cto recanalization - effect of the retrograde approachretrograde attempt procedural time 118 min. 90...
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CTO Recanalization -CTO Recanalization -Effect of the Retrograde Approach
Valeri GelevValeri Gelev
No conflict of interest regarding this presentation.
Rational for CTO Recanalization
• Symptom control• Angina• Angina• CHF• Fatigue
• Improve LV function• Improve LV function• Regional• Global
• Survival• Improved tolerance of AMI• Complete revascularization• Complete revascularization• Ischemic Risk
Development of CTO Techniques
Single wire
Parallel wireParallel wire
IVUS guided
STAR
Retrograde
STAR
Antegrade SCTs
Dissection & Reentry
20
00
20
00
20
01
20
01
20
05
20
05
20
04
20
04
20
08
20
08
CTO-PCI Success Ratein Toyohashi Heart Center
100
in Toyohashi Heart Center
64.9
71.374 73.5
7984.2 86.3
92.4 92.2 91.6 91.5 92.6
80
100
%
64.9
40
60
0
20
01999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
European Registry Update
Retrograde approach improve success rate ofCTO PCI
European Registry Update
Sianos G, CTO Summit, NY, 2015
Numbers of Retrograde Procedures Success RateEuropeEurope
Galassi, A.R. et al. J Am Coll Cardiol. 2015; 65(22):2388–400.
SummarySummary
Japanese CTO PCI Expert Registry
SummarySummary
Japanese experts frequently chose the bidirectional approach as the primary
strategy (27.9%), especially for more complex CTO lesions, with a technicalstrategy (27.9%), especially for more complex CTO lesions, with a technical
success rate of about 90%.
For intermediate CTO lesions (J-CTO score < 2), experts mainly performed For intermediate CTO lesions (J-CTO score < 2), experts mainly performed
the antegrade approach alone, with a very high success rate (more than 95%).
However, for RBA, the success rate decreased to less than 80%.
The experts frequently used the parallel wiring and IVUS-guided penetration
in antegrade approach, with high technical success (75.0%–88.9%).
Severe lesion calcification was a strong predictor of failure.
Etsuo Tsuchikane CTO Summit New York 2017
PROspective Global REgiStry for the Study of CTOinterventions
www.progresscto.org
5/2012 to 2/201716 centers, 2,102 lesionsTechnical success: 88%Major complications: 2.6%
•Appleton Cardiology, WI•Baylor Heart and Vascular Hospital, TX•Columbia University, NY•Central Arkansas VAMC, AR•Dallas VAMC/UTSW, TX•Henry Ford Hospital, MI•Massachusetts General Hospital, MA Major complications: 2.6%•Massachusetts General Hospital, MA•Medical Center of the Rockies, CO•Minneapolis VAMC, MN•Minneapolis Heart Institute, MN•PeaceHealth St. Joseph MC, WA•Piedmont Heart Institute, GA•San Diego VAMC and UCSD, CA•St Luke’s Mid America Heart Institute, MO Successful technique
0.6% mortality, 0.9% MI0.9% pericardiocentesis, 0.2% stroke
0.1% CABG, 0.3% re-PCI
•St Luke’s Mid America Heart Institute, MO•Torrance Medical Center, CA•UPMC Medical Center, PA
Antegrade wiring
Antegrade dissection/re-entry
Retrograde77.1%80.00%
100.00%
Antegrade
Antegrade DR
Successful technique
49%
24%
27%
77.1%
34.3%39.5%
20.00%
40.00%
60.00%
80.00%
Retrograde
24%
0.00%
20.00%
Techniques Used
Emmanouil S. Brilakis CTO Summit New York 2017
January 2010Starting our experience withStarting our experience with
Retrograde Approach
George Sianosand
Alexander DoganovAlexander Doganov
DuringSecond Retrograde CTOSecond Retrograde CTO
Workshop
• When to Consider Retrograde Approach
• In difficult anatomy
• To achieve fast and predictable result in• To achieve fast and predictable result innot that complex cases with goodretrograde options, while preserving theretrograde options, while preserving theanatomy of the vessel
CTO Complexity – J CTO score
• Blunt tip/none or unclear tip: 53.7%• Calcification*: 33.7%• Calcification*: 33.7%• Bending*: 8.5%• Occlusion length>20mm: 61.7%• Re-try lesion: 11.6%
*Score was counted based on judgment more thanIn difficult CTOs (J-CTO score 2), successful
antegrade wiring of the CTO within 30 minutes
35.4%40%
50%
*Score was counted based on judgment more than“moderate” grade for calcification and bending
In difficult CTOs (J-CTO score 2), successfulantegrade wiring of the CTO within 30 minutes
of fluoroscopy time can be accomplished inless than 50%
15.0%
35.4%
31.5%
18.2%20%
30%
40%less than 50%
0%
10%
Easy (0) Intermediate (1) Difficult (2) Very difficult (>3)
When to Consider Retrograde Approach
• Abrupt occlusion with a large side branch• Ambiguous anatomy of proximal cap and
vessel course.vessel course.• Length of CTO 20mm• Bending in the CTO body• Severe Calcifications• Severe Calcifications• Poor distal landing zone or bifurcation• Previous failed attempt
Interventional collaterals presentInterventional collaterals present• Dependent on the experience of the operator• Absent in 20-30 % of cases
RCA CTO – J CTO score 0-1Primary Retrograde ApproachPrimary Retrograde Approach
RCA CTO
Retrograde crossing with Sion over Corsair Ultimate through distal cap
RCA CTO
Antegrade wiring with Ultimate Reverse CART with 2,5/15 balloonUltimate wire exchanged with Pilot 150
Final result after 3DES
RCA CTO Final result and Procedural Details
Final result after 3DES
AntegradeAttempt
RetrogradeAttempt
Procedural time 118 min. 90 min.Procedural time 118 min. 90 min.
