal tracking groups, in both
antegrade and retrograde approach.
• Acute QCA analysis identified longer occlusion and stent lengths in the
Sub-intimal tracking group.
• FU QCA analysis showed a higher late loss in the Sub-intimal group,
but no difference in re-occlusion rate.
20. J-PROCTOR Conclusion
• No clinical negative impact by EES implantation
after localized Sub-intimal tracking in either
antegrade or retrograde manner at 1 year was
demonstrated in this study.
21. 1. Subintimal tracking is more predictable in the retrograde
approach than the antegrade. But not so common even if
reverse CART is commonly used (>50%).
2. Occlusion length may influence the incidence of subintimal
tracking in both approaches.
Lessons from J-PROCTOR
22. 13,7
17,6
43
12,3
9
45
0
10
20
30
40
50
J-Proctor Tsujita et al.* Muhammad et al.**
CTO length (mm) Incidence of subintimal tracking (%)
(**CCI 2012;79:43-48)
(*JACC Intv 2009;2:846-54)
(n=26)
4 retrograde(n=23)(n=57)
CTO length and Subintimal tracking
Antegrade approach
24. 1. Subintimal tracking is more predictable in the retrograde
approach than the antegrade. But not so common even if
reverse CART is commonly used (>50%).
2. Occlusion length may influence the incidence of subintimal
tracking in both approaches.
3. Restenosis does not always occur in DES with subintimal
dilatation.
Lessons from J-PROCTOR
25. TVR at 12 months
Antegrade (Intimal vs. Sub-intimal)
Retrograde (Intimal vs. Sub-intimal)
10.4%
(13) 8.0%
(4)
12.0%
(9)
12.9%
(4)
0%
(0)
16.7%
(4)
0%
10%
20%
30%
40%
50%
All Antegrade Retrograde
Intimal
Subintimal
p=0.75 p=1.00 p=0.51
26. 9-month QCA Results
Retrograde: Intimal vs. Sub-Intimal
Intimal
77.3% (58)
Sub-Intimal
75.0% (18)
p value
In Stent
RVD, mm 3.02±0.49 3.00±0.43 0.86
MLD, mm 2.32±0.73 1.92±0.83 0.05
% DS, % 23.2±20.3 34.8±26.7 0.05
Late Loss, mm 0.29±0.63 0.71±0.98 0.037
Loss Index, % 10.8±24.9 24.6±31.4 0.06
Reocclusion 3.4% (2) 5.6% (1) 0.56
Aneurysm 1.7% (1) 11.1% (2) 0.14
Aneurysm (from QCA core lab) = an expansion of the lumen by at least 20% compared with the normal lumen dimensions in the
treatment region (analysis segment) that extends with a wide or narrow mouth beyond the apparent normal contour
31. TVR Case in Retrograde Group #3
Subintimal tracking
Restenosis
9Mo Fu angiogram
32. No difference between 2 groups regarding the pattern of ISR. No
relationship betwen restenosis site and subintimal tracking portion
J-PROCTOR registry
Site and pattern of restenosis in patients
undergoing target vessel revascularization
33. 1. Subintimal tracking is more predictable in the retrograde
approach than the antegrade. But not so common even if
reverse CART is commonly used (>50%).
2. Occlusion length may influence the incidence of subintimal
tracking in both approaches.
3. Restenosis does not always occur in DES with subintimal
dilatation.
4. Short subintimal tracking and a final TIMI flow grade 3 with
well preserved distal side branches may not worsen the vessel
patency.
