Update on Chronic Total Occlusion Percutaneous Coronary Intervention: An Interview With Emmanouil S. Brilakis, MD, PhD

Dr Deepak L. Bhatt and Dr Emmanouil S. Brilakis discuss the latest updates on chronic total occlusion percutaneous coronary intervention. Read the article here.

Transcript:

Dr Bhatt: Hello, I'm Dr. Deepak Bhat, Editor-in-Chief of the Journal of Invasive Cardiology, and I'm really lucky to have Dr. Manos Brilakis with me here today. Dr. Brilakis is from the Minneapolis Heart Institute where he does lots of complex procedures and also does a lot of research pertaining to complex coronary intervention. He had one of the Top 10 papers in 2023 in the Journal of Invasive Cardiology that pertained to chronic total occlusion, PCI, and in this month's issue, March, of the Journal of Invasive Cardiology, he has another update on CTO-PCI. Well, welcome, Manos.

Dr Brilakis: Thank you. Thanks again, Deepak, really appreciate the opportunity to be with you today.

Dr Bhatt: I was hoping you could tell us about the state of the art in CTO-PCI as your recent article nicely summarized.

Dr Brilakis: Yeah, thank you so much again; it's a lot of information. What we try to do in those review articles to get the most influential, so to speak, studies that have been published during the previous year and discuss how they affect the way to do CTO intervention. So maybe I will start with a more recent one from 2024. One of the key publications last year was about the indications of the procedure and how it can help long-term and also about the safety. So we did have the long-term follow-up from the Euro-CTO study from Werner and colleagues that did show that patients who underwent CTO-PCI did have good safety outcomes even during the long-term follow-up. There was still, as we know from the previous publication. significant symptomatic benefit in terms of undergoing CTO-PCI vs no CTO-PCI. So, this was one of them.

Then a second important paper is the long-term follow-up of the common CTO which showed good safety down the line. There have been several studies looking at men vs women. And actually, women in some of the studies have had higher success but they also have had a little less complex chronic total occlusions. Another subgroup that is very important is that of previous coronary bypass graft surgery. Unfortunately, in that group of patients, although we have overall improved, we still are likely by about 5 to 6 points less success and we do have more complications, which does reflect some of the more complexity of the leisure, but also the patients are older and they have more comorbidities.

Another factor we looked at this year and I think it's less appreciated so far is the importance of the distal vessel quality. So we had a publication that did show that the more diseased the digital vessel, the more challenging to open it, less success and the more complications.

Dr Bhatt: Well that really is what we learned from the surgeons that is the surgeons will say the same thing in terms of bypass grafting.

Dr Brilakis: Yeah, absolutely, and the same factors that affect the patency of the bypass as you as you mentioned affect also the success of the procedure I think part of the problem is if the wire goes into the extra-plaque space and the vessel is very, very small, the difficulty of getting it back in is very high. So, then you may have to go retrograde, which increases the risk and creates other problems. But also, the challenge in CTO is that sometimes when you recanalize the vessel, you have some negative remodeling and some under-filling of the vessel because of the poor perfusion, and it can grow. And I suspect the same happens during bypass. Some people get bypassed in very small-looking vessels, they come back sometimes after several months or a year, and then the vessel has clogged up because now it does have flow. So, it's not perfect, but it is a marker of complexity and helps plan better where and how to recanalize those blockers.

Dr Bhatt: And what about radial vs femoral and same-day discharge, that sort of thing. In non-CTO-PCI, many places in the world now, including in the US, radial become the dominant mode of vascular access. And some operators even are recommending it for CTO. Some are still liking femoral for more complex procedures. But same-day discharge, especially during the pandemic in general, became much more popular, though a lot of times that's predicated on radial access. What are your thoughts about those two somewhat interrelated issues?

Dr Brilakis: Absolutely, and we used to think that bifemoral is the way to go, but we did have, there was a couple of papers last year, the year before, with 2 randomized trials, one was not pure CTO, but mostly CTO; another one was from Turkey, which was 100% CTO. They both were very consistent in showing that access was the same with radial and femoral. The complications in terms of particular access complications were as expected less in the radial access group.

