Collagenase Total Occlusion-1 (CTO-1) trial: a phase I, dose-escalation, safety study

Abstract

Background: Percutaneous interventions for chronic total occlusions have low success rates, primarily because of failure of guide wire crossing. Collagen-rich matrix constitutes the main barrier to chronic total occlusion crossing. In preclinical studies, local delivery of a bacterial collagenase formulation improved guide wire crossing. The Collagenase Total Occlusion-1 (CTO-1) Trial is a phase I, dose-escalation trial to assess the safety and efficacy of collagenase therapy to facilitate guide wire crossing in coronary artery chronic occlusions.

Methods and results: Twenty subjects with ≥1 previous failure of chronic total occlusion guide wire crossing were enrolled at 2 sites. Subjects were treated in 4 distinct cohorts of 5 patients, with escalation of collagenase dose in each cohort from 300 to 1200 μg. Collagenase was locally delivered into the occlusions with either an over-the-wire balloon system (n=8) or a fine-cross microcatheter (n=12) for a period of 30 minutes. Subjects were brought back to the catheterization laboratory for guide wire crossing and angioplasty the next day. Guide wire crossing was successfully achieved in 15 subjects (75%). A soft-tip guide wire (Whisper, Pilot-50, Fielder XT) was either the sole or predominant guide wire used in 75% of successful crossings. Non-ST-segment-elevation myocardial infarctions occurred in 3 patients as a result of side-branch ischemia during stenting. Computed tomographic angiography at 3 months showed no late complications and patent stents in successfully treated chronic total occlusion. Anginal improvement occurred with a reduction in Canadian Cardiovascular Society class from baseline to 3 months (2.5±0.6 versus 0.9±0.9; P<0.001).

Conclusion: Local delivery of collagenase into coronary chronic total occlusion is feasible and safe with encouraging guide wire crossing results in previously failed cases. Larger clinical trials are required to determine efficacy.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01271335.

Figures

Figure

Left circumflex chronic total occlusion in a 58-year-old man treated with 1200 μg collage-nase. A, Preprocedural angiogram showing chronic total occlusion (indicated by 2 white arrows). B, Positioning of the fine-cross microcatheter (dot in distal end of catheter indicated by white arrow) into first the few millimeters of the occlusion for the injection. C, Pre–percutaneous coronary intervention (PCI) angiogram the next day showing no deleterious effects of the collagenase injection. D, Post-PCI angiogram after successful recanalization and placement of 2 Promus drug-eluting stents with a total stent length of 43 mm.