Complex coronary cases
PCI of CTO RCA via Antegrade/Retrograde Approach – Nov 2013

73-year-old male presented on Oct 21, 2013 with new onset Class II angina and large inferolateral and mild lateral wall ischemia. Cardiac Cath revealed 3V CAD (90% moderate size D1, 100% small OM2 and 100% large proximal RCA, fills via LAD and LCx collaterals) and LVEF 60%; SYNTAX score 21. Patient underwent DES of D1 with excellent results. Patient continued to have Class II angina on maximal medical therapy. Now planned for PCI of CTO RCA via antegrade and/or retrograde approach.

1:34:13

Q&A
Q
What are your major efficient, short cuts for retrograde CTO?
A.

Using balloon trap technique to advance the Corsair, then bring the Finecross antegradely (kiss technique) and then remove the retrograde wire without shearing the vessel intima are the efficient, short, simple and minimally traumatic techniques we have adopted (and teaching) for retrograde recanakuzation.


Q
What factors contributed to the splendid success of your CTO case?
A.

Timely decision to switch to retrograde technique, when realizing that multiple antegrade wire passage attempts were subintimal, led to the excellent success of our CTO case.


Q
Which is the single factor that you feel contributes to CTO failure?
A.

Heavy calcification in my opinion at present has the highest OR of CTO failure in this current era of antegrade & retrograde recanalization


Q
Rather than abandon and bring patient back for a re-do attempt after failed antegrade procedure, what factors compel you to attempt retrograde technique during same procedure?
A.

In this particular case we even discussed before the procedure that should we start this case as retrograde technique rather than antegrade, led us to rapidly switch to retrograde approach and continue the procedure (rather than abandoning and staging). In regular cases also, if decision is made early in the procedure to switch to retrograde from antegrade, it will be advisable.


Q
Is choice of most appropriate septal the most critical component of retrograde success?
A.

Yes choice of the septal channel (size, course and angulation) is one of the most critical component of retrograde success.


Q
The LAD apical portion seems to have continuity with PDA ? Is this option for retrograde?
A.

Yes in this case, apical LAD had a large epicardial collateral to RPDA, but are not usually conducive to retrograde recanalization because very tortuous quigley course, prone for rupture.


Q
Corsair removal ? Clockwise
A.

Corsair is advanced clockwise and removed counterclockwise. Make sure to disengage the guide during Corsair removal, as frequently it sucks the guide in.


Q
IVUS can streamline the retrograde tracking or not? And do you use IVUS in these cases often?
A.

IVUS may have some use for antegrade wiring to find the true lumen, but is of very limited value for retrograde recanalization. We rarely use IVUS to guide CTO recanalization in our lab.


Q
The Guide support seems to be unfavorable in left main. Would 7F with guideliner preloaded on Corsair be possible?
A.

In this particular case Guideliner could have been useful if we could not advanced the Corsair retrogradely into the early part of septal. But that was not the case as difficulty was in advancing Corsair across the last bend of the septal channel. Leaving Corsair at the angle and then let it slowly be advanced with the cardiac cycle, worked well.


Q
Any usefulness of using 2 wires in this antegrade approach?
A.

Yes using the parallel wire antegradely could be useful in some cases of antegrade recanalization.


comments

Leave a Reply

Your email address will not be published. Required fields are marked *


By submitting this form, you are consenting to receive marketing emails from: Mount Sinai Hospital, One Gustave L. Levy Place, Box, New York, NY, 10029, https://ccclivecases.org. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

suggestion
Suggestions
Complex prox RCA CTO Recanalization via Retrograde Approach – February 2021
Views 204

56-year-old male presented with Class III unstable angina and positive stress MPI for significant inferior ischemia. A Cardiac Cath on November 20, 2020 at outside hospital revealed 2 V VAD: 85% mid LAD, 70% D1 and CTO proximal RCA with distal vessel fills retrogradely via septal collaterals (J-CTO Score 3), LVEF = 50% and Syntax […]


High-Risk Complex PCI of Diffuse Multivessel CAD – January 2021
Views 502

  Case and Plan: 45-year-old male with multiple CAD risk factors presented to OSH on November 6, 2020 with unstable angina and positive ETT. A Cardiac Cath on November 9, 2020 revealed extensive 3V CAD: 100% mid LAD, 90% D2, 70% proximal LCx, 100% LCx-OM1, 100% mid RCA with LVEF = 60% and SYNTAX Score […]


Extremely Tortuous Angulated mid LAD Diagonal Bifurcation Lesion – December 2020
Views 664

Case and Plan: 75-year-old female presented with new onset CCS Class II angina and positive stress MPI on November 9, 2020 revealing moderate apical and inferior ischemia. A Cardiac Cath on November 24, 2020 revealed 2 V CAD: 95% proximal RCA, angulated tortuous 95% mid LAD bifurcation lesion, LVEF = 60% and SYNTAX Score = […]


Staged PCI of RCA multilayer DES CTO ISR using rotational atherectomy and IVBT – November 2020
Views 392

Case and Plan: 65-year old male with known long standing history of chronic ischemic heart disease requiring multiple PCI’s over the years after declining CABG, presented with CCS Class III angina and high risk stress MPI for multivessel ischemia. A Cardiac Cath on September 28, 2020 revealed 3 V CAD: 100% proximal RCA due to […]