Staged PCI of mid LAD CTO using Retrograde Approach – Sept 2013

56 year old male with multiple CAD risk factors and new onset exertional fatigue, underwent stress echo revealing fall in LVEF (50% from baseline of 59%) with multi segment hypocontractility. A Cardiac Cath on July 11th, 2013 revealed two vessel CAD (CTO of prox RCA and CTO of mid LAD) and minimal LV dysfunction. Patient underwent PCI of prox RCA CTO with Xience Xpedition DES and did well. Patient continued to have symptoms of exertional fatigue. Now for staged PCI of mid LAD CTO using antegrade approach.

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Q&A

Q How often are you using the guide extension, "mother and child" catheters?
A. In tortuous cases, mother and child catheters work very well. We use these catheters in about 10-12% of our PCI cases (40-50 cases per month).
Q How do you compare the Guidezilla and the Guideliner?
A. Guideliner we have been using for last many years and Guidezilla only recently. It seems that both are working very well.
Q In what situations should you not use these catheters?
A. In thrombotic lesions and coronary dissections, Guideliner should not be used.
Q What is the single biggest tip in using the Guideliner?
A. Bring the Guideliner to the tip of the guide catheter and then advance balloon/ stent thru it. Then further advance the Guideliner on these devices for further support.
Q Does 6 French suffice for these catheters?
A. Yes, that is what we use in 95% of cases.
Q Where would you use the epicardial approach in CTO? Should it be an absolute last resort?
A. Epicardial collateral approach should be the last resort as these collateral vessels have tendency to rupture.
Q Based upon the ACCOST trial, what changes are you proposing to make?
A. No change at all and just continue the way we were using Prasugrel; give it on the Cath table at the start of the PCI. It seems to be the best approach.
Q What are your present guidelines for using Prasugrel and Ticagrelor?
A. Prasugrel in STEMI and diabetic pts and Ticagrelor in NSTEMI and elderly pts with prior CVA.
Q Are you reducing dose of Prasugrel in certain subsets?
A. In majority of cases we use Prasugrel 5mg daily unless pt is over 100kg. Recent pharmacodynamic data have suggested that 5mg dose of Prasugrel will suffice in majority.
Q Is CTO expertise in the U.S. comparable to Japan?
A. I can now say for sure that CTO experience of many USA Interventionalists is comparable to Japanese experts.

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