Case and Plan:
67-year-old male with new onset angina equivalent and positive SPECT MPI for multivessel ischemia. A Cardiac Cath on January 28, 2022 revealed 2 V CAD: CTO of distal RCA (distal vessel filling via bridge and retrograde collaterals), 80% calcified mid LAD with LVEF = 40% and SYNTAX Score of 26. Patient underwent successful PCI of mid LAD using RA and Promus Elite DES. Patient is now planned for staged PCI of RCA CTO via antegrade, if fails retrograde approach for continued symptoms and documented ischemia.
Q&A
Q
In looking back, could something have been done differently in this case?
A.
We could have done differently in this case that going to RAO view at the outset so that Corsair couldn’t have directed the Guidewire posteriorly. Also Finecross rather then Corsair should have been selected.
Q
Did LAD stent encroach on the diagonal branch make it difficult?
A.
Yes LAD stent extending into Diagonal and jailing the 3rd septal (key retrograde connection) made retrograde wiring and advancement of Corsair impossible.
Q
What are your dye and radiation limits for CTO?
A.
Dye volume of 5ml/kg, radiation dose of >7.5 Air Karma & fluoro time of 60 minutes are the common parameters where we usually stop the CTO procedure.
Q
When in a CTO intervention do you stop anticoagulation?
A.
Majority of CTO cases are done with heparin blouses to keep ACT around 250-275 sec. ACT is checked every 20 minutes. If perforation in noted, then no additional heparin is given. Rarely IV protamine is needed to reverse the heparin effect. If pt is on Bivalirudin, then we stop/interrupt the infusion when even minor perforation (wire tip or cloud around the CTO) is noted.
Q
100% CTO with unfractionated heparin?
A.
Yes about 80-90% CTO are done with unfractionated heparin and bivalirudin in remaining; usually when other nonCTO PCI is also being done at the same sitting.
Q
Any different DAPT preferences for CTO?
A.
Yes we try to avoid stronger P2Y12 inhibitors before CTO procedure is done; usually clopidogrel is loaded. Once successful, based on the case, we switch to Prasugrel or Ticagrelor in about half of the cases because of procedural complexity.
Q
Which is your best equipment for septal surfing?
A.
Long Corsair (150cm length) with Fielder XT-A or XT-R is our best initial strategy for septal surfing. Some cases we use Sion Black to navigate thru the tortuous septal collaterals.
Q
Why is it taking so long for FDA approval for DCB in the U.S.?
A.
Because of the concerns of higher long term mortality after peripheral DCB, FDA is very reluctant to approve the Coronary DCB trials. But finally 2 coronary DCB trials got the nod by FDA and are set to start in few months in USA.
Q
How do you compare Biolimus and Paclitaxil for DCB applications?
A.
Looks like all 3 DCB drugs (Paclitaxel, Sirolimus and now Biolimus drug) are equally effective with most extensive data on Paclitaxel coating.
Q
Which among your numerous apps do you find most beneficial?
A.
Bifurcaid and Bifurcaid3D apps are most frequently used and quoted by many Interventionslists in their discussion and presentations.
