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Antegrade vs Retrograde DecisionAntegrade vs. Retrograde Decision‐Making: Hybrid ThinkingMaking: Hybrid Thinking

Junbo Ge, MD,FACC, FESC, FSCAI, FAPSIC

Department of Cardiology,

Zhongshan Hospital, Fudan University

Shanghai Institute of Cardiovascular DiseasesShanghai Institute of Cardiovascular Diseases

Update from the "Retrograde Summit"p gYamane M. CTO Summit, 2013, NY

N=1166 cases （2009-11 in 27 centers）

Primary Retrograde Approach (716)

Immediately After Failed Antegrade (450)

Successful GW collateral channel cross

pp ( ) g ( )

f82.3% (960/1166)

Retrograde Success:

Change to Antegrade Approach (252)

Retrograde Success: 87.3% (838/960)

Success 58.3% Success 58.3% Failure/Halt /CMX

15.5% (181)Overall Success 84.5%

( 985/1166)

(147/252(147/252)

Antegrade vs. Retrograde Decision‐Making: Hybrid

Thinking and Changing Course

Hybrid Approach is common in

complex CTO‐PCI!p



Indication of Retrograde approaches



Hybrid ApproachAnatomy Dictates StrategyAnatomy Dictates Strategy

Th F Q tiThe Four Questions1. Is the Proximal cap well defined or ambiguous?2 Quality of the distal target2. Quality of the distal target3. Suitability of “interventional” collaterals4. Lesion length < or > 20mm



Ad Hoc Strategy for CTO PCI

Antegrade techniqueTapered stump

Short CTO segment

Antegrade technique as first strategy

Angiographic viasualization of microchannels

Absence of calcification in CTOAbsence of calcification in CTO segment

Retrograde technique Long CTO segment (>40mm)

Easy retrograde collateral routeas first strategy

Easy retrograde collateral route

Severe calcification in CTO segment



Case 1：Male, 60 yrs, Recurrent Chest Pain for 4 mons

021567



021567


Attempted to open CTO with the antegrade approach but failed


Attempted to open CTO with the antegrade approach, but failed.

7FEBU 3 757FEBU 3.75

Crosswire NT

2.0F Progreat

021567



Retrograde GW could not access into the antegrade GC

0215676F JR4 GC; 2.0F Progreat MC; Fielder GW


R l Wi T i T h i


Reversal Wire Trapping Technique

021567Amplatz Goose Neck（ev3， Plymouth, Minnesota）


R l Wi T i T h i


Reversal Wire Trapping Technique

021567



021567



Runthrough GWRunthrough GW

021567


Fi l R l


Final Result

021567



Dose this statement hold true?

Antegrade approach should be always tried in all g pp yCTO‐PCI, if its failed, then choose retrograde

approach!

Maybe not!Maybe not!



Indication of Retrograde Approachas a Primary Procedureas a Primary Procedure

• Antegrade wiring seems very difficult in terms ofanatomical factors (complex CTO)

Th i h i ibl d i ll l• The patient has visible and continuous collaterals

• The donor vessel is healthy (or can be treated)• The donor vessel is healthy (or can be treated)

• Re‐attempt after previous failurep p



Case 2:Male, 54 yrs, SA for 3 mons (CTOCC 2009)

022638(2)First attempt with antegrade approach was failed.



CC 1-2 from L to R

022638(2)



Fielder FC + Corsair

022638(2)


Att ti Ki i Wi T h i b t f il


Attempting Kissing Wire Technique, but failure

Fielder FC – Crosswire NT 022638(2)


R CART T h i


Reverse CART Technique

Conquest Pro

Ryujin plus 1.5* 15mm @ 6-10atm Ryujin plus 2.5*15mm @ 6-10atm 022638(2)


R CART T h i


Reverse CART Technique

Apex 3.5* 20mm @ 8atm 022638(2)


300 Fi ld FC


300cm Fielder FC

Ryujin 2.5*15mm @ 6-10atm 022638(2)


Final Res lts


Final Results

022638(2)


Wh ill thi CTO ith t d


Who will reopen this CTO with antegrade approach firstly?app oac st y

018760Case 3: Female, 65 yrs, chest pain for 2 mons



Tip Injection

Ch l Dil t Fielder FC018760

Channel Dilator Fielder FC



Retrograde GW could not access into the JR4 GC

018760Miracle 3+ Channel Dilator



Retrograde wire trapping technique

018760

Advanced Channel Dilator into the root of aorta and changed Miracle 3 GW to Fielder FC (300cm)

Amplatz Goose Neck（ev3， Plymouth, Minnesota）


B k E d b ll i MC l


Back-End ballooning + MC reversal

018760Ma’sla Just（2.5*15mm）



Final Result

018760


h k d hThinking and Changing Course

Change Course: Ad hoc or Stage?

IF large amount of contrast used

IF long period of fluoro time spent

IF the operator and/or patient exhausted

IF the equipment is insufficient

Stage procedure may be reasonable!



Take home message

• Changing course is common in some complex

CTO‐PCI.

• Hybrid strategy can increase success of CTO‐

PCI Th CTO h ld lPCI. The CTO expert operator should learn to

be versatile and be ready to adopt differentbe versatile and be ready to adopt different

techniques during the same proceduretechniques during the same procedure.

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