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.

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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.

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