retrograde approach septal collateral channels paul hsien-li kao, md associate professor national...
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RETROGRADE APPROACHSEPTAL COLLATERAL CHANNELSPaul Hsien-Li Kao, MD
Associate Professor
National Taiwan University Hospital
Paul K
ao C
CT
2013
CCT2013COI Disclosure Paul Hsien-Li Kao
The authors have no financial conflicts of interest to disclose concerning the presentation.
Septals in retrograde PCI
Connects LAD and RCA(PDA)
Most frequently used in retrograde PCI for CTO’s of LAD or RCA
In theory, more straight forward course than epicardial channels
Variable channel size/diameter
Can be very tortuous too
Paul K
ao C
CT
2013
Devices used to track septals
Microcatheter Corsair Finecross Sortana, etc
Guidewire Sion Sion Blue, Suoh, XTR, etc
OTW BC
Paul K
ao C
CT
2013
Viewing the septal course
Take-off from LAD RAO cranial
Take-off from PDA RAO caudal
Septal track RAO
Tip injection from micro-catheter to isolate the track is important to isolate the desired track
Paul K
ao C
CT
2013
Unusual conditions
Ipsi-lateral connection for m-LAD CTO p-LAD septal d-LAD
Ipsi-lateral connection for m-RCA CTO p-RCA conus branch septal PDA
Part of collateral loop involving other epicardial channel, connecting not only between LAD and RCA
Paul K
ao C
CT
2013
Which septal to choose?
Multiple septal connections may be present, can we select one logically or just by chance?
AA and LEP Rhythm issues Total loop length Cardiac cycle motion
“Septal surfing”
Paul K
ao C
CT
2013
Attack angle (AA) & length from emerge point (LEP)
Paul K
ao C
CT
2013
large AA
small AA
short LEP
long LEP
Consequence of rupture
Hematoma – mostly benign, but may develop into abscess/VSD
AV fistula - benign
Dry tamponade/acute HOCM – extremely fatal!
Paul K
ao C
CT
2013
What is dry tamponade?
Rare, but has been reported as a consequence of dissecting septal hematoma after surgical VSD repair
Septum bulging into ventricles reducing the end-diastolic volume, with hemodynamic effects similar to pericardial tamponade
If positioned at LVOT level, will also create HOCM-like hemodymanics
High mortality (~90%) if managed conservatively Surgical evacuation and un-roofing Hemostasis is not effective!!
Vargus-Barron J, et al.Echocardiography 2009; 26:254
Paul K
ao C
CT
2013
Conclusions
With current devices and treatment strategies, CTO PCI produces acceptable and consistent results
The choice of collaterals should be liberal, and pre-PCI planning is important
Septals are useful and important, but as delicate and dangerous as other collaterals
We still need improved wire design for better and safer tracking
Paul K
ao C
CT
2013
Personal breakdown
300 consecutive unselected CTO attempts from 2012-Jan to 2013-Sep
10 failures, without emergent surgery nor mortality Success rate 96.7%
155 retrograde (51.7% of all CTO procedures) with 96.1% success
72 using septal, 46.5% of all retrograde cases, with 98.6% success
Paul K
ao C
CT
2013