Staged PCI of Proximal LAD/Diagonal Bifurcation Lesions and mid LAD CTO filling via Bridge Collaterals – May 2014

62-year-old-male presented with crescendo CCS Class III angina with positive stress MPI for moderate anterior and lateral ischemia. A Cardiac Cath on April 15, 2014 revealed 2V CAD of multiple lesions in LAD/Diagonal and 80% lesion in OM3 with LVEF 55%. Patient underwent PCI of OM3 using Promus Premier DES. Now planned for staged PCI of complex proximal LAD/Diagonal bifurcation lesions and of mid LAD CTO filling via bridge collaterals.
Moderator: Sameer Mehta, MD

1:10:02

Q&A

Q Dr. Mehta and yourself have stated that CTO results in the U.S. compare with Japan now. Is that correct?
A. Yes that is correct as in the recent contemporary US EXPERT CTO trial, the overall success rate of CTO recanalization was over 90%; similar to the Japanese reports.
Q What are the CTO success rates at your institution presently?
A. First attempt 85% and with second attempt 92-94%
Q What is the breakdown of antegrade versus retrograde?
A. Still 90% antegrade and if fails again antegrade and then retrograde. Rare cases of flush ostial occlusion, retrograde approach may be the first line of attempt.
Q All 100% femoral access? Will you consider radial access in any case?
A. Yes CTO procedure in our lab are dual femoral access in majority (>98%). In rare case of difficult femoral access, radial approach has been tried.
Q What percentage are 6F? Where do you use 7F?
A. Majority (>95%) are 6Fr. 7Fr is used only in cases where CTO is at the bifurcation and 2 stents might be used after successful recanalization and balloon anchor technique is needed.
Q Where are you not using a bilateral cannulation?
A. WE are not using bilateral cannulation, when there are ipsilateral collaterals like LAD giving collaterals to occluded LCx.
Q 100% successful wire crossing is finished with DES?
A. YES and is clearly supported by trial (PRISON II) and CTO registry data.
Q What is your reported TVR after CTO success?
A. One year TVR of successful CTOs is about 6-8% at Mount Sinai Hospital; which in large part be attributed to liberal use of EES.
Q What contributes more to CTO success - the Guideliner or Corsair, or both?
A. Both Guideliner and Corsair have improved our CTO success but actually it is the CTO wires which have escalated our success over 90% now compared to in 70% range 6-7 years ago.
Q What is the most promising device you are looking forward to for further improving CTO success?
A. Still further improvement in the dedicated CTO guidewires has promise to improve the success rates of CTO further.

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