A journey to CTO interventions—CTO in ARMS: 2018 CTO Cases Competition

Chronic total occlusion (CTO) is a formidable challenge for interventionists. To overcome this challenge and provide practical information on CTO intervention, the 2018 CTO Cases Competition was held. This competition offered a great platform for contestants to make extensive discussions and exchanges on CTO treatment solutions and strategies, bringing about much better impacts on CTO treatment than the initial expectation.

The 2018 CTO Cases Competition lasted four months, included three regional contests, and one final national contest. A total of 100 doctors brought their CTO cases to participate in the preliminary screening, among whom 24 contestants were shortlisted into the regional contests, and 10 doctors made their way to the final contest (Table 1). Nineteen experts with profound experience in CTO interventional therapy were invited to be judges at the competitions (Table 2). The three regional competitions were separately held on July 22 (Northeast competition, Figure 1), July 28 (Northwest competition, Figure 2), and August 4 (Northern competition, Figure 3). The national competition was held on October 13 during the periods of the 29th Great Wall International Congress of Cardiology (Figure 4).

Table 1 Contestants (alphabetical by Surname)
Full table

Table 2 Judges of the competition (alphabetical by Surname)
Full table

Figure 1 A group photo in the Northeast competition venue.

Figure 2 Group photos in the Northeast competition venue.

Figure 3 A group photo in the Northern competition venue.

Figures 4 Group photos in the national competition venue.

The competition was jointly organized by the Quality Control Committee of Interventional Therapy on Cardiovascular Diseases of General Military Region and the CTO IN ARMS. During the Northeast Cardiovascular Forum in June 2018, Academician Yaling Han (General Hospital of Northern Military Region) initiated the establishment of the CTO IN ARMS. Prof. Quanmin Jing was named the executive chairman of the panel, and several interventional therapy experts including Yingfeng Liu, Leisheng Ru, Chengxiang Li, Chun Liang, Jun Guo, and Yaoming Song were elected executive vice chairman. This group is established initially to treat cardiovascular diseases for all military officers, their family members as well as people who had worked or studied at military hospitals. “Leave no comrade-in-arms fall behind” is the mission of the panel. The CTO Cases Competition will be held every year since 2018 in a bid to improve CTO interventional therapies at all military hospitals and other hospitals in China. Academician Han is the chairman of the organizing committee of the competition, and Prof. Quanmin Jing is the executive chairman.

Unbalanced development of CTO interventions in China

According to Academician Han, China has made remarkable progress in CTO interventional therapy in recent years:

• There has been a dramatic increase in the number of doctors exploring CTO interventional technology. About 15–20 years ago, only a small number of Chinese interventionalists tried to perform CTO recanalization. Thanks to a significant advance in cardiovascular interventions, more interventional cardiologists have joined our team, including a growing percentage of young and middle-aged doctors.
• Rates and cases of successful recanalization of CTOs have significantly increased. At many large heart centers in China, the rates of successful recanalization of CTOs have exceeded 90%. For instance, the Cardiovascular Department in the General Hospital of Northern Military Region has performed about 8,000 CTO interventions in the past two decades, and the success rate has always been higher than 90% in the recent 15 years.
• CTO recanalization technology has improved, and the involved equipments have been updated. The primary treatments have been extensively popularized in China, and the retrograde technique has already been adopted in many heart centers. With the introduction of Antegrade Dissection Re-entry (ADR) into China, some heart centers have explored CTO recanalization with the assistance of Crossboss and Stingray instruments.

Despite the tremendous advances in CTO interventions in China, the progress is uneven among different regions and different hospitals. Many hospitals and doctors have misunderstandings and blind spots in areas such as surgical indications, preoperative preparations by patients and surgeons, management of intraoperative and perioperative complications, the timing of terminating a surgery and scheduling another surgery, technical training for the operator and surgery team, and learning curve of basic and advanced techniques. Meanwhile, CTO remains the biggest problem in the interventional treatment of coronary heart disease, and the technical challenges leaves uneven clinical performances in dealing with this extremely complicated disease. Unfortunately, regular training programs cannot deliver sufficient and adequate training for interventionists and thus cannot meet the domestic demand of making better CTO interventions available to more patients.

“Therefore, experienced hospitals and doctors should provide help to hospitals and doctors that have not carried out CTO interventions. To that end, we decide to hold this case competition, so that participating doctors, experts, and the audience can join together. Ten winners in the three regional competitions in Northeast, Northwest, Northern China have stood out to take part in the final national competition”, said Academician Han.

