FELLOWS’ CORNER
SANDEEP KUMAR KRISHNAN, MD
Fellow-in-Training, University of Washington Medical Center, Seattle, WA
Chronic Total Occlusions
At the Precipice of a Revolution
N
othing can be more frustrating to both
patients and cardiologists alike than
coronary chronic total occlusions (CTOs).
CTOs are lesions with Thrombolysis In Myocardial Infarction (TIMI) 0 flow for ≥ 3 months1
and are commonly found in patients undergoing
coronary angiography (in 18.4% to 52%).2-5 Due
to the technical difficulty of the procedures and
their historically low success rates, patients with
CTOs are often referred for coronary artery bypass
graft surgery (CABG)2,3 but percutaneous coronary
intervention (PCI) may be preferred for some,
especially those with prior CABG and those with
non-left anterior descending single vessel coronary
disease.6
Although no randomized controlled clinical
trials comparing CTO PCI with medical therapy
have been published to date, there is a growing
body of evidence suggesting clinical benefits of
percutaneous revascularization
of CTO. These benefits include
an improvement in anginal
symptoms,7,8 decreased need
for anti-anginal medications,
improved exercise capacity,9
improved left ventricular systolic function,10 decreased risk
William Lombardi, MD
for arrhythmias,11 decreased
12
mortality, and overall improvement in clinical
outcomes.13,14 Because CTOs are the most common
reason for failing to achieve complete revascularization,15 they are often viewed with apprehension by fellows-in-training (FITS) and practicing
interventionalists alike.
I recently had an opportunity to sit down with
one of the pioneers in the CTO space and a mentor
of mine—William Lombardi, MD—to get his
thoughts on the field of CTO PCI and why fellows
should be interested in the field. Here are some
excerpts from my interview with Dr. Lombardi.
Dr. Krishnan: Why should fellows learn to
treat CTOs?
Dr. Lombardi: Historically PCI operators fixed
what they could fix. Now that we have learned to
treat CTOs with almost 90% success rates without cherry picking; we now have the ability to do
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CardioSource WorldNews: Interventions
complete revascularization for our patients. Along
the way, all the knowledge we have gained—how
to use a Corsair, the algorithms for impenetrable
caps, the algorithms for devices that won’t pass,
how to manage guide extensions, how to do
use atherectomy outside where it was originally
intended—led our profession to a point where we
could overcome the historic barriers to complete
revascularization including CTO, small vessels,
calcification, tortuosity, bifurcations, ostial lesions.
It has given us a skill set to allow us to evolve into
percutaneous surgeons.
The importance to FITs is to change their mindset about how they are being trained. Don’t treat
pictures—treat patients. Don’t think about right
and wrong ways—discover the algorithms for success. Having that fluid mindset of evolution and
creativity and focusing on the real agenda for any
intervention—complete revascularization—is the
key. How you get there is meaningless—whether
a surgeon does it, an interventionalist does it, a
surgeon and an interventionalist do it—all the
patients and the myocytes know is that they got
revascularized. If we focus on that we will get better at our craft.
As our skillsets for tackling CTOs grow and we
gain the ability to revascularize more complex
right coronary artery and left circumflex lesions,
will there be a larger role for hybrid coronary
procedures (in those patients with triple vessel
disease) moving forward?
What we are trying to do here at the University
of Washington is to do it backwards. The
interventionalists start in the hybrid OR by fixing
the right and left circumflex coronary arteries and
then, on Plavix, the surgeon will put an internal
mammary to the left anterior descending. If we
don’t get the right or the circumflex fixed, then
they [the surgeons] will graft that vessel as well.
What we do not want is hybrid procedures to give
an inferior result.
Historically, the interventional cardiology
mindset always pitted PCI as a competitor to
surgery, which, in my opinion, was the wrong
mindset. Unsurprisingly, PCI lost every time
because as the anatomy got harder we did a worse
“The importance
to the FITs is to
challenge their
mindset about
how they are
being trained.
Don’t treat
pictures—treat
patients. Don’t
think about
right and wrong
ways—discover
algorithms for
success.”
—William Lombardi, MD
job attaining complete revascularization. There is a
litany of data to support this clinical construct. So
we have to do something really hard as a profession. Instead of looking at a mirror and patting
ourselves on the back and saying “Gosh look how
great we are,” we have to ask “Why have we always
lost to surgery? Why are we getting incomplete
revascularization? Where are the gaps in our
training and skill sets? Where are the gaps in our
technology?”
This will help us focus on what the patient
September/October 2016