Complex prox RCA CTO Recanalization via Retrograde Approach – February 2021

56-year-old male presented with Class III unstable angina and positive stress MPI for significant inferior ischemia. A Cardiac Cath on November 20, 2020 at outside hospital revealed 2 V VAD: 85% mid LAD, 70% D1 and CTO proximal RCA with distal vessel fills retrogradely via septal collaterals (J-CTO Score 3), LVEF = 50% and Syntax Score of 26. Patient underwent successful PCI of mid LAD and diagonal using two Xience Sierra DES. Patient is now planned for complex CTO RCA recanalization using retrograde approach via septal collaterals.

Q&A

Q In retrospect, should the case have been planned at antegrade
A. Actually this case as per the CTO algorithm, was appropriate for retrograde recanalizaion. We are pleased that while we later succeeded antegradely, we were able to show and highlighted all the steps of retrograde recanalization. Will try again next month to showcase a successful retrograde technique for CTO recanalization.
Q What made you decide for retrograde to begin with?
A. Again as per the CTO algorithm, it was decided to try retrograde approach and also there have been requests by our audience to show retrograde techniques.
Q Any other approaches that may have been tried for the retrograde?
A. We went with the septal collaterals, which is the most common retrograde approach. Other being via Epicardial collaterals, but they were not present in this case and hence was not possible.
Q How would you compare the Turnpike with the Corsair?
A. Both are similar with minor differences of crossing profiles and torqueability; both little better with Turnpike.
Q Should one avoid accessing septal collaterals via previously placed stents?
A. Yes by enlarge we should avoid using stent jailed septals for retrograde approach; but as discussed, they can also be used after opening the stent strut with a small 1.5-2mm balloon.
Q Which is your preference for the CTO scores - Progress CTO, JCTO or CASTLE?
A. I still think that JCTO score is simple to calculate and has good discriminatory power; hence my preferred one. CASTLE score is also good and provides better discriminatory power in more complex advances CTO cases.
Q Do you rigidly follow the Hybrid protocol before planning cases?
A. We don't follow the Hybrid protocol in entirety but do it as a working algorithm for devising the CTO recanalization strategy. We differ mainly on the concept of antegrade or retrograde dissection and reentry; which we neither practice nor teach others as these dissection techniques have higher peri-procedure enzyme elevation, more stents use and higher restenosis.
Q Q8. Where does Gaia guidewire fit in your wire escalation strategy?
A. Gaia 2/3 guidewires is our first wire of choice after fielder in CTO escalation strategy. It is followed by MiracleBro 6 and then Confianza 9/12.
Q Do you feel US approval is imminent for DCB?
A. Two small scale trials of DCB have started in USA and I believe that DCB will be available for clinical use earliest by Q1 2022.
Q What all applications will the DCB have?
A. Most common application of DCB will be DES ISR treatment. Then it will be used in sidebranch in provisional stent techniques, in order to avoid stenting. Lastly small vessel PCI (<2.5mm size) where DCB has shown to be comparable to DES without the need for long term DAPT.

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