China is approaching or catching up with Europe and the U.S. in CTO interventions

“Twenty years ago, we began to participate in academic exchange activities with our Japanese colleagues. I have accepted many invitations to attend CTO conferences in Japan, Europe, and the U.S.”, said Academician Han, adding that she gave two lectures at Japan’s CTO-Club in 2004—“Current status of CTO interventions in China” and “Antegrade CTO interventional in China (report of four cases)”. In February 2007, she accepted an invitation from the Cardiovascular Research Foundation (CRF) of the United States and attended the fourth CTO international summit in New York, and she was the only chairing member from China. She disclosed that her team had published a summary report about the experience of CTO interventions at the Chinese Medical Journal, and that report was recommended at the summit as the only teaching material from China.

“In the early years, I felt that China was trailing behind the developed countries like Japan, the U.S., and Europe in medical hardware and instruments, but we are basically as good as them in surgical skills, theories, and strategies (in particular, Chinese doctors often figured out some ‘tips’ based on their practical experience)”, said Academician Han. Thanks to the constant improvements in economic performance and medical technology in China, China is approaching or even catching up with the U.S. and Europe in CTO interventions, and the gap with Japan is also narrowing.

Comprehensive capability for CTO interventions

The comprehensive capability of a surgeon is required for CTO interventions, according to Academician Han. When a surgeon faces a CTO patient, he or she needs to think carefully and considerately before working out the suitable treatment protocol, which mainly includes: whether the CTO needs to be recanalized; how severe the recanalization can be; what’s the major difficulty; how to select an antegrade wire; how to update the antegrade wire when the preferred antegrade wire fails; when to convert to a retrograde approach when the antegrade treatment fails; how to deal the situation when the guide wire is passed through the lesion, but the balloon fails; which new instruments are required in addition to conventional instruments such as guide wire, balloon, and stent; which measures have been taken to protect heart and kidney functions; are there any reasonable antithrombotic measures; and how to prevent and treat various complications. The operators must be well-prepared for these questions before they become a mature and excellent CTO surgeon.

Therefore, all the cases presented in the matches were evaluated comprehensively regarding pre-operation strategy, necessary operation steps, results of lesion management, and patient safety.

In the final competition, Dr. Haiwei Liu from the General Hospital of Northern Military Region won the first prize, Dr. Liang Guo from The First Hospital of China Medical University won the second prize, and Dr. Zhaoqing Sun from Shengjing Hospital of China Medical University and Dr. Yuan Han from the General Hospital of Norther Military Region won the third prizes. Dr. Huan Wang from Xijing Hospital of the Fourth Military Medical University, Dr. Haokao Gao from Xijing Hospital of the Fourth Military Medical University, Dr. Peng Yang from China-Japan Friendship Hospital, Dr. Jinguo Fu from Cangzhou Central Hospital, Dr. Lijun Wang from Shijiazhuang The Third Hospital, and Dr. Xingang Zhang from The First Hospital of China Medical University were the winners of the “Excellent Award”.

Among them, Dr. Haiwei Liu reported a case of “LAD CTO recanalization using retrograde approach after treatment of CTO through epicardial collateral failed” (Figures 5-12).

Figures 5 RCA and LCX stents were patent, with occlusion and calcification at the proximal LAD. RCA, right coronary artery; LCX, left circumflex artery; LAD, left anterior descending artery.

Figure 6 Antegrade attempt: Cosair + Fielder XT-A were delivered to the pseudolumen, and GAIA 2 entered the pseudolumen. Then a retrograde attempt was applied through an epicardial collateral.

Figures 7 The epicardial collateral was too tortuous. Finecross (1.5 m) + Sion black could not pass through, although Fielder XT-R passed through the epicardial collateral.

Figure 8 The epicardial collateral was too long and tortuous. Finecross cannot approach occlusion to provide support. During the retrograde attempt, GAIA 3 and Conquest pro-8-20 could not pass through the occluded lesion. Trapping technique was applied for the antegradely delivered GAIA 3 wire, and the antegrade and retrograde wires could not meet together. A decision of terminating the surgery was then made: after three hours of surgery, and the use of 400 mL of contrast agent, both antegrade wire and retrograde wire might be under the intima, and the retrograde microwire could not be pushed forward (no good support could be offered for wire operation).

Figure 9 Re-examination with angiography: possible vasospasm in epicardial collateral resulted in clear visualization of septal collateral.

Figure 10 On February 20, 2018, a second PCI was performed. The wire was not in the true lumen during the antegrade attempt; a retrograde attempt was performed via the septal collateral. The Fielder XT-A guide wire was replaced. It could not meet with the antegrade wire after repeated adjustment of its direction; then, the GAIA 2 was replaced, which will meet with the antegrade wire after adjustment.

Figure 11 The GAIA guide wire entered the antegrade GC; however, Finecross could not be delivered into the antegrade GC; RG3 was replaced, and the antegrade Guidezilla was used to meet RG3 before establishing the track. GC, guiding catheter.

Figure 12 Three stents (2.5/33 mm, 2.75/33 mm, and 4.0/13 mm) were implanted successively. Spasm at the distal stent was relieved by nitroglycerin, and then the operation was completed.