5. These suggestions warrants further evaluations.
Lessons from J-PROCTOR
34. J-PROCTOR 2 STUDY
PROMUS STENT TREATMENT OF
CHRONIC TOTAL OCCLUSIONS
USING TWO DIFFERENT RECANALIZATION
TECHNIQUES IN JAPAN
35. Retrospective analysis of successfully treated cases from
“Retrograde Summit Registry 2012” with procedural
recorded IVUS images and 1yr clinical follow-up
Same definition, inclusion and exclusion criteria as J-
PROCTOR
Independent IVUS evaluation
Primary endpoint was 1yr TVR and secondary was 1yr
MACE (same as J-PROCTOR)
Study Design
36. Enrolled CTO cases in Retrogarde
Summit Registry 2012
1573
GW cross lesion success
1411
EES implanted and matched
inclusion criteria of J-PROCTOR
894
Study Design
Flow Chart
Checked IVUS for
GW penetration position
387
No IVUS image
: 507
37. Study Enrollment
Antegrade 242 : Retrograde 81
Study Design
Flow Chart
Checked IVUS for
GW penetration position
387
Eligible for IVUS analysis
352
Poor IVUS image
: 35
Available for 12mo clinical FU
323
Primary Endpoint: 12 mo. TVR
Secondary Endpoint: 12 mo. MACE
38. Baseline Patient Characteristics
Antegrade
242
Retrograde
81
p value
Male 83.1% 79.0% 0.41
Age (years) 67.8 ±10.4 67.4 ±10.9 0.71
Previous MI 28.5% 48.1% 0.001
Previous CABG 4.1% 9.9% 0.053
Hypertension 75.2% 77.8% 0.6
Diabetes mellitus 34.3% 37.0% 0.66
Hyperlipidemia 65.7% 76.5% 0.07
Smoking 40.1% 56.8% 0.009
Average diseased vessel 1.8±0.7 1.9±0.8 0.66
Multi vessel disease 63.6% 60.5% 0.19
47. Procedural Results
by IVUS classification
Intimal
270
Sub-Intimal
53
p value
Number of GW 2.9±1.8 4.5±2.8 <0.0001
IVUS guided wiring 11.5% 41.5% <0.0001
Number of stent 1.8±0.8 2.2±0.8 0.002
Stent diameter, mm 2.9±0.3 2.8±0.3 0.17
Stent length, mm 49.2±22.9 62.5±27.0 <0.0001
Maximum stent pressure, atm 17.5±3.9 17.3±4.0 0.71
48. Procedural Results
by IVUS classification
Intimal
270
Sub-Intimal
53
p value
Procedure time, min 127.2 ±75.1 185.2±80.7 <0.0001
Contrast dose, ml 221.3±95.2 261.5±93.5 0.006
Fluoroscopic time, min 55.9±34.8 96.4±48.9 <0.0001
Procedure events 0.4% (1) 3.8% (2) 0.07
- GW perforation 0.4% (1) 1.9% (1) 0.3
- Channel injury 0% 1.9% (1) 0.16
- Donor artery trouble 0% 0% >0.99
In hospital MACE 0% 0% >0.99
Non Q wave MI 0% 0% >0.99
56. PCI Procedure
Retrograde: Intimal vs. Sub-Intimal
Intimal
56
Sub-Intimal
25
p value
Number of GW 4.1±1.8 5.9±2.6 0.003
IVUS guided wiring 39.3% 76.0% 0.002
Number of stent 1.7±0.7 1.8±0.8 0.03
Stent diameter, mm 2.9±0.3 2.9±0.3 0.21
Stent length, mm 59.7±24.4 74.0±24.4 0.02
Maximum stent pressure, atm 17.1±4.2 17.1±3.8 0.99
57. Retrograde Case 1: Mid RCA
Pre Post F/U
Sub-intimal
tracking zone
In-Stent
58. Retrograde Case 2: Distal RCA
Sub-intimal
tracking zone
Pre Post F/U
In-Stent
59. Retrograde Case 3: Mid LAD
Sub-intimal
tracking zone
Pre Post F/U
In-Stent
60. Retrograde Case 4: Proximal RCA
Sub-intimal
tracking zone
Pre Post F/U
In-Stent
61. Independent Predictors of
TVR
Overall Odds Ratio (95% CI) p value
Retrograde approach 3.6 (1.3 -10.5) 0.02
Retrograde
Bridge collateral 7.0 (9.5 -32.9) 0.01
62. Limitations
• Non randomized observational study
• Retrospective study
• Short clinical follow-up period (1 year)
• Low angiographic follow-up rate (36.8%)
63. J-PROCTOR 2 Summary
• Subintimal tracking was more predictable in the retrograde
approach (30.9% vs. 11.9%).
