62 year old NIDDM male presented with CCS Class II angina and positive SPECT MPI for infero-lateral and apical ischemia. A Cardiac Cath on June 4, 2018 revealed 3 V CAD; CTO of mid RCA distal vessel fills via bridge collaterals, 95% proximal LAD, 90% proximal LCx with LVEF 60% and SYNTAX Score 28. After Heart Team discussion, patient opted for multi-vessel staged PCI. Patient underwent successful intervention of proximal LAD using DES (Xience Sierra 3.25 x 23) and proximal LCx using DES (Xience Sierra 3.25 x 18). Patient is now planned for staged PCI of RCA CTO using antegrade or retrograde approach.
Moderator: Sameer Mehta, MD
Q&A
Q
What are unique attributes of the Gaia 3 wire that make it so special for crossing CTO?
A.
Three unique attributes of Gaia wire family are; high maneuverability, flexibility combined with high tip penetration.
Q
You have begun using Confianza 12 more for antergrade crossing?
A.
We use Confianza 12 as the 3rd escalation guide wire for tough CTO recanalization.
Q
On the same topic, why Gaia 2 and Confianza 9 for retro grade crossing?
A.
Gaia 2 and Confianza 9 can rarely be used as the 2nd and 3rd escalation wire for retrograde crossing after Fielder wire failure due to calcification.
Q
How does Caravel compare with Fine Cross?
A.
We have preferably used Finecross as the workhorse micro catheter, but because of its limited supply, we are now using other microcathters; Caravel and Turnpike. Both Caravel and Finecross seems to work equal in their performance. Although our experience is small so far, but we are really impressed by the performance of Turnpike catheters in terms of pushability and crossing, in the tough lesions.
Q
Despite higher early and long term complications, why is ante grade dissection approach still prevalent?
A.
Original data of extensive ante grade dissection entry showed higher procedural MI rates, restenosis and TO on follow-up. Since then approach of limited ante grade dissection entry (LAST: limited antegrade subintimal tracking or BRIDGEPOINT reentry system with stingray needle/crossboss) have shown to be less harmful than conventional ante-grade dissection. Long-term data of these limited ante-grade dissection reentry techniques are awaited before we can make any final statement on this issue.
Q
You have stopped using Progress wires for CTO?
A.
Yes. Progress wire is rarely used now and in my opinion only indication will be the use of Progress 200T wire for severely calcified CTO as the last resort.
Q
After crossing a CTO, do you have a preferred DES?
A.
We now have the data for all 3 DES types (Xience, Promus and Resolute) and results are comparable but no direct comparison in the RCTs. There seems to be slight advantage of Xience family DES with lower ST (<0.5%) and lower TLR (5-6%) as reported in the Expert CTO trial data at 1-year.
Q
What are your present recommendations to prevent contrast nephropathy?
A.
Besides IV hydration with 0.45-0.9% NS at 0.5-1cc/kg/hr for 3-6hrs pre and 3-6hrs post, we still use NAC 1200mg one dose pre and one post procedure; it may just have placebo effect but patients and referring MDs feels better and satisfied. We do not stop ACEI or Metformin pre-procedure but hold Metformin for 48hrs post procedure. All pts receives low or iso osmolar contrast media. We are waiting for the final data of forced diuresis trial before adopting it routinely (Renal Guard system). Hemodynamic guided (LVEDP) fluid administration to prevent CIN (POSRIDON trial) is also rarely used in our cath lab especially in high CIN risk cases with LV dysfunction and SCr >2mg%.
Q
Is the recommendation of transferring to expert sites a CTO with JCTO>2, being implemented by referral institutions/operators?
A.
CTO pts with high J-CTO score are routinely being referred to our center due to excellent track record of success and safety. We have been disseminating this message that while any operator can try simple CTOs (J-CTO <2), but CTO with J-CTO score of >2 should be referred to the designated CTO centers and expert CTO interventionalists (like ours).
Q
For a staged PCI, it is an ongoing battle to obtain insurance approval for reperfusion imaging, and without that staged procedure is not authorized? How can this situation be ameliorated?
A.
That is correct that we used to get resistance in getting stress MPI approved by the insurance companies to justify staged PCI after the index PCI, but it has become easier now. Also one way to circumvent this issue will be to FFR of the staged vessel at the time of index PCI and then staged PCI will be appropriate if FFR is <0.81.
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