59 year old male presented with new onset CCS Class III angina and a positive stress MPI for multivessel ischemia. A Cardiac Cath on July 25, 2017 revealed extensive III Vessel CAD: multiple CTO’s of RCA filling via LAD/LCx collaterals, 80% LAD-Diagonal bifurcation, 95% LCx-LP1 with SYNTAX Score of 33. Heart Team discussion recommended CABG, but declined by patient and family. Patient underwent successful interventions of mid LAD (Xience DES), LAD-D1 (Flextome atherotomy PTCA) and LCx-LPL1 (Xience DES). Patient is now planned for staged PCI of RCA CTO via antegrade approach utilizing contralateral injection for guidance.
Moderator: Sameer Mehta, MD
Gaia series (1,2,3) of guide wires are made of a special composite core with a twisted rope technology to provide 1:1 torque in CTO cases with very small lumen space. Another advantage of the Gaia wire is that it has low chance of perforation and sub-intimal passage. Because of all these attributes, Gaia family of wires are the #1 CTO wires in Japan and now getting big momentum in USA also. We start with Gaia 2 and if fails then quickly go to Gaia 3 with stronger penetration capability.
Using 7Fr or 8Fr guide catheters is the conventional teaching for CTO recanalization especially to get the back up support. We have been teaching to use 6Fr guide catheter in majority along with the long (45cm) sheath and frequent use of Guideliner, to gain extra support.
Antegrade CTO guidewire escalation in our lab is as follows; Gaia 2 or MiracleBro 6, followed by Confianza 9 or Gaia 3, followed by Confianza 12 or Progress 200T. Astato 20 is the final escalation wire.
Rare cases where we will start with retrograde approach of CTO recanalization are; True ostial occlusion (RCA, LM or LAD or LCx) where there is absolutely no stump , very calcific cap or a large side-branch at CTO site with ambiguous cap.
Yes, Guideliner is commonly used in CTO cases; our last analysis showed that almost 1/3rd of CTO PCIs require use of Guideliner.
Fine cross is our #1 support catheter followed by Corsair.
Syntax trial showing data on both complete and incomplete revascularization in routine clinical practice is more contemporary of the 3 trials discussed today.
I doubt that guidelines will change on the meta-analysis data. To change the guidelines we have to perform the trial of culprit vessel PCI only vs complete revascularization in stable MV CAD. If such trial is positive, then guideline will change, just as happened in the STEMI MV PCI case.
The message from the current meta-analysis from the surgical point of view is that try to bypass all diseased vessels (>1.5-2mm size) possible but there is little penalty, if some vessels are left unbypassed. On the contrary message for the interventional community is clear that if we want to have similar long-term outcomes of PCI as after CABG in MV CAD, make sure to achieve complete revascularization of all angiographically diseased lesions/vessels.
I agree that OCT could be an alternate tool to IVUS for calcium detection but in my opinion it’s interpretation is still very subjective and requires retraining our eyes; while we all have learned to quantify the extent and degree of calcium on IVUS.
86 year old female with chronic stable angina CCS Class II and positive MPI for two years being managed on medication.
62 year old male presented with CCS Class II angina and positive SPECT MPI for basal inferior and inferolateral moderate size area of ischemia and infarction.
53 year old male with CKD on HD, known extensive inoperable severe calcific CAD and s/p SAVR in Nov 2017.
74 year old male with CKD Stage III presented with CCS Class II angina and positive stress MPI for moderate inferoapical ischemia.