78 year-old male with long standing history of stable angina presented with CCS Class III angina. A stress MPI test revealed moderate inferior and apical ischemia. A Cardiac Cath on October 20, 2015 revealed 2V CAD; CTO of proximal LAD and 80% proximal LCx with mild systolic LV dysfunction and SYNTAX Score of 26.5. Totally occluded LAD segment is >30mm in length and fills retrogradely via grade III collaterals from RCA. Patient underwent successful intervention of proximal LCx using Promus Premier DES. Patient is now planned for staged PCI of LAD CTO via antegrade or retrograde approach.
Moderator: Sameer Mehta, MD
Q&A
Q
Does the new information on wrist access provide a reality check for the unbridled enthusiasm for radial access?
A.
The information of higher vascular complication and possibly MACE rates in high volume radial operators has just now come to the limelight. My opinion on this issue is clear that there is no question that TRI in ACS/MI cases saves lives but do not forget your femoral skills. Hence keeping 20-25% of cases being done by femoral approach will circumvent this issue of ‘forgetting the femoral access skills’.
Q
Is the major fault in operators, in particular, the new ones, losing the diligence in learning femoral access?
A.
I believe the fault was too much emphasis to become the skilled radial operator but at the same time thinking that there is no training needed for femoral access. Balance and education on both accesses should be the focus of current training.
Q
It is very hard to explain how the large volume sites had more trans femoral complications?
A.
It was the large volume radial operators who had higher femoral complication, which could just be due to ‘femoral ignorance’.
Q
How are you dealing with this information at your institution?
A.
We still have not encountered this problem as our lab still does only under 25% cath procedures as radial.
Q
Is your training for fellows going to recalibrate how they master vascular access?
A.
Yes we will continue to educate our interventional fellows in both femoral and radial procedures.
Q
There has been a rush to modify guidelines about wrist access - is this data a reason to pause and contemplate?
A.
I still believe that emphasis on radial approach is appropriate and then only we will cross the threshold of 50% PCI as the radial intervention in USA. But do not ignore the femorals.
Q
What are your plans for this patient with unsuccessful ante grade and retro grade CTO?
A.
Today’s case with unsuccessful antegrade and retrograde approach is planned to come back in 1st week of April for 2nd try and we are optimistic that we will succeed. Whatever the outcome will be, we will share the future PCI outcome of this pt with our CCCLivecases audience.
Q
It is not uncommon for these CTO to recanalize through one of these multiple wire channels that would have been created and that would make a repeat procedure successful?
A.
That exactly has been our observation and many times 2nd attempt is made much simpler by those small recanalized channels.
Q
Any role in such patients benefiting from LMWH in the interim phase for the repeat procedure?
A.
We don’t believe in strong antithrombotic therapy in these pts as long there has been no thrombus or side branch closure during PCI.
Q
A repeat procedure should begin with ante grade approach?
A.
Yes and also first do the full cath, when pt comes back for repeat PCI, by single access. Then after the angio evaluation and if needed then only puncture the contralateral side. Initial approach will be decided by the status of the CTO with likely antegrade as the start point.
