Complex PCI of RCA CTO via Antegrade or Retrograde – Feb 2013

60‐year‐old male with multiple CAD risk factors, CCS Class II angina, presented on 12/21/12 with high risk stress echocardiogram for inferior and lateral ischemia. Cath revealed 2V CAD (SYNTAX score 20), normal LV function. Patient had successful PCI (DES) of LCx-High Lateral.
Now scheduled for complex PCI of RCA CTO via antegrade or retrograde approach.



Q Do you consider the CorSair device a game-changer for CTO?
A. Yes. It was designed to facilitate crossing and dilating retrograde channels due to its hydrophilic tapered tip. Hence also called the 'Channel dilator'. It has also been used to cross the uncrossable chronic tough lesions.
Q Do you employ it in 100% of Retrograde CTO's?
A. Yes.
Q What do you feel are the most important criteria for selecting a septal for retrograde attempts?
A. Septal with the direct communication to the RPDA. One study showed that one of the factor of retrograde failure is, >45degree angle of the collateral channel to the receiving vessel.
Q In what circumstances would you contemplate proceeding with retrograde as the first strategy?
A. Ostial occlusion of RCA or LAD. Otherwise retrograde attempt is reserved for the 2nd or 3rd CTO attempt.
Q What precautions should be exercised for re-entry strategies?
A. Try to keep subintimal passage short and use taperd tip wires (Confianza or Progress family). Stringray balloon with needle and Crossboss catheter have increased the success of antegrade re-entry.
Q You demonstrated the Whisper wire use very nicely - it almost made a reasonable substitute to a Fielder FC?
A. Yes Whisper ES can also be used to navigate through angulated septals; but Fielder FC should be the workhorse wire for retrograde passage.
Q If the balloon catheter from the retrograde technique not revealed a good channel, would you have called quit and made later attempts?
A. Yes and sometimes another septal could also be tried.
Q In experienced hands, what are the angiographic criteria for CTO that concern you the most?
A. Heavily calcified CTO lesions.
Q As you mentioned, should retrograde CTO's have dedicated operators?
A. Yes and before embarking on retrograde approach, operator should have done >200 CTO PCIs.
Q Are there any situations left to clinically use Verify Now or other assays? Is the Arctic Trial a death-nail?
A. Based on the 3 negative trials of VerifyNow assay (Gravitas, Trigger PCI and Arctic trials) incorporating change in antiplatelet therapy during PCI, we can say with confidence that VerifyNow assay has NO role in stable PCIs. In some high risk cases such as ULM, proximal bifurcations, multiple stents VerifyNow assay may have some role. That is what we are practicing at our center.


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