• In Japanese antegrade approach, TVR rate was quite low
(2.9%) in both intimal and subintimal tracking group.
• Although the occlusion length was similar, subintimal
tracking group required a longer stent length compared to
intimal tracking group in retrograde approach.
• TVR was more frequent for subintimal tracking group not in
antegrade but in retrograde approach.
• However TVR portion was not related to subintimal tracking
portion.
64. J-PROCTOR 2 Conclusion
Intimal tracking should be recommended in
retrograde approach to reduce stent length and
to improve follow-up outcomes.
However, subinitimal tracking does not
directly affect the late loss.
65. • STAR technique with KWT should never be applied
for major trunk. It’s allowable only for side branches.
• Subintimal tracking in contemporary wiring without
Stingray is not rare (>10%). However, long-term
outcomes must be good.
• How often do we need Stingray? Does it increase
overall success rate?
We Should Stay Intimal or Not?
In Antegrade Approach
66. Contemporary Japanese CTO-PCI
from Retrograde Summit Registry
2012 (1553) 2013 (1676) P
Successful CTO crossing by GW 89.6% 89.6% 0.9925
Number of guidewire used for CTO
approach
3.1±2.2 3.2±2.3 0.1788
Stent deployment 93.5% 100.0% <0.0001
Number of stent 1.8±1.0 1.9±0.9 0.0033
Total stent length, mm 51.8±24.9 55.4±27.9 0.0008
Use of drug-eluting stent 98.0% 98.8% 0.0907
Procedure success 88.3% 88.4% 0.9437
Procedure time, min 142.7±83.4 153.2±88.0 0.0012
Contrast dose, ml 228.7±107.2 226.2±103.4 0.5187
Fluoroscopy time, min 64.2±42.4 70.6±47.8 0.0002
Air Kerma, mGy 4715.8±3760.8 4920.3±3879.7 0.2031
67. Registry Overview
Retrograde Summit
General Registry
Japanese CTO PCI
Expert Registry
Organization Retrograde Summit Japanese Board of CTO
interventional specialist
Participants
As of Nov. 2014
56 of Japanese
Centers
31 of Japanese expert
Physicians
Criteria for the
Participants
Centers which were
approved by administrative
board
Cases by experts are
excluded.
• More than 300 cases of
experience of CTO-PCI
• More than 50 cases of CTO-
PCI per year
• Recommendation from two
or more steering committee
member
Core lab ー Adjudication of Success
71. GW Technique for
Successful CTO body Crossing
60%
26%
13%
1%
HC
57%31%
3%
9%
LC
Single wire
Parallel wire
IVUS guide
Other
P=0.007
Antegrade approach after
retrograde approach failure (296)
HC (131) LC (165) P value
Successful CTO body crossing by GW 74.8% (98) 54.6% (90) 0.0003
72. Development of CTO-PCI procedure
Miracle
Conquest
Parallel wiring
IVUS guidance
Retrograde approach
1995 2000 2005 2010
Fielder XT
Fielder XTR
GAIA
BridgePoint
MDCT
Corsair
wire, device
imaging modality
wiring technique
SION
2015
Euro CTO Club
Hybrid approach
CTO Fundamentals
CTO Club
75. Objective
To promote CTO-PCI based on the well developed
technology (devices, techniques) for more than 20
years in Asian-Pacific region.
To educate the next generation of Asian-Pacific CTO
operators for the patients living in this region.
76. Directors
Ji Yan Chen Guangdong General Hospital China
Lei Ge Zhongshan Hospital Fudan University China
Scott Harding Wellington Hospital New Zealand
Paul Hsien-Li Kao National Taiwan University Hospital Taiwan
Seung-Whan Lee Asan Medical Center Korea
Soo Teik Lim National Heart Centre Singapore Singapore
Sidney Tsz Ho Lo Liverpool Hospital Australia
Jie Qian Fu Wai Hospital China
Etsuo Tsuchikane Toyohashi Heart Center Japan
Eugene B. Wu Prince of Wales Hospital Hong Kong
78. Supervisors
Jumbo Ge Zhongshan Hospital Fudan University China
Yang-Soo Jang Severance Hospital, Yonsei University Hospital Korea
Osamu Katoh Japan
Tian Hai Koh National Heart Centre Singapore Singapore
Sum Kin Leung Keen Heart Medical Practice HongKong
Jim Stewart Auckland City Hospital New Zealand
Yeujin Yang Beijing Fuwai Hospital China
Chiung-Jen Wu Kaohsiung Chang Gung Memorial Hospital Taiwan
79. What’s AP CTO Club role and activity
in AP region?
