What specific features are you focusing on while reviewing collaterals for retrograde approach?
The size and angulation of the retrograde collaterals is the most important factor in determining the success of retrograde procedures. In very angulated (>75% bend) small collaterals (<0.5mm size) success is very low.
In present day CTO interventions, should a meticulous collateral review be conducted at the commencement of each procedure?
Yes, once planning the CTO recanalization, contralateral injection is essential to improve the CTO success by visualizing the distal wire past CTO lesion and limit distal dissection or if wire has exited extravascular causing any potential perforation.
If collaterals suggest an excellent approach, would you ever use retrograde as first approach?
Retrograde approach could be the first line approach in rare cases of aorto-ostial lesions or blunt ostial occlusion of ostial LAD/LCx. Otherwise it should be 3rd line approach after 2 failed antegrade CTOs. Q4. Or, is the antegrade always the essential first option? A. Yes by enlarge antegrade should be preferred first approach as retrograde approach always cause extensive dissection, more stent length and slightly higher cardiac enzyme elevation.
Fielder - Runthrough - Miracle - Confianza - Progress : good 5 wire escalation approach?
I suggest the following wire escalation approach for CTO; Fielder- Miracle 3 or 6- Confianza 9 or 12- Progress 200T or GAWA III. Q6. When specifically will you use the Progress wire? A. Progress 200T is specially designed for short calcified CTOs because of a strong tapered tip.
When specifically will you use the Pilot wire?
Pilot 50-200 are used in angulated CTOs and sometimes also for retrograde recanalization to pierce the retrograde cap. Q8. Except for lack of access via femoral approach, would you consider wrist access? A. Transradial approach is frequently used by many operators with well known limitation of lack of guide support in complex CTOs.
How would you, in these situations, deal with retrograde cannulation?
Bilateral Transradial PCI with retrograde approach has been reported with similar technique of wire exteriorization as femoral approach but via contralateral radial guide catheter.
In what specific CTO, would you consider using an Impella device?
Most of the CTO cases are elective and well tolerated hemodynamically and hence rarely additional mechanical hemodynamic support is required. Rare cases of borderline hemodynamic (LVEF <20-25% and SBP <90-100 mmHg) especially in cases of single contralateral patent but stenosed vessel, IMPELLA device may be a useful adjunct.
Imaging Guided Calcified LM PCI with Interactive Discussion about EXCEL Trial Results by Dr. Gregg Stone and Dr. John Puskas – November 2019
Tags: Complex coronary | excel trial | left main intervention | Rotablator
Case and Plan: 77 year-old male with stable class II angina and exertional dyspnea was noted to have calcified 90-95% left internal carotid artery stenosis on carotid duplex for ongoing neurological symptoms. A Cardiac Cath on November 18, 2019 as the part of pre-op evaluation for carotid endarterectomy revealed calcified severe 2V (RCA and LCx) […]
Recanalization of a complex RCA CTO using Antegrade/Retrograde Approach – Oct 2019
50-year-old female with multiple CAD risk factors presented with new onset CCS Class II angina for two months and stress echo revealed moderate inferior ischemia. A Cardiac Cath on October 7, 2019, performed at an outside hospital, revealed 1 V CAD: CTO of prox RCA, which fills via collaterals from left system with non obstructive […]
Impella Assisted Protected Multivessel PCI using Rotational Atherectomy – Sept 2019
62-year-old male presented with new onset Class III angina, NIDDM and positive MPI for multivessel ischemia in inferior, lateral and anterior walls. A Cardiac Cath on September 6, 2019 revealed 3V CAD: 100% proximal RCA, 80% calcified proximal LAD/D1 bifurcation Medina (1,1,1), calcified 80% mid LAD, calcified diffuse subtotal LCx-OM2 with SYNTAX Score of 39 […]
FFR & OCT Guided Staged PCI of LAD Diagonal Bifurcation – Aug 2019
Tags: Bifurcation | Complex coronary | LAD
50-year-old female with new onset Class II angina and strongly positive stress MPI for multivessel myocardial ischemia with TID. A Cardiac Cath on June 26, 2019 revealed 3V CAD: 70% severely calcific prox LAD with diagonal bifurcation, 80% LCx-LPL, 80% mid RCA with SYNTAX Score of 23 and LVEF of 60%. Patient underwent successful DES […]