PCI of mid RCA CTO via Antegrade/Retrograde Approach
Complex Coronary
December 2022
CASE & Plan: 58-year-old male with prior PCIs had CCS Class III angina and positive SPECT MPI. A Cardiac Cath on November 8, 2022 revealed 3 V CAD: 100% CTO mid RCA, 90% small size LAD-D2, 80% calcified proximal LCx with SYNTAX Score of 20 and normal LV function. Patient underwent successful intervention of proximal LCx using Rotablator and DES. Patient is now planned for staged PCI of RCA CTO using antegrade and/or retrograde approach.
Q&A
Q
Did the laser help in this case?
A.
Yes, Laser helped to penetrate the initial moderately calcified cap in this Pt and then allowing easier passage of subsequent devices and good stent expansion.
Q
Do you often end up changing the fluence for the laser catheters?
A.
Yes we start with 40:40 fluence and then go to 60:60 after 2 tries and if still does not cross after 5 attempts, then go to 80:80. It is rare (<5%) that with this escalation, laser catheter will not cross the tough lesion.
Q
Are all your cases performed with the 0.9 and 1.4 mm laser catheters?
A.
We use 0.9mm laser Catheter in over 95% of cases. Larger 1.4mm laser catheter (needs 7Fr guide) is used in large vessels; 4.5-5.5mm size, SVGs and ISR in vessels <4mm.
Q
f there are challenges with the tip of the GAIA wire, how do you manage it?
A.
We usually use pre-shaped (1mm) tip of the new GAIA wires but sometimes will make another secondary 45degree tip bend for advancement in the angulated vessels. Usually start with new GAIA 2 and then escalate to new GAIA 3
Q
Why do you like the Miracle wires?
A.
MiracleBro 6 due to strong penetrating power (0.014”), easy torqueability and strong body, makes it as the first line CTO wire. These features also minimizes subintimal passage of the MiracleBro wire tip.
Q
Is the Miracle 6 your most commonly used wire among the Miracle wires? Why?
A.
Yes, for the factors mentioned above, MiracleBro 6 is our favorite 1st line CTO wire with GAIA-3, as the alternate choice. MiracleBro also comes in 9 and 12, but we don’t carry them. If need to go more aggressive, then Confianza 9 or 12 are escalated; ultimate being Astato 20 & 40.
Q
What criteria do you use to select stents for CTO?
A.
Newer generation all stents type, have shown to be equally effective in CTO after successful recanalization. If extensive subintimal dissection occurs without distal penetration in the true lumen, then will settle for PTCA only and will bring back the pt for retry after 6-8 weeks. This strategy works very well in majority of cases.
Q
Are there any CTO for which you will proceed straight away with a retrograde approach?
A.
Only flush ostial occlusions (ostial RCA, ostial LAD), will be attempted as the initial first retrograde approach. In our CTO cases, retrograde approach is used in about 4-5% of cases; and that too after failed 2-3 antegrade attempts
Q
What is your present rate of converting from antegrade to retrograde?
A.
Very rare ad hoc (<1%) conversion from antegrade to retrograde approach but planned retrograde approach in about 5% of CTO recanalization at MSH.
Q
How much have guide extension catheters helped in CTO? As much as microcatheters?
A.
Microcatheters have improved the CTO recanalization success tremendously. Guide extenders have added to improve the success little bit further.
