51 year old male with history of NIDDM has CCS Class II angina and high risk stress MPI for multi vessel ischemia. A Cardiac Cath done at outside hospital revealed two vessel CAD with calcific total occlusion of mid LAD, 80% D1, 80% prox-LCx and 99% LPL with LVEF 55% and SYNTAX Score of 22. Patient had Heart Team discussion, which recommended CABG, but patient elected for PCI. Patient continued to have angina despite MMT. Patient is now planned for revascularization of totally occluded mid LAD via antegrade and/or retrograde approach.
Q&A
Q
What specific features are you focusing on while reviewing collaterals for retrograde approach?
A.
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.
Q
In present day CTO interventions, should a meticulous collateral review be conducted at the commencement of each procedure?
A.
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.
Q
If collaterals suggest an excellent approach, would you ever use retrograde as first approach?
A.
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.
Q
Fielder - Runthrough - Miracle - Confianza - Progress : good 5 wire escalation approach?
A.
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.
Q
When specifically will you use the Pilot wire?
A.
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.
Q
How would you, in these situations, deal with retrograde cannulation?
A.
Bilateral Transradial PCI with retrograde approach has been reported with similar technique of wire exteriorization as femoral approach but via contralateral radial guide catheter.
Q
In what specific CTO, would you consider using an Impella device?
A.
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.
