post cabg cto challenges · post cabg challenges petros s. dardas, md, fesc st lukes’ hospital...
TRANSCRIPT
![Page 1: POST CABG CTO CHALLENGES · POST CABG CHALLENGES Petros S. Dardas, MD, FESC St Lukes’ Hospital Thessaloniki, GREECE •PROCTOR –TAVI (MEDTRONIC) –ROTABLATION (BOSTON) The future:](https://reader033.vdocuments.net/reader033/viewer/2022050608/5faefb6aaedc4c1c0736dfd1/html5/thumbnails/1.jpg)
POST CABG CHALLENGES
Petros S. Dardas, MD, FESC
St Lukes’ Hospital
Thessaloniki, GREECE
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• PROCTOR
– TAVI (MEDTRONIC)
– ROTABLATION (BOSTON)
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The future: treat native coronariesinstead of SVGs?
![Page 4: POST CABG CTO CHALLENGES · POST CABG CHALLENGES Petros S. Dardas, MD, FESC St Lukes’ Hospital Thessaloniki, GREECE •PROCTOR –TAVI (MEDTRONIC) –ROTABLATION (BOSTON) The future:](https://reader033.vdocuments.net/reader033/viewer/2022050608/5faefb6aaedc4c1c0736dfd1/html5/thumbnails/4.jpg)
CASE 1
• 68 MALE
• 2015 CABG
– LIMA LAD
– RIMA BIG IM
– SVG RCA
• 4 MONTHS LATER: INCREASING ANGINA
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LHC• 100% LIMA LAD distally
• SEVERE STENOSIS DISTAL RIMA –IM
• 100% SVG RCA
1ST PCI • NATIVE RCA
• DISTAL RIMA - IM
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1st PCI
RCA pre RCA post
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1st PCI
RIMA pre RIMA post
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2ND PCI
• RETROGRADE OSTIAL LAD CTO
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2ND PCI
Pre 1 Pre 2
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2ND PCI
Pre 3 1.5 mm balloon LMS-Cx
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2ND PCI
ENHANCER RX LMS CXENHANCER RX CONFIANZA PRO -LAD
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2ND PCI
TURNPIKE LP –de-escalation GAIA II GAIA II in false lumen
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2ND PCI
RETROGRADE INJECTION THROUGH TURNPIKE
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2ND PCI
SION inability to cross SION BLACK
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2ND PCI
SION BLACK DIAGONALREVERSE CART GAIA II unable to cross
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2ND PCI
REVERSE CART GAIA II unable to cross REVERSE CART PILOT 200
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2ND PCI
PILOT succesfull RG3 externalization
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2ND PCI
ENHANCER RX PROXIMAL LADENHANCER RX GAIA II unable to cross distally
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2ND PCI
ENHANCER RX BIFURCATION LAD SEPTAL
ENHANCER RX GAIA II SUCCESFULL REENTRY TRUE LUMEN
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2ND PCI
BMU true lumen LAD ballooning
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2ND PCIFINAL
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CASE 2
• 44 male
• Familial hyperlipidemia
• 2006:
– PCI distal RCA, ostial IM
• 2008:
– RIMA LAD
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• 2 years h/o increasing SOB – stable angina
• TH SCAN: – severe inferolateral reversible defect
• LHC: – Patent RIMA
– Patent IM stent
– Long heavily calcified proximal mid RCA CTO
– Bridging collaterals – small epicardial collateral from CX
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PRE
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TURNPIKE SPIRAL – MIRACLE 6 –unable to cross CONFIANZA PRO 12 proximal cap
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DEESCALATION MIRACLE 6 PILOT 200
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GAIA II
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BIG HEMATOMA
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FIELDER XT - KNUCKLE
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MIRACLE 12 STING RAY BALLOON
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STING RAY BALLOON COAXIAL
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STING RAY WIRE various attempts
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PILOT 200 various attempts
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PILOT 200 distally BHW distally
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FINAL
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CASE 3GRAFT FAILURE - PCI OF NATIVE
DISEASE
• HEAVILY CALCIFIED LESIONS-increased use of Rotablation
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63 male – CABG x3 – blocked grafts –heavy calcification of native vessels
Severe LMS – prox LAD calcified disease Blocked LIMA
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63 male – CABG x3 – blocked grafts –heavy calcification of native vessels
Rota 1.25 mm Rota 1.5 mm
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63 male – CABG x3 – blocked grafts –heavy calcification of native vessels
FINAL 1 FINAL 2
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63 male – CABG x3 – blocked grafts –heavily calcified extremely tortuous
superdominant RCA
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MOTHER IN CHILD IN GRAND CHILD TECHNIQUE
6 FR GUIDEZILLA INSIDE 8 FR GUIDEZILLA
ADVANCE THE SYSTEM AS A WHOLE UNIT
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MOTHER IN CHILD IN GRAND CHILD TECHNIQUE
