PCI of CTO of RCA via Retrograde Approach using LAD Septal Collaterals – May 2015

66 year-old diabetic female with new onset CCS Class II angina and positive ETT and Cardiac Cath on March 26, 2015 revealed 2V CAD (80-90% prox & mid LAD and CTO prox RCA) and normal LV function with SYNTAX Score of 26. Heart team discussion took place and patient elected for PCI and underwent PCI of LAD (Xience Alpine x2) and did well. Now planned for PCI of CTO of RCA via retrograde approach using LAD septal collaterals.



Q In retrospect, ante grade route would have been the better decision?
A. We agree that antegrade approach should have been the better choice but we wanted to show the steps of retrograde approach of CTO recanalization.
Q What are some practical tips for using the Corsair?
A. After advancing the guide wire, Corsair is advanced by clockwise rotation for 12-14 turns and then counterclockwise and withdraw before advancing it again. Also hold the guide catheter while advancing the Corsair.
Q How does when recognize a CTO reentry - going sub intimal and then reentering the lumen? Is it angiography apparent or it is done by carefully monitoring the way the wire has tracked?
A. Antegrade or retrograde subintimal guidewire entry can only be recognized by the wire movement and course on angiography. Subintimal passage will give more resistance to wire advancement with lack of resistance when wire is free in the true lumen.
Q What is the real role for reentry devices and of the reentry techniques for CTO?
A. The re-entry devices and techniques although may increase the success of CTO, but causes extensive dissection and higher periprocedure enzyme elevation. Also one CTO registry reported very high restenosis and repeat CTO with antegrade dissection techniques. Hence at Sinai, we do not use planned antegrade re-entry devices such as CrossBoss or Stingray catheters.
Q Please describe the GAIA wire's unique attributes for CTO?
A. The GAIA wires are based on a special unique composite core technology with a microcone tip for focused entry and maneuverability into lesion. The wire tip deflects going subintimal and has the directional control. It is available in 1, 2 or 3 types with increasing tip load.
Q Can it be used interchangeably with the SION wire?
A. Yes GAIA wire performs better then SION wire and can be used interchangeably. GAIA wire in my opinion should be reserved for CTO crossings.
Q If a Corsair catheter is not available, should one not attempt a retrograde route for a CTO?
A. It has been shown that Corsair use has increased the success of retrograde recanalization by 20%, but other over-the-wire catheters can also be tried; that is what we used to do before the Corsair 3-4 years ago.
Q Have you had a perforation into the chamber cavity during a CTO? How did you handle it?
A. The LV cavity perforation (Type IIIC) are benign perforation and occurs infrequently and are managed conservatively. They should be left alone if does not close by simple balloon inflation for 5-10 minutes as it does not cause any hemodynamic compromise.


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