Staged PCI of Diffuse Totally Occluded LAD CTO using Antegrade/Retrograde Technique – May 2022

Case and Plan:

68-year-old male presented with known 3V CAD (refused CABG in the past as developed CVA post Cath), severe CCS Class III angina and positive SPECT MPI. A Cardiac Cath on May 10, 2022 revealed 3 V CAD and 50% distal LM: 80% prox LAD with long diffuse CTO mid LAD and distal vessel fills via antegrade bridge and retrograde RCA collaterals (J-CTO Score 3), 80% mid RCA, 70% LPL with SYNTAX Score of 33 and LVEF = 40%. Patient underwent successful intervention of mid RCA using Promus Elite DES. Patient is now planned for staged PCI of LAD CTO using antegrade/retrograde recanilzation and IVUS interrogation of moderate LM lesion.


Q Would this case be done with as much ease with wrist access?
A. We needed 2 vascular accesses for this pt for CTO LAD PCI and used both femoral accesses. Alternatively, could use left radial access for contralateral injection and femoral for antegrade recanalization. Few operators will use bilateral radial accesses for CTOs; that number is 10-15% as per the CTO registry data, we presented few years ago.
Q Radiation dose would probably be higher with wrist access?
A. Yes most studies have shown higher radiation exposure in radial approach vs femoral approach.
Q Would the contrast agent volume be similar?
A. Most of the studies have shown either similar or slightly lower contrast use in radial access vs femoral access.
Q Is Fielder and Finecross your preferred beginning strategy for most antegrade approaches?
A. Yes Fielder wire with Finecross is our initial strategy in over 80% of CTO cases.
Q How often do you end up wiring the LCX in cases where you stent across the LAD?
A. If there is no ostial LCx lesion, then we usually do not wire the LCx in LM-LAD crossover stenting.
Q When using bifurcating stenting of distal LMCA, always POT?
A. Yes we strongly recommend and do POT technique in all LM stentings (1 or 2 stents) crossing the the bifurcations. It is essential due to disparate sizes of LM and distal branches of LAD or LCX and hence POT will result in optimal LM stent expansion and apposition.
Q What is your preferred wire for proximal cap penetration?
A. My preferred wire for CTO proximal cap penetration is Gaia 3 follower by Confinza 9-12.
Q For septal surfing?
A. We have now started using SUOH and Sion Blue wires septal surfing. Fielder XT-A used to be common wire in the past for septal surfing.
Q For what lesion or clinical subsets could a polymer-free stents such as EVO be useful?
A. Actually many other studies like ISAR-Test along with latest Sugar trial have shown either equivalent or even slightly better outcome with polymer free drug coated stents vs polymer coated DES; similar TLR and ST upto 810yrs followup. Hence EVO stent can be used in all PCIs especially in Pt's with Diabetes.
Q Besides hydration, what are your other approaches for preventing AKI with contrast agents?
A. Most important additional approach to reduce CA-AKi is to limit the contrast use by avoiding unnecessary fluoro tests shots and use Imaging for stent optimization. High dose statins prePCI has also shine to reduce CA-AKI which we also use routinely.


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