PCI of CTO mid LAD via Antegrade or Retrograde – April 2013

53-year-old male with NIDDM and positive F/H presented with intermittent chest pain on strenuous exertion, and occasionally at rest, associated with SOB for the last 3 months. Cath on 2/26/13 revealed one vessel CAD of total occlusion of mid LAD and LVEF 56%. Patient was inappropriate for PCI because of no documented ischemia and medical therapy; no PCI was performed. Patient was started on maximal medical therapy; a follow-up stress MPI revealed moderate-sized large anterolateral & apical ischemia. Patient is now scheduled for PCI of CTO mid LAD via antegrade or retrograde approach.

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Q&A

Q Have you ever broken your oft-spoken norm and proceeded with retrograde first?
A. No. Always have given the first try for antegrade even in the ostial RCA occlusion. Yes many times both antegrade and retrograde approach were used in the first attempt.
Q In what circumstances will you attempt Re-entry strategies?
A. Extensive antegrade dissection with the caveat that this technique has higher restenosis.
Q Completely abandoned STAR?
A. Almost, but in rare cases when retrograde technique failed and third try as the STAR technique.
Q How often are you using Stingray?
A. We are just learning the Stingray device and despite the best technique, so far had not good success with device yet. But still our experience is very limited and device has the potential in some cases.
Q In which cases do you find it most useful?
A. Extensive antegrade dissection and unable to re-enter in the true lumen will be best case for Stingray's use.
Q Do you use the Cross Boss catheter - any particular situations where it is most beneficial?
A. Yes Cross Boss catheter is very good device in non-crossable lesions where Corsair has failed to cross.
Q Where will you use the findings of the FIRST trial?
A. FIRST trial showed that the minimal lumen CSA of 4mm2 may be too generous to correlate with FFR of <0.8 and lumen CSA of 3.1mm2 is the better predictor. We are still in process of evaluating these data in our cath lab.
Q Is there any situation where you will prefer IVUS MLA over FFR?
A. In calcified and ISR lesions
Q Various diverse hypothesis are presented to explain why VH IVUS did not correlate with FFR? Do you have any thoughts on this issue?
A. VH IVUS shows the plaque morphology better then the true obstruction; hence the reason for the disparity.
Q Any situation where you will not use Bivalirudin for CTO?
A. No. All our CTOs are done with Bivalirudin and with utmost safety.

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