Now, there are some concerns by some operators regarding the complexity, which is super complex lesion bypass patients that the femoral might have some advantage, but I think for many CTOs, radial access works fairly well and improves the patient's comfort as well as reduces the risk of complications. But to your point about same-day discharge, radial access does facilitate tremendously going home the same day, less concern for bleeding from the femoral access side, and we have seen an increase in the same-day discharge for uncomplicated CTOs. Still, it's, I think, in the early stages, and there are some CTOs that are potentially less suitable for same-day discharge, if there is difficulty, if there has been any perforation or any other complications, but generally, I think we're seeing for uncomplicated procedures an increase in the rate of same-day discharge for CTO-PCI, especially with radial access.

Dr Bhatt: And that's terrific. You know, the Japanese have described a method of recanalizing aorto-ostial CTOs. It seems to be something where you really do want to have specific experience with this. But any thoughts about that approach?

Dr Brilakis: Yeah, absolutely. And I think the differences between the Japanese way I think has to do in part with equipment availability, but also with general philosophy. So, in Japan, people are much more patient with wire manipulations. So, they will spend much more time compared with Americans, and I think most Europeans as well, trying to find the right wire that goes through the lesion. Also, they’re much more into guidance, so they will use intravascular ultrasound a lot. They have actually some lower profile IVUS catheters, this catheter, that can go on the same wire as the microcatheter to the lumen, and that can help visualize, and help you even reentering the true lumen if the guidewire goes into the extraplaque location.

In contrast, I think in the US, people are more likely to use the extraplaque or subintimal crossing strategies, more like, for example, if the wire goes extraplaque to use, it's actually re-entered with a Stingray balloon, vs to try the parallel wiring or spend as much time in wire manipulation. Again, that reflects availability, I think Stingray is much more accessible in the US compared to other parts of the world, and also the cumulative experience, there's been much more experience in using antegrade dissection and re-entry in the US and parts of Europe compared with the rest of the world.

Dr Bhatt: Yeah, no, really great insights. Any other points that you think you should make to the audience, either folks that are already doing CTOs or contemplating starting?

Dr Brilakis: Yeah, I think 1 major trend we are witnessing right now, and I think it's going to continue to expand over time, is the use of coronary CT angiogram. We have seen in many parts of the world an increase in the use, better understanding of how to use the CT data. For example, the full moon morphology is a high predictor of failure. It's going to require extraplaque crossing strategies. But having a coronary CT helps, first of all, understand the CTO. There was one showing high success with previous coronary CTA. But also, sometimes you can understand the guide, understand the difficulty. So this, I think, is going to grow in CTO-PCI and like in other parts of PCI, complex and uncomplex.

Dr Bhatt: Yeah, no, totally agree with that. The final question I just want to ask you some folks out there say we really need more in the way of randomized trials of opening up CTOs to see just how much value they add, some say even just for quality of life issues, there I think with careful patient selection probably there are patients that are really benefiting, but looking at harder endpoints as well, what are your thoughts about that?

Dr Brilakis: Excellent point, and there is still the quest for having a control trial, like ORBITA and ORBITA-2. Actually, the ORBITA group is doing a small pilot, the ORBITA CTO in which they're using the same methodology to look at the quality-of-life improvement in CTO-PCI. But again, you’re right. It would be very nice to have a definitive proof that the benefit we get, or the patient's care with CTO-PCI, is independent of the placebo effect.

Having said that, the major challenge in that area, apart from the technical difficulty and the logistics of running such a trial, is that most symptomatic patients, the ones that were more likely to see this potential benefit, these are the ones who are less likely to get into a study like this because they have poorly controlled symptoms and they really want to find a solution to their symptoms. So, if we do the study with less symptomatic patients, then unfortunately, we might not witness or see what is more representative of the general population we are treating.

Dr Bhatt: Yeah, no, really thoughtful comments. Well, it's been a pleasure speaking with you about CTOs. I think there's so much interest out there, especially among our readership of the Journal Invasive Cardiology. We'll evaluate your contributions to the field and to the journal. Thanks so much.

Dr Brilakis: Appreciate it. Thank you so much.