6 FR GUIDEZILLA INSIDE 8 FR GUIDEZILLA 1.5 mm balloon cannot cross
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ROTAWIREROTA 1.25 MM difficult to negotiate the bend
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ROTA 1.25 mm 140000 rpm ROTA 1.25 mm 180000 rpm
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ROTA 1.5 mm ROTA 2.0 mm
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Post rotaMOTHER in CHILD in GRANDCHILD with balloon anchoring
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MOTHER in CHILD in GRANDCHILD STENT CROSSING
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63 male – CABG x3 – blocked grafts –heavy calcification of native vessels
FINAL RESULT
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In Conclusion…
• Various challenges post CABG
• Require expertise in:
– Various CTO techniques
– Rotablation
– Complex high risk PCI
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Rotablation in the extremies: Mechanical support assisted
unprotected left main stem rotationalatherectomy
Petros Dardas, MD, FESC
St Luke’s Hospital
Thessaloniki, GREECE
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History
Past medical history• Male 61 years old,
hypertensive, non diabetic with moderate kidney disease
• 1997 Aortic Valve replacement- metallic (bicuspid aortic stenosis)
• 1997 Valvular Heart Failure (EF=35%)
• 2009 PCI Left Anterior Descending
• 2011 ICD implantation for primary prevention (EF=25%)
Cause of hospitalization
• Heart Failure Decompensation: peripheral edema + dyspnoea
• Electrical Storm: 3 ICD therapies for VF
• ECHOCARDIOGRAPHY:
– EF=15%
– Metallic Aortic Valve: normal function
– Mitral Valve: moderate to severe regurgitation
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EF=15%
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CORONARY ANGIOGRAPHYRCA: normal AVR: normal
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CORONARY ANGIOGRAPHYsevere heavily calcified distal LMS ostial LAD ostial CX (MEDINA
1,1,1)
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Coronary angiography
• OPTIONS:– CABG – declined by surgeons
STS score >10– PCI – Rotablation without
support– PCI – Rotablation with
mechanical support
• DECISION– PCI – Rotablation with
mechanical support– IABP: Inadequate support– IMPELLA: Non applicable (AVR)
ECMO
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ECMO
• Percutaneous femoral cannulation of both the common femoral vein (24 Fr cannula) and artery (18 Fr cannula with added distal leg perfusion branch)
• the circuit was connected to a third generation (magnetically levitated) centrifugal pump (Centrimag, Levitronix) and to a long term (low pressure) membrane oxygenator (Medtronic)
• cardiopulmonary support with flows up to
5.5 l/min
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PILOT 50 LAD - FINECROSS IVUS CANNOT CROSS
PTCA: Rotablation LAD, CX, CULOTTE technique
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ROTAWIRE THROUGH FINECROSS ROTABURR 1.25mm 140000rpm
PTCA: Rotablation LAD, CX, CULOTTE technique
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ROTABURR 1.5mm 140000rpm POST ROTA LAD
PTCA: Rotablation LAD, CX, CULOTTE technique
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ROTABURR 1.5 mm CX 140000rpm POST ROTA CX
PTCA: Rotablation LAD, CX, CULOTTE technique
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STENT LAD DEPLOYED FINAL KISSING
PTCA: Rotablation LAD, CX, CULOTTE technique
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PTCA: Rotablation LAD, CX, CULOTTE technique
• FINAL POT 4.5 BALLOON 26 Atm
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PTCA: Rotablation LAD, CX, CULOTTE techniqueFINAL RESULT
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PTCA: Rotablation LAD, CX, CULOTTE techniqueFINAL IVUS RESULT
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• Day 1: patient completely dependent on ECMO –pressure tracing direct line – iv inotropes
• Day 5: ECMO removed – full recovery
• Day 8: patient discharged – NYHA I – EF 35%
• Mitral Regurgitation improved grade II
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PRE 15% POST 35%
EF
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Conclusions (I)
• High Risk PCI is feasible if facilitated by Mechanical Circulatory Support
• IABP remains the old fashioned gold-standard• ECMO is indicated for life threatening pulmonary
or cardiac failure, when any other forms of treatment have been failed
• ECMO provides full hemodynamic support although at the expense of a higher complication rate due to the increased invasiveness of the procedure in the femoral vessels and the presence of an oxygenator which increases the inflammatory response
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Conclusions (II)
• Identification of high risk patients who most likely will benefit from Mechanical Circulatory Support is crucial
• Type of Mechanical Circulatory Support depends on:
– Left Ventricular - circulatory status
– type and duration of procedure» rotablation in heavily calcified tandem lesions, where any
other method of percutaneous intervention would have failed with detrimental effect for these particular patients