Complex coronary cases
Staged PCI of CTO RCA via Retrograde Approach – June 2015
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57 year-old male presented with new onset CCS Class IV angina. A Cardiac Cath on April 6, 2015 revealed 2V CAD (CTO of RCA and subtotal occlusion of Circumflex-LPL branch) with normal LV function and SYNTAX Score of 24. Patient underwent successful intervention of LCx-LPL (Xience DES) and failed attempt at antegrade recanalization of CTO RCA. Subsequently, patient continued to have Class II angina and a stress MPI last week revealed moderate ischemia in the RCA territory. Now planned for staged PCI of CTO RCA via retrograde approach due to failed ategrade approach.

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Q&A
Q
Are your results at Mt. Sinai comparable to the European Registry? Or better?
A.

CTO results of MSH with initial success rate of about 80% initial and approx. 92% after 2-3rd attempt is comparable to European CTO results. One major technical difference between two, is <5% retrograde recanalization at MSH while it is 18-20% in European registry.


Q
Besides experience and new wires, are there other factors that have improved the retrograde CTO results?
A.

Most important factor responsible for improved retrograde CTO success is the introduction of Corsair channel dilator.


Q
Why is CART and Reverse CART not used often in your hospital?
A.

We do not believe in CART or reverse CART for retrograde recanalization and largely depends on direct retrograde wire recanalization and then perform the antegrade and retrograde kiss technique for wire exchange.


Q
You do not appear to be a strong proponent of re entry and re entry devices?
A.

Yes we are not the proponent of reentry techniques (STAR), largely due to data reporting high restenosis rates and reCTO at follow-up. Our teaching has been to limit antegrade dissection and also limit the total stent length. Hence we rarely feel the need of Stringray device or reentry technique.


Q
Probably rare to do a retrograde CTO without Corsair?
A.

Yes agree, retrograde CTO is always attempted with 150 cm length Corsair.


Q
What are some teaching tips for using Corsair?
A.

Rotate Corsair clockwise 12-15 times and then counterclockwise 6-8 times while slight withdrawal and then repeat the sequence. Torque device placed on the guidewire at the Corsair end helps to control the device movements.


Q
Which is the best long wire for externalizing the retrograde CTO?
A.

Classical being Viper 0.014” 325cm length use for externalizing the retrograde wire. Abbott has new wire for this purpose (RG 3, 330cm 0.010”) , but we do not have experience with this wire yet.


Q
How many CTO procedures on an average do your fellows do during their training?
A.

We do about 500 CTOs (12% of our PCIs) per year and are divided between 8 Interventional fellows; hence approx. 60 CTOs are done by each fellow during their one year of Interventional training.


Q
Has the mother and child catheter been of much help for CTO interventions?
A.

Yes mother and child catheter is very helpful in tough CTOs, and help to cross the CTOs with small balloon or Corsair in calcific tough CTOs. Sometimes it is also needed for stent delivery in distal tortuous lesions.


Q
In 2016, have you turned down any CTO? For what reason?
A.

Yes we turn down CTO PCI for 2 reasons; 1) If CTO recanalization is not clinically indicated as per AUC criteria and 2) Heavily calcified very long lesions (>30-40mm in length). The later makes about 5-6 cases per month from within Sinai or referred cases.


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