The judges expressed their opinions during the competition.

Academician Yaling Han agreed that this is a fascinating case. When the epicardial collateral is in good condition, the septal collateral is not apparent. Thus, the epicardial collateral may be selectively blocked by using a balloon, to find an excellent septal approach under the effect of positive blood pressure. By doing so, we may find more and safer approaches to retrograde interventions. Also, the epicardial collateral is associated with more substantial risks. Any of its related complications can be fatal. Thus, adequate preparation must be taken to ensure the patient’s safety.

Professor Ling Tao from Xijing Hospital of the Fourth Military Medical University commented that, during the first operation of this case, the guide wire was delivered through the highly tortuous epicardial collateral, which reflected Director Haiwei Liu’s extraordinary surgical skill. However, since the antegrade and retrograde guide wires could not meet each other, the possibility of a successful surgery was low. If we could use a subintimal approach instead, the first attempt might have been successful.

Professor Leisheng Ru from Bethune International Peace Hospital pointed out that the first operation lasted more than three hours; when the surgeon was ready to give up, the septal collateral was found and used. The timely termination of the operation reflected the technical maturity of the operator. We do not have to succeed after a single attempt. Longer surgical duration means higher radiation dose and more significant damage to the patient. More attempts may be a better choice for both patients and doctors.

Some issues still need to be addressed: (I) selection of epicardial collateral or the septal collateral: should surfing be first applied when the septal collateral was not visible? (II) When the epicardial collateral is excellent, can it be temporarily blocked by balloon to facilitate the search for the septal collateral? (III) When the epicardial collateral is used for the retrograde attempt, full preparation should be made to ensure patient safety; and (IV) a surgery should be timely terminated if necessary. Do not go on and on. Although there might be hope of recanalization, two or more attempts are required to reduce the harm of contrast agents and radiation. (V) Some doctors prefer to use wire guide technology, which has less harm to blood vessels; however, it is limited by its low efficiency. Sometimes when the guide wire is difficult to be delivered, we may decisively apply the reentry technology via the subintimal path, which may effectively recanalize the blood vessels.

The audience was overwhelmed by the contestants’ charming skills and the judges’ insightful comments. There is a long way to get significant improvements in CTO interventions, but every match is a steady step. The half-day competitions were short, but their impacts were far-reaching.

Voices

“I hope young and middle-aged doctors can continue their predecessors’ spirit of perseverance and innovation and cultivate more outstanding CTO professionals based on the academic and technology platform of CTO IN ARMS and enhance the overall effect of China’s CTO interventions.” (Figure 13).

Figure 13 Prof. Yaling Han.

—Prof. Yaling Han, chairman of the competition

“This competition turned out to have produced better results than our expectations. Cases presented by the winners are very influential even in the international medical community. Every case has been a rational and reasonable basis. In clinical practice, safety should always come ahead of technology, because essentially, we are treating patients, not diseases.” (Figure 14).

Figure 14 Prof. Quanmin Jing.

—Prof. Quanmin Jing, executive chairman of the competition

“CTO intervention is not about surgery or a strategy, but the overall health conditions of the patient. The surgeon should not only focus on the lesion but also look at the patient’s heart and kidney functions. CTO surgeons must pay much attention to the patient’s kidney function and the amount of contrast agent.”

“The surgeon must not care only about the surgery itself; the patient’s conditions are more important. Sometimes, although the surgery is well performed, a small blood clot could put the patient’s life at risk.”

“Preoperative strategy is fundamental. All possibilities must be taken into account before the surgery.”

“In the clinical practices, when there is an emergency, you should ask yourself how to fix the problem. Try to be resilient, resourceful, and responsible.”

—Judges at the competition

“I am very grateful that the competition offers a wonderful platform to improve our understanding of CTO interventions.”

“I have learned a lot from other participants’ presentations and the judges’ comments. Some information has been unheard of for me, and it is beneficial for my future work.”

“Before surgery, we should make full preparations and thoughtful considerations to prevent complications. These suggestions are very thoughtful and helpful.”

—Contestants

“Cases discussed at the competition are high-level ones, and rarely available on ordinary occasions. Therefore, I decided to come here even though there are other lectures at the same time.”

—Audience

The 2018 CTO Cases Competition was supported by AME Publishing Company and Boston Scientific Corporation. Some exceptional cases presented at the regional and final competitions will be compiled into the book titled Fighting Against CTO by Interventions, which is expected to be published in the first half of 2019 by the People’s Medical Publishing House. An official launch ceremony of the book will be held on the sideline of the 2019 Northeast Cardiovascular Forum.

We look forward to more high-quality CTO case competitions in 2019.

Acknowledgements

Reviewed by: Academician Yaling Han (General Hospital of Northern Military Region) and Prof. Quanmin Jing (General Hospital of Northern Military Region).

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.