Staged PCI of RCA CTO using Antegrade/Retrograde Approach – November 2022

37-year-old male male presented with severe CCS Class IV angina. A Cardiac Cath done @ OSH on October 4, 2022 revealed 3 V CAD: 100% distal RCA with extensive collaterals from LAD, 80% mid LAD, 90% LCx-OM1, 100% distal LCx with SYNTAX Score of 33 and normal LV function. In view of extensive CAD, CABG was recommended, but patient declined due to young age. Patient underwent successful PCI of mid LAD, LCx-OM1 and distal LCx using 3 x Promus Elite DES. Patient continued to have Class II angina, but has limited activity since PCI. Patient is now planned for staged PCI of distal RCA CTO using antegrade approach and if fails, then retrograde approach.


Q Over the next few decades, this patient could end up with 10 stents easily?
A. That is correct that many young pts with MV CAD (like our young Pt) may require multiple PCIs with stents in their lifetime. I am of opinion that repeat PCI for new lesions or ISR is ok as long pt does not develop stent thrombosis or MI at the time of repeat presentation.
Q What aggressive lifestyle management would you advocate for him?
A. Two pints; 1) to avoid having new lesions in native vessels, aggressive life style modifications and control of CAD risk factors are very important. These have shown to have very positive impact on future CAD progression; 2) For prevention of ISR, there is not much role of life style modification except control of diabetes in diabetic pts. In my opinion procedural factors of stent optimization are of paramount importance in preventing future ISR.
Q Any new modality on the horizon for such patients?
A. Theoretical prospects of bringing LDL to less then 50mg/dL by monthly injection of PCSK-9 inhibitors or 6 monthly injection of Inclisiran, may avert future new CAD lesions (although not much role in reducing ISR).
Q Would there be circumstances where you would consider surgery for this patient?
A. Actually, this pt with extensive MV CAD is appropriate for surgical total arterial revascularization by an expert CT surgeon. This pt had surgical consultation, but decided staged MV PCI with percutaneous revascularization as the initial approach; which is also appropriate giving his young age.
Q What is your overall rate for the retrograde approach?
A. Of the CTO PCIs at Sinai, retrograde approach is used in about 5% of cases; usually after failure of 2-3 attempts of antegrade recanalization.
Q Have you had several cases where the first choice was the retrograde approach?
A. Rare cases where retrograde approach is the first choice; ostial occlusion of RCA or LAD without any visible stump. This happens in 1 of 100 CTO cases.
Q Is your wire escalation strategy for CTO exactly as in the CTO App?
A. That is correct that our routine daily CTO wire escalation strategy is what has been depicted in GuidewireAID for CTO recanalization.
Q Can one expect updates about those wires?
A. GuidewireAID app will be updated after one year as we are currently updating our CalcificAID-2 and OCTAID-2 apps.
Q Regarding MedStream 360, how do we register?
A. MedStream 360 will have simple free registration process by inputting few key demographics. This MedStream registration website will be functional soon.
Q Will ccclivecases continue after MedStream360?
A. Yes CCClivecases being the parent entity, will continue even after start of MedStream 360 and will complement our educational mission to the new heights.


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