• Development of AP CTO-PCI Algorithm
• Web Site Open
• Educational Training Program
– Workshop in each regional annual meeting for young
physician’s CTO training
• Web-cast Live Demonstration?
– To share CTO live-demonstration through web-cast for
education purpose
• Asian Pacific CTO Registry?
– Collect CTO data and publish as AP CTO data
• Other??
80. Retrograde approach
Features favoring early use of KWT
and/or dissection re-entry
• Ambiguous course in CTO
• Length >20 mm
• Tortuous CTO segment
• Heavy calcification
• Previous failed attempt
Consider stopping if >3 hours, 3.7 x eGFR ml contrast, Air Kerma > 5 Gy unless procedure well advanced
Proximal cap ambiguity IVUS guided entry
No
Poor quality distal vessel or
bifurcation at distal cap
Careful analysis of angiogram / MSCT
No
Yes
Yes
No
Interventional collaterals present
Yes
No
Yes
In-stent restenosis
Consider use of CrossBoss as
primary crossing strategy
Antegrade wire
based approach
Dissection Reentry
(crossboss-stingray)
Parallel wiring
IVUS guided wiring
If suitable
re-entry
zone
81. What’s AP CTO Club activities
in AP region
• “Umbrella” covering CTO workshops and major meetings in AP region
– Jun. 19-20 CTO Club in Nagoya
– Aug. 21-22 Guangzhou CTO Workshop in China
– Sep. 11-12 CTO Interventions Live course in Singapore
– Oct. 23-24 CTOCC in Shanghai
– Oct. 29-31 CCT in Kobe
– Nov. 18-20 ANZCCT in Brisbane
– Jan. 8-9 TTT in Taipei
– Mar. 17-20 CIT in Beijing
– Apr. 26 CTO Live@TCT AP in Seoul
– Jun. 9-10 ANZCTO Club in Perth
– Jun. 17-18 CTO Club in Nagoya
2015
2016
82. What’s AP CTO Club activities
in AP region
• “Umbrella” covering CTO workshops and major meetings in AP region
– Jun. 19-20 CTO Club in Nagoya
– Aug. 21-22 Guangzhou CTO Workshop in China
– Sep. 11-12 CTO Interventions Live course in Singapore
– Oct. 23-24 CTOCC in Shanghai
– Oct. 29-31 CCT in Kobe
– Nov. 18-20 ANZCCT in Brisbane
– Jan. 8-9 TTT in Taipei
– Mar. 17-20 CIT in Beijing
– Apr. 26 CTO Live@TCT AP in Seoul
– Jun. 9-10 ANZCTO Club in Perth
– Jun. 17-18 CTO Club in Nagoya
2015
2016
83. • STAR technique with KWT should never be applied
for major trunk.
• Subintimal tracking in contemporary wiring without
Stingray is not rare (>10%). However, long-term
outcomes must be good.
• The use of Stingray must be limited just because we
do not need it generally.
We Should Stay Intimal or Not?
In Antegrade Approach
84. • Reverse CART does not always cause subintimal
tracking.
• Retrograde approach requires subintimal tracking
more frequently than antegrade based on lesion
characteristics, which we can’t control techniqually.
• Two J-Proctor studies may suggest the subintimal
tracking does not always affect the late loss.
We Should Stay Intimal or Not?
In Retrograde Approach
When necessary,
we may go subintimal!
85. 17th CTO Club
June 17 fri.-18 sat., 2016, Nagoya, Japan
www.cct.gr.jp/ctoclub
