BCIS ACI 2020: Arguments for CTO PCI approach — Dr James Spratt

CTO PCI is often used to treat patients with chronic total occlusion (CTO), or complete blockages of the coronary arteries. Dr James Spratt (London Bridge Hospital, London, UK) argues for the cost-effectiveness and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusion. 

Questions:

1. Which patients should be considered for CTO PCI and which should be referred to surgery? 
2. Why is there a debate as to whether CTO PCIs are cost-effective?
3. Does the type of CTO approach affect your technique ?
4. What is your opinion on this matter? 
5. What is needed to silence the naysayers? 

Filmed in London at BCIS ACI 2020.
Interviewer: Mirjam Boros
Videographer: Natacha Wienand / Dominic Woodruff

 

Transcript Below :

Question 1 : 

[Spratt ] Okay, so every patient's an individual. We always start off with their clinical scenario. What problems they have. A little bit about their medical background, but also quite a bit about them as a person. What matters to them as a person? Because the decision we're making is one which is the treatment that best helps them. And that can be very different for different patients. It may be that some patients don't want the morbidity of surgery. Morbidity is basically bad things that happen without dying. So the pain, the recovery period and so on. Of course, the feasibility of the two procedures, bypass versus CTO, Which is the most likely to be effective? And generally the feasibility is not something which differentiates things too much. So a lot of it comes down to patient choice. And broadly speaking, the extent of disease. So, the more extensive the disease, the more likely the patient is to benefit from surgery. And the more focal the disease the more likely is the patient is to benefit from angioplasty. Now, the big thing in terms of the patient history that would matter would be diabetes. So diabetes is associated with less good outcomes for a CTO PCI. And that kind of adverse effect of diabetes is a bit ameliorated for bypass surgery. So there's very few patients, nowadays, that can't have CTO PCI treatment, but at the end of the day, it's what's best for the patient. 

Question 2 : Why is there a debate as to whether CTO PCIs are cost-effective?

[Spratt ] Well, cost-effectiveness is a debate that's not confined to CTO PCI. Of course, we have discussions about spending money at every stage of healthcare. And not just within cardiology, but within social care particularly, is a massive debate about is that money well spent? There are many areas within cardiology that are a lot more controversial in terms of treatment. For example, percutaneous aortic valves, that's generally in a very elderly population, who often have a lot of comorbidity anyway. And actually, while CTO PCI is slightly more expensive than normal PCI, the difference isn't very marked. And it's a lot more cost effective than surgery. So I don't think it's much of a debate, really. Do you mean in terms of the technique applied? Well, not really because my field of expertise is CTO PCI, so I should be good at all aspects of it. 

Question 3 : Does the type of CTO approach affect your technique ?

[Spratt ] And no, it doesn't matter too much to me. I think there are some suggestion that retrograde procedures associate with a slightly higher risk of patient harm. So I think you defer those to when you really need them. And of course, like a lot of procedures, informed consent is absolutely critical that we have that discussion with the patient. We explain to them what we can offer them in terms of symptom benefit. And we explain in a kind of interactive way what the potential risks are. And like all procedures we do our very best to reduce those risks. 

Question 4 : What is needed to silence the naysayers?

[Spratt ] You know what, I think it's better to approach that question in terms of what do we need to have a fully mature programme? We need to have a procedure which is safe, effective and durable. And I think we've made tremendous strides. I think if you're being critical you would say that the expertise that's certain elite operators have is not as widely disseminated. Because CTO PCI is more difficult. So the training process is longer. And there are less people capable of doing the very difficult cases. So I think more education, more training, I think those things are definitely a benefit. And actually meetings like these are a great opportunity to show people what we can do. And to encourage young doctors who are interested in helping patients that this is a great field to be in.