23rd Cardiovascular Conference at Beaver Creek Coronary Chronic Total Occlusions: Retrograde PCI approaches R. Kevin Rogers, MD MSc Interventional Cardiology University of Colorado Duke 23rd Cardiovascular Conference at Beaver Creek Case (HPI) 49 year-old male janitor presenting with anterior STEMI in rural midwest Duke 23rd Cardiovascular Conference at Beaver Creek Initial Coronary Angiogram Duke 23rd Cardiovascular Conference at Beaver Creek Initial Coronary Angiogram (con’t) Duke 23rd Cardiovascular Conference at Beaver Creek Initial Coronary Angiogram (con’t) Duke 23rd Cardiovascular Conference at Beaver Creek Initial Coronary Angiogram (con’t) Duke 23rd Cardiovascular Conference at Beaver Creek IABP placed Transferred for urgent CABG Duke 23rd Cardiovascular Conference at Beaver Creek Case (HPI) Over following 2 months, experienced lifestylelimiting angina and 2 admissions for angina at rest associated with elevated BP. Duke 23rd Cardiovascular Conference at Beaver Creek Case (PMH) No DM Stopped smoking at CABG Hyperlipidemia Hypertension 3 / 4 siblings CAD <50 yo Duke 23rd Cardiovascular Conference at Beaver Creek Meds Aspirin 81 Clopidogrel Atorvastatin 80 Carvedilol 25 bid Lisinopril 10 mg daily Isosorbide mononitrate 60 mg daily Ranolazine 1000 mg bid Duke 23rd Cardiovascular Conference at Beaver Creek Exam 102 / 64, 62 Thin, well appearing No HF RRR no mrg Rad, fem 2+ bilat Duke 23rd Cardiovascular Conference at Beaver Creek Objective Data ETT: 2 mm ST dep in 5 leads, hypotension, angina at 6.2 METS Perfusion study: Anterior ischemia, EF 35% Repeat Coronary angiography Duke 23rd Cardiovascular Conference at Beaver Creek LAD Duke 23rd Cardiovascular Conference at Beaver Creek LAD Duke 23rd Cardiovascular Conference at Beaver Creek RCA Duke 23rd Cardiovascular Conference at Beaver Creek LIMA-LAD Duke 23rd Cardiovascular Conference at Beaver Creek SVG-OM Duke 23rd Cardiovascular Conference at Beaver Creek Referred for PCI of CTO Indications: - Symptom relief - Safe return to work? - Improvement in LV function? - Mortality? Quoted: - 80% chance for success - 10% risk of major or minor complication Duke 23rd Cardiovascular Conference at Beaver Creek Preprocedural planning Overall strategy: - Antegrade (wire escalation, then Cross boss) - Consider retrograde (LIMA, RCA) Access 8F RCFA – LM (Prox LAD) 6F L radial -- LIMA (mid LAD) 6F LCFA – RCA (Distal LAD) Anticoagulation: UFH, ACT 250-300 Duke 23rd Cardiovascular Conference at Beaver Creek Simultaneous Injections Duke 23rd Cardiovascular Conference at Beaver Creek Initial Strategy: Antegrade wire escalation Fielder XT Pilot 200 Corsair Duke 23rd Cardiovascular Conference at Beaver Creek Antegrade with Crossing Device Cross Boss Duke 23rd Cardiovascular Conference at Beaver Creek Redirected Cross Boss Switched to Confianza Pro 12 at distal cap Still subintimal Slower flow in LIMA CP, ECG changes Next step? Continue antegrade? Stingray? Retrograde? Duke 23rd Cardiovascular Conference at Beaver Creek Retrograde via LIMA Duke 23rd Cardiovascular Conference at Beaver Creek Crossing Retrograde Prowater to cap Pilot 200 / Corsair Duke 23rd Cardiovascular Conference at Beaver Creek Retrograde Crossing How to reconcile subintimal spaces? ‘Reverse CART’ Duke 23rd Cardiovascular Conference at Beaver Creek Reverse CART Duke Illustration by Dr. J C Spratt / VascularPerspectives, www.ctoibooks.com 23rd Cardiovascular Conference at Beaver Creek Attempt at CART 2.5 mm balloon antegrade Duke 23rd Cardiovascular Conference at Beaver Creek CART with Guideliner Guideliner antegrade over subintimal balloon Nowhere else to go for retrograde wire but into Guideliner. . . . Duke 23rd Cardiovascular Conference at Beaver Creek Retrograde wire through antegrade guide Duke 23rd Cardiovascular Conference at Beaver Creek Externalizing Retrograde Wire Retrograde Corsair into antegrade guide Exchange retrograde wire for Viper wire (335 cm) through retrograde Corsair (Rotaglide) Externalize through antegrade guide Work Rx over soft end of Viper wire Duke 23rd Cardiovascular Conference at Beaver Creek Retrograde Corsair Retracted Avoid retrograde Corsair interacting with antegrade balloons / stents Duke 23rd Cardiovascular Conference at Beaver Creek Post Angioplasty CTO #1 Duke 23rd Cardiovascular Conference at Beaver Creek Post PCI – CTO #1 CTO #1 treated - 3.0 x 24 DES - 