Case: 57-year old male with CABG x2 (in 1990) presented with new onset angina and moderate inferior and mild septal ischemia on stress MPI and cath on January 15, 2012, revealed 3V CAD, patient LIMA to LAD, occluded SVG to RCA and normal LV function. Native RCA in totally occluded in mid and fills via bridge collaterals and retrograde collaterals via 90% stenosed large first septal branch. Patient underwent DES of first septal branch but angina persists despite maximal medical therapy. Patient is now planned for PCI of native CTO RCA via antegrade or retrograde technique.
Q&A
Q
Below what percentage of your expected success rate, will you absolutely not accept a CTO for intervention? Is there a role of CT as a guide pre CTO procedure?
A.
That magic number based on our experience is 50% success rate. There are some CTO’s which will have <50% chance of success such as calcified with blunt tip and extensive bridge collaterals; these CTOs are not tried. But remaining CTOs, once clinically indicated based on AUC criteria, will have a 70-75% chance of recanalization at first attempt and hence are routinely done. CT scan to lay out the course of the coronary vessel, has been reported in literature but has not been incorporated at Sinai at present time.
Q
Are most CTO referred to you or are generated from within the hospital's large practice?
A.
Before 2010 we rarely used to get referrals for CTOs from outside, but in last 2 years, the success of our CTO program by live cases and CCC symposium, has established our center as the CTO referral center in the Tristate area. Dr Kini has done a tremendous job of elevating this field at Sinai. As a last count, of the average 30 CTOs per month being done at Sinai, 10 (33%) are coming from outside Sinai system.
Q
What is the single better thing the Japanese operators do than us? What is the success rate at Sinai? Any role of IVUS?
A.
Persistence, persistence and persistence along with innovative techniques (retrograde, CART etc.) are the main factors for higher success rate of CTO recanalization by the Japanese Interventionalists. At MSH our initial success rate of CTO recanalization is approximately 70% and additional 20-22% at second attempt making it total 92% in last 2 years. Retrograde technique being used during 2nd or 3rd attempt has added 8-10% of this high success. We don’t use IVUS to guide for CTO recanalization and only a handful of Interventionalists in the world are comfortable in incorporating IVUS guidance during CTO recanalization.
Q
Do they have access to better equipment that we still do not have, like newer guide wires?
A.
With the availability of 1.2-1.25mm balloons and Corsair in USA, we now have all the tools (like our Japanese colleagues) necessary for CTO recanalization. It just needs persistence and getting familiar with retrograde techniques.
Q
How much is your fluoroscopy cut off? And for dye?
A.
Fluoroscopy in three digits (>100minutes) or dye use >8ml/kg (usually 600ml) are our usual cutoff for concluding a CTO procedure even if unsuccessful. These cases are routinely staged after 6-8 weeks even if there has been extensive dissection and minor wire perforation.
Q
Bivalirudin for CTO too?
A.
YES and is supported by our publication in this field showing that these wire perforations are very benign once Bivalirudin on board vs Heparin. This is true despite there is no direct antidote for Bivalirudin but its effect rapidly wears off. Hence we fully support the use of Bivalirudin in all PCIs, even more so in PCIs involving CTOs.
Q
If you fail the first time, what is the percentage of success of another staged procedure? Any role of bilateral Radial Interventions?
A.
About 20-22% success rate at second attempt; rarely third attempt is done. We do radial PCIs but is not favored for CTOs largely due to lack of a good guide support. We have never used bilateral radials for CTO PCIs.
Q
How do you manage a patient's expectations for failure and to attempt again?
A.
This remains a major emotional challenge of facing the pt & family, after unsuccessful CTO PCIs as it rarely happens (<0.5%) in non-CTO PCIs. The way I prepare pt and family is by saying that, we should try CTO PCIs (once clinically indicated) and if we succeed then will tremendously reduce the chances of future CABG; of course in 30% we may fail initially but will try in 2 stages making it a >90% success rate.
Q
What is the strategy for staging - time, anti-platelets, insurance approval?
A.
Staging is usually done 6-8 weeks later and most of them are on plavix for other non CTO PCIs and hence is continued. We try not to use Prasugrel in these cases because of strong antiplatelet efficacy and anecdotally higher wire perforation with its use during PCI. Usually Insurance approval is not a limiting factor in any way as all are being done on the clinical ground meeting the Appropriate use criteria Guidelines.
Q
What percentage of success does the retrograde technique add to your CTO rates?
A.
Retrograde technique adds approximately 8-10% success for CTO recanalization and is only used as the 2nd or 3rd line strategy.