X ray time 57 min. 35 min.
Contrast Volume 450 ml 330 ml
Retrograde Approach, even in not that complex cases,provides the opportunity to achieveContrast Volume 450 ml 330 ml
# of CTO wires 4 4
provides the opportunity to achievefast, predictable success, sparing the anatomy
of the vessel.
Failure Success
CTO Experience
National Heat Hospital 2002 - 2005
2006 117
National Heat Hospital
2007 159
2008 154National Heat Hospital 2008 154
2009 81
Emergency Center "Pirogov 2010 - March2013 164
Tokuda Hospital March2013-2016 238Tokuda Hospital March2013-2016 238
235Antegrade
only235
403 Antegrade/Retrograde
only
[CATEGORY NAME]
16,5%16,5%
[CATEGOR[CATEGORY NAME]
83,5%
JCTO Score
1.231.4
0.96
1.23
1
1.2
0.4
0.6
0.8
0
0.2
0.4
Antegrade/Retrograde
Antegradeonly
Success Rates for CTO RecanalizationSuccess Rates for CTO Recanalization
[VALUE]%90
[VALUE]%
[VALUE]%
60
70
80
30
40
50
60
0
10
20
30
0
Antegrade/Retrograde
Antegradeonly
Antegrade/Retrograde
Antegradeonly
J-CTO scores in Antegrade and Retrograde Patients
1.49
1.4
1.6
Success rate ~90%
1.18
1
1.2
1.4Success rate ~90%
0.4
0.6
0.8
0
0.2
RetrogradeAntegrade
The Impact of the Retrograde Approach
Gives you the opportunity:To threat more complex CTO casesIn a more predictable mannerIn a more predictable mannerWith higher success rates
Additionally(something which is no measurable):Additionally(something which is no measurable):• Increases your knowledge: anatomy, pathology, technology and
devices…• Improving your skills – retrograde procedures are very demanding• Improving your skills – retrograde procedures are very demanding• Acquire new techniques – trapping, wire externalization, tip in tip,
randevouz…• Developing a new mind-set, useful not only in CTO recanalizations.• Developing a new mind-set, useful not only in CTO recanalizations.
Male 47y; Admitted with ACS w/o ST elevationAug. 2007 – ACS – Severe ostial LAD stenosis - dedicated bifurcation stentAug. 2007 – ACS – Severe ostial LAD stenosis - dedicated bifurcation stentNov. 2007 – instent restenosis - ACB x 2 LIMA –LAD; SVG - RIM
Normal nonNormal nondominant RCA
High grade stenosis of LCx after the origin of RIM
Patent LIMA – LAD and SVG - RIMPatent LIMA – LAD and SVG - RIM
PCI Procedure
Wires in LAD and RIM
Right radial access6F EBU
Impossible to wire the LCx because ofImpossible to wire the LCx because ofunfavorable angle- any type of wires ( 4 different types)- after predilatations at the carina site 2,5/15- after predilatations at the carina site 2,5/15- using a double lumen catheter – “Crusade”
PCI Procedure
Retrograde approachRetrograde approachAdditional left radial access 7F AL 1,5 for SVGCorsair 150 cmRunthrough wire retrograde successfullyRunthrough wire retrograde successfullypassed
PCI Procedure
Corsair couldn’t follow the wire
Exchange with OTW 1,5/15
Retrograde dilatation at the ostiumof Cx
Successful antegrade wiring of CxSuccessful antegrade wiring of Cx
PCI ProcedureFinal ResultFinal Result
Procedural DetailsProcedural DetailsX-ray time - 70 min
Antegrade attempt – 49 minRetrograde pass - 2 min
Procedural time - 110 minContrast amount – 450 ml
Another example…..
Another example…..
Peripheral Angio of Right Leg
After failed antegrade attempt, no clear vessel course.Retrograde attempt - unable to get in the true lumen retrogradly,Retrograde attempt - unable to get in the true lumen retrogradly,probably due to aneurysmatical changes at the proximal cup.
Retrograde attempt - Stent Facilitated Reverse CARTOver the antegrade wire, a balloon expandable coronary stent wasimplanted with the proximal part of the stent deployed in the poplitealimplanted with the proximal part of the stent deployed in the poplitealartery while distal part expanded in the subintimal space.
Verification of the proper passage of the retrograde wire trough the stent
Final result after externalization and balloon angioplasty, achieving a“straight line” to the foot with rapid recovery of the patient.“straight line” to the foot with rapid recovery of the patient.
Retrograde approach is vital component of a CTOprogram, increasing the success rates even in veryprogram, increasing the success rates even in verycomplex anatomy.
The retrograde concept creates a different mind-setand skills-set which improves the overalland skills-set which improves the overallperformance of the interventional cardiologist.