Complex coronary cases
PCI of CTO RCA using Retrograde Recanalization – Aug 2013

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62- year- old male with NIDDM, new onset of angina, and positive stress echo for infero-lateral ischemia presented on June 26, 2013, which revealed 3V CAD (60% proximal LAD, 80% distal LCx, 100% distal RCA) and normal LV function(SYNTAX score 22). Patient was recommended CABG but declined and underwent zotarolimus-eluting stent (3.5/30mm) PCI of distal LCx. Patient continues to have class II angina on MMT and is now scheduled for PCI of CTO RCA using retrograde recanalization approach.

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Q&A
Q
What are the essential differences between the existing retrograde CTO techniques and the Kini Modified Retrograde CTO technique?
A.

Essential differences in Kini's retrograde technique vs conventional retrograde techniques are; 1) visual selection of septal perforator (seeking) vs traditional angiographic surfing by injecting into the septal; 2) antegrade wire passage once retrograde wire reaches the retrograde CTO cap; 3) advancing the Finecross antegradely upto the distal septal touching the Corsair (‘kiss technique’) over the exteriorized guidewire, and then withdraw the exteriorized wire along with the corsair. This last process causes least trauma to the inside liming of both CTO and the feeder vessels and minimizes coronary vasospasm.


Q
Which three specific steps in the Kini technique make this the prefered approach? A: Kini's steps are to reduce the contrast load and the Fluoro time by eliminating few traditional steps as described above; seek the septal channel visually, try antegrade CTO wire once retrograde wire reaches the cap and use Finecross to remove the exteriorized wire by advancing it antegradely touching the Corsair in the septal (‘Kiss technique’).
A.

Kini's steps are to reduce the contrast load and the Fluoro time by eliminating few traditional steps as described above; seek the septal channel visually, try antegrade CTO wire once retrograde wire reaches the cap and use Finecross to remove the exteriorized wire by advancing it antegradely touching the Corsair in the septal (‘Kiss technique’).


Q
How many procedures have been done at MSMC with the Kini technique?
A.

Approximately 32 cases.


Q
How much is the reduction in fluoro time and in the dye load with the Kini technique?
A.

Both fluoro time and dye load traditionally reported to be approx. 60 minutes and 300cc with retrograde technique. With steps described by Dr Kini for retrograde recanalization, fluoro time is about 30 minutes and dye load is 120-150cc; hence 50% of the reported.


Q
What are the take home messages for the handling of the Corsair catheter?
A.

Corsair catheter can be advanced over the wire with continuous 16-20 clockwise turns and then counter-clock wise turns to either retract or to go forward further.


Q
Do you always have two experienced operators for CTO?
A.

Usually we don't have 2 experienced interventionalists for CTO in routine cases, but in Live cases, always there are 2 experienced interventionalists. An experienced interventionalist is always there when a junior interventionalist is attempting CTO PCI in our Cath lab.


Q
When do you proceed straight to retrograde CTO technique?
A.

Cases of ostial occlusion especially aorto-ostial and CTO with extensive bridge collaterals, should be tried as retrograde approach as the first line. Otherwise retrograde recanalization remains the 2nd or 3rd line approach because of longer procedure time, more stent use and more side branch closure to subintimal dissections.


Q
What specific situation will you use IVUS in CTO?
A.

We rarely use IVUS guidance during CTO recanalization, but IVUS has been reported to be useful in CTO cases of extensive intimal flaps and at origin of sidebranch, to guide the wire penetration into the CTO lumen.


Q
Are you using any pre procedure CTA for navigation?
A.

We do not use CTA to guide our CTO procedures, but Japanese operators use it frequently to understand the course of distal vessel and to quantify the atheroma burden which correlates with peri-procedure MI.


Q
Are there specific advantages of using Bivalirudin.
A.

Bivalirudin use during CTO PCI by virtue of its short half-life, causes less complications of wire perforation which occurs not uncommonly during CTO PCI. This is true despite lack of any antidote for Bivalirudin. We have published our center data to support this statement (Kini A et al. Cathet Cardiovasc Interven 74:700, 2009).


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