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.
Staged PCI of RCA multilayer DES CTO ISR using rotational atherectomy and IVBT – November 2020
Case and Plan: 65-year old male with known long standing history of chronic ischemic heart disease requiring multiple PCI’s over the years after declining CABG, presented with CCS Class III angina and high risk stress MPI for multivessel ischemia. A Cardiac Cath on September 28, 2020 revealed 3 V CAD: 100% proximal RCA due to […]
Complex Multivessel PCI in a High SYNTAX Score Patient – October 2020
Tags: Multi-Vessel PCI | PVD | Rotablator
Case and Plan: 74-year-old obese male on HD presented with CCS Class II angina and positive SPECT MPI on July 14, 2020 done as pre-op for renal transplant revealing moderate apical, inferior and inferolateral ischemia. A Cardiac Cath on August 20, 2020 revealed 3 V CAD: 70% mid RCA, 100% RCA-AV Cont, subtotal calcified mid-distal […]
Radial PCI of Long Complex Calcified LAD post TAVR – September 2020
Case and Plan: 78 year-old-male presented on August 7, 2020 with progressive exertional dyspnea, NYHA class III. Workup revealed severe AS (AVA 0.7cm2), normal LV function and STS mortality of 1.1%. After heart team discussion, patient underwent successful TAVR using 26mm SAPIEN-3 Ultra with excellent results, AV area of 2.0cm2 and no PVL. A coronary […]
Stent Ablation with RA of Underexpanded Multilayer DES – August 2020
Tags: Instent Restenosis | Oct | Rotablator
63 year-old male with known CAD, CABG x2 (1999) and multiple PCI’s to SVG to RCA and LCx branches presented with CCS Class IV angina and non-STEMI (TnI 1.2U). A Cardiac Cath on June 22, 2020 revealed patent LIMA to LAD, non obstructive LCx branches with patent prior stents and 90% multilayer in-stent restenosis of […]