Complex coronary cases
PCI of CTO RCA using Antegrade/Retrograde Approach – Nov 2012
Views 973

Case: 43‐year-old male presented on 9/22/12 with NSTEMI and cath revealed 2V CAD and normal LV function (SYNTAX score 26). Patient underwent culprit vessel PCI of 95% LAD/diagonal bifurcation lesion using zotarolimus-eluting stent of LAD and CB PTCA of diagonal. Patient continues to have class II angina and a follow‐up stress MPI revealed moderate inferolateral ischemia. Patient is now scheduled for PCI of chronic total occlusion (CTO) of RCA using antegrade/retrograde approach.

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Q&A
Q
Do you use Reopro in addition to Angiomax in this case? What is the anticoagulant of your Choice and goal ACT?
A.

In selected high risk PCI cases (approx. 15%), one like this, we will use GP IIb/IIIa inhibitor bolus (2 boluses for Integrilin and one bolus for ReoPro). This approach is consistent with the various trials of Angiomax where GP inhibitors were used as bailout in 4-8% of cases (Replace 2, Acuity and Horizons AMI). Integrilin is used in most cases and ReoPro is reserved for STEMI cases. Angiomax is used in all. We use GP IIb/IIIa inhibitors as the planned agent rather than the bailout use. Cases we will use GP IIb/IIIa inhibitor will be pts with LVEF <30%, bifurcation ULM requiring Rotablator, multiple side branch PCIs and ADP receptor blockers loading on the table in these cases. ACT is always confirmed to be >300sec before the start of PCI even with Angiomax. In the past when using heparin and GP IIb/IIIa inhibitors, ACT was kept between 225-250 sec as per ESPIRIT trial.


Q
Do you recommend us to use IABP during PCI?
A.

Yes IABP should be used in ULM cases which requires tremendous manipulation of devices (like Rota and 2 stent approach) and LVEF is 30-50%. In pts with LVEF <30%, we will recommend use of Impella device for these cases to get optimal PCI results.


Q
Could you have considered T Stenting approaching the Cx 1st? Using this technique, is there a recommended angulation between the LM and LCX for this to be effective or any chance of failure?Can we use run through wire in both LAD and Circ in this case ? Can we draw the RunThrough wire jailed by stent?
A.

As I showed in my square grid of preferred stent approach in ULM bifurcation, 2 stents with SKS technique is commonly used in large size bifurcations involving both branches and angulations. Yes other techniques such as T Stenting and Crush stenting can also be used. Also we do jail all kinds of wires (RunThrough or Fileder) and then can be safely removed as long as wire is not bent or stuck in a small distal branch.


Q
Which unprotected LMCA will even you not do?
A.

ULM cases with high Syntax scores should preferably referred for CABG and we should not offer PCI as the first line approach. If pts refuses CABG then PCI can be done in any ULM case. Only situation, I will not perform ULM PCI, will be where there is no femoral access for LV assist device use (IABP or Impella) and LVEF is <30%.


Q
Are you routinely following the EuroSCORE, in addition to the SYNTAX? Do you then employ the Global Risk Classification? Or, do you feel it is an overkill to do so in most cases?
A.

Presently we do not calculate EuroScore or STS score for Global risk calculation. Soon (as of May 2012) we will start calculating both these scores as per the ACC guidelines as Class I recommendation to calculate these scores in pts with complex CAD and so that we can have the optimal Heart Team discussion. Hence I believe, we need to go beyond calculating Syntax score in pts with complex CAD as we are presently doing for TAVI/TAVR cases.


Q
Congratulations for the NY State rankings. What do you attribute largely to your success?
A.

Universal adoption of evidence based protocols and always availability of a senior expert interventionalists until cath lab finishes every day are the 2 key factors in getting excellent outcomes year after year.


Q
Does an active training program with its deep requirement of training fellows make your task easier or harder?
A.

Interventional fellows are the backbone of our program and yes it requires training new fellows every year but make our task easier. Hence we will continue to train 8-9 fellows every year.


Q
What lessons can you give to institutions struggling with quality statistics?
A.

Adoption of system based protocol and critical analysis of owns outcome, has shown to improve quality.


Q
Has the heart team contributed in a major way in your progress?
A.

Yes. Heart team allows unbiased decision to be made in overall well-being of the patient. But I donot think that Heart team has anything to do with the great outcomes; as we have been having great outcomes for 15 years while Heart Team concept has just came in vogue for last 2-3 years.


Q
Do you feel guideliner and Corsair are essentials in CTO cases.
A.

Yes both are essential to get successful outcomes of CTO; especially Corsair.


Q
Any other tool that may qualify as a game changer?
A.

Confianza family of guidewires have certainly increased our success of CTO recanalization. Also wide spread teaching and adoption of various retrograde approaches, could be considered the game changer in the field of CTO recanalization.


Q
As a general rule, how many successful antegrade CTO must one have prior to a retrograde CTO procedure?
A.

My recommendation will be to have atleast 100 successful antegrade CTOs before attempting retrograde CTOs; some experts believe it should even be 200.


Q
What are your tips in evaluating angiograms prior to CTO attempt?
A.

Most important factor I consider is that ‘is there a stump to engage the guidewire’ and secondly the length of CTO (as judged by the retrograde collaterals)


Q
Multi scan CT or IVUS useful?
A.

In the literature, multiscan CT as well IVUS helped to increase the success of CTO recanalization. But at our center, we donot use either of these technology while performing CTO recanalization.


Q
When would you consider trans radial CTO - it does add complexity and more radiation?
A.

In my opinion Trans-radial Intervention for CTO procedures, add further to the complexity by poor guide support, increase radiation and usual limitation of not able to use >6Fr sheath in the majority. Also retrograde technique can’t be freely used due to inability to exteriorize the guide wire via contralateral approach.


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