2.5 x 38 DES Next step? Duke 23rd Cardiovascular Conference at Beaver Creek Crossing CTO #2 Wire escalation New antegrade wire / catheter beside externalized retrograde wire Corsair Duke 23rd Cardiovascular Conference at Beaver Creek Crossing CTO #2 Pilot 200 Cross boss True lumen!! Duke 23rd Cardiovascular Conference at Beaver Creek Remove retrograde equipment Stored tension in equipment Should have watched antegrade wire!! Duke 23rd Cardiovascular Conference at Beaver Creek Final 3.0 x 24 DES 2.5 x 38 DES 2.25 x 32 DES 2.4 Gy 102 min fluoro 250 cc contrast Duke 23rd Cardiovascular Conference at Beaver Creek Clinical course Improvement in exercise tolerance Angina free No admissions last 9 months Duke 23rd Cardiovascular Conference at Beaver Creek Case 2 46 year-old male Lifestyle-limiting angina on Metoprolol 100 mg bid, amlodipine 10 mg daily, isosorbide 60 mg daily, ranolazine 1000 mg bid Prior smoking, no DM, +htn, +hyperlipidemia, +Fam Hx Inferior ischemia, EF 55% Duke 23rd Cardiovascular Conference at Beaver Creek RCA Angiography - ?Proximal Cap Duke 23rd Cardiovascular Conference at Beaver Creek Simultaneous Injections 8F EBU 8F AL 0.75 Duke 23rd Cardiovascular Conference at Beaver Creek Retrograde Septal Crossing Corsair Sion wire Duke 23rd Cardiovascular Conference at Beaver Creek Retrograde Dissection Re-entry Duke 23rd Cardiovascular Conference at Beaver Creek Reverse CART Duke 23rd Cardiovascular Conference at Beaver Creek Snaring Retrograde Wire Duke 23rd Cardiovascular Conference at Beaver Creek Advance Antegrade Guide over Snared, Externalized Wire Duke 23rd Cardiovascular Conference at Beaver Creek Treat Duke 23rd Cardiovascular Conference at Beaver Creek Final Duke 23rd Cardiovascular Conference at Beaver Creek Case 3 62 year-old active male Presented with lifestyle-limiting angina Perfusion study – anterior and inferior ischemia. EF 50% Angiography – 80% LAD stenosis, RCA CTO Poor RCA target for CABG PCI to LAD Continued angina despite: metoprolol 100 mg bid isosorbide 120 mg daily amlodipine 10 mg daily Duke ranolazine 500 mg bid 23rd Cardiovascular Conference at Beaver Creek Duke 23rd Cardiovascular Conference at Beaver Creek Duke 23rd Cardiovascular Conference at Beaver Creek Duke 23rd Cardiovascular Conference at Beaver Creek Proximal Cap? Duke 23rd Cardiovascular Conference at Beaver Creek Duke 23rd Cardiovascular Conference at Beaver Creek Simultaneous Injections Duke 23rd Cardiovascular Conference at Beaver Creek Antegrade Attempt Duke 23rd Cardiovascular Conference at Beaver Creek Wire escalation Corsair for support Duke 23rd Cardiovascular Conference at Beaver Creek Duke 23rd Cardiovascular Conference at Beaver Creek Duke 23rd Cardiovascular Conference at Beaver Creek Unclear wire location Did not move to CrossBoss or StingRay Duke 23rd Cardiovascular Conference at Beaver Creek Retrograde Attempt Could not deliver Corsair to jailed septal Duke 23rd Cardiovascular Conference at Beaver Creek Advice? Repeat antegrade attempt? Retrograde attempt via septal? Retrograde via epicardial collateral? CABG? None of the above? Duke 23rd Cardiovascular Conference at Beaver Creek Thank you! Questions? Duke 23rd Cardiovascular Conference at Beaver Creek Impact of Successful CTO-PCI: Angina Long-term angina benefit favors CTO-PCI success Angioi, et al. Drozd, et. al. Finci, et. al. Ivanhoe, et. al. Olivari, et. al. Warren, et. al. Total (n=1030) Duke Joyal D, Afilalo J, Rinfret S. Am Heart J, 2010. 23rd Cardiovascular Conference at Beaver Creek Improvement of LV function with CTO-PCI Ejection Fraction (EF) Segmental Wall Thickening (SWT) MRI assessment at baseline and at 6 months shows an improvement in EF and SWT in patients who had successfulDuke CTO-PCI Paul et al, Heart 2011. 23rd Cardiovascular Conference at Beaver Creek Impact of Successful CTO-PCI: Mortality Long-term survival benefit favors CTO-PCI success Duke Joyal D, Afilalo J, Rinfret S. Am Heart J, 2010. 23rd Cardiovascular Conference at Beaver Creek The Hybrid Algorithm Clear Proximal Cap Good Distal Target YES NO Retrograde Antegrade YES Wire Escalation NO FAIL Length < 20mm Dissection ReEntry (CrossBoss™Stingray™) YES Wire Escalation FAIL Dissection ReEntry (Reverse CART) FAIL FAIL Dissection Re-Entry (Reverse CART) NO Duke Dissection Re-Entry (CrossBoss™- Stingray™)
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