Complex coronary cases
Revascularization of mid LAD CTO via Antegrade/Retrograde Approach – April 2015
Views 15233

51 year old male with history of NIDDM has CCS Class II angina and high risk stress MPI for multi vessel ischemia. A Cardiac Cath done at outside hospital revealed two vessel CAD with calcific total occlusion of mid LAD, 80% D1, 80% prox-LCx and 99% LPL with LVEF 55% and SYNTAX Score of 22. Patient had Heart Team discussion, which recommended CABG, but patient elected for PCI. Patient continued to have angina despite MMT. Patient is now planned for revascularization of totally occluded mid LAD via antegrade and/or retrograde approach.


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.


Leave a Reply

Your email address will not be published. Required fields are marked *

OCT Guided Complex Intervention of LM and Long Calcified Aneurysmal LAD – January 2020
Tags: | |
Views 144

Case and Plan: 76-year-old female presented with new onset CCS Class III angina with positive SPECT MPI for mild lateral ischemia. A Cardiac Cath on January 6, 2020 revealed 3 V + LM CAD: 70% distal LM, 80% proximal LAD/D1 bifurcation, 80% long calcified aneurysmal mid LAD, 80% LCx-OM1, SYNTAX Score of 35 and LVEF […]

OCT Guided PCI of Calcified LAD Bifurcation using 2-Stent + OA – December 17, 2019
Views 654

Case and Plan: 67-year-old male controlled NIDDM, presented with CCS Class I angina and positive stress echo for multi vessel ischemia. A Cardiac Cath on August 9, 2019 revealed 3 V CAD: calcified 80% mid LAD and D2 bifurcation, 70% distal LAD, CTO mid RCA and CTO proximal LCx, SYNTAX Score of 38 with moderate […]

Imaging Guided Calcified LM PCI with Interactive Discussion about EXCEL Trial Results by Dr. Gregg Stone and Dr. John Puskas – November 2019
Tags: | | |
Views 1033

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
Views 816

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 […]