Hybrid PCI strategy rules for complex CTO
REPORTING FROM EUROPCR 2018
“I think the key message is you need to have more than one option to treat complicated disease. Half of patients had a switch in strategy,” Dr. Walsh observed.
Intravascular ultrasound (IVUS) adjudication in the central core lab showed a humbling rate of discordance between the operators’ impression of how their procedures were proceeding and what was really going on.
“There’s a bit of a mantra [that says] if you’re wiring stuff you’re always in the lumen, and if you’re using dissection techniques you’re always not in the lumen. In fact, that’s nonsense. You get it wrong one in six times. When you use IVUS adjudication to see if you’re outside the lumen or not, with wire-based retrograde escalation you’re out of the lumen and in the subintimal space 27% of the time. And with dissection strategies you’re wrong in about 15%,” according to the cardiologist.
He described the study participants as “extremely limited” at baseline as evidenced by their scores on the Seattle Angina Questionnaire Physical Limitation, Angina Stability, and Angina Frequency domains. At 12 months of follow-up, patients averaged 20- to 40-point improvements across all three domains.
One member of the discussion panel expressed a wish that the study had included a sham PCI arm. He raised the possibility that PCI had exerted an enormous placebo effect that could conceivably account for the substantial quality of life benefits documented in the study. But another panelist scoffed at this notion. This wasn’t a modest improvement in quality of life, nor was it measured after a mere 6 weeks, as was the case in the sham-controlled ORBITA trial.
“It’s really difficult to imagine a sham effect that persists out to a year,” he argued.
Dr. Walsh reported receiving research grants from and serving as a consultant to Boston Scientific, which funded the CONSISTENT CTO Study.
