PCI of mid RCA CTO via Antegrade Recanalization – May 2018
48 year old morbidly obese male with diabetes and ESRD on HD (pre-renal transplant), presented with CCS Class I angina and high risk stress MPI for moderate to severe lateral and inferior ischemia and EF of 50%. A Cardiac Cath on April 27, 2018 revealed 2V CAD: calcified long CTO of mid RCA, (J-CTO Score 4), 80% LCx-OM1, mild diffuse LAD/D1/D2 with LVEF of 55% and SYNTAX Score of 12. Patient underwent successful intervention of LCx-OM1 using Promus Premier DES. Now patient is planned for staged PCI of complex mid RCA CTO via antegrade recanalization and if fails, then retrograde recanalization technique.
QWhat are your preferred escalation guide wires for antegrade CTO approach?
A.We start with Gaia 3, then Miraclebro 6 and then go to Confianza 9 and then 12. We repeat the same sequence all the time.
QSame for retrograde approach?
A.For retrograde recanalization, it is usually softer wire of Fielder FC and rarely Gaia 2.
QAnd the preferred microcatheters?
A.Finecross is the workhorse microcatheter followed by Corsair.
QWhat is your success rate for first attempt with antegrade?
A.Over last 2-3 years, success of first attempt CTO recanalization is around 85-88%.
QAnd the success rate combined after second attempt?
A.The success after second attempt for CTO recanalization is 92-94%.
QAnd for the retrograde approach overall?
A.We do retrograde in 6-8% of our CTOs and success rate is about 80%.
QWhat should be some strategies for patients with JCTO score>2 to be automatically referred to specialized centers? Or this is too much to expect?
A.Actually these complex CTOs with high JCTO score are usually referred to specialists and special center (like Mount Sinai). That is what we get; of the 40 CTOs we do per month, about 20 are referred from other hospitals and Interventionalists.
QWhen will you absolutely decline a CTO?
A.There are 2 important reasons to decline the CTO PCI; 1) If not needed clinically and fits in Inappropriate of the ACC AUC category 2) If heavily calcified CTO with extensive bridge collaterals, as in these cases, likelihood of success is <50%.
QCan you speculate results of Decision CTO Trial with a third arm of CABG?
A.My guess will be that even CABG would have had similar 5 year outcome as MT or PCI in the Decision CTO.
QAre you planning CTO cases during your Annual Symposium?
A.Yes we plan 2-3 complex CTOs for the CCVVC symposium. All CTO recanalizations in the CCVVC will be tried antegrade first.