Experts "Live" CTO Workshop 2014 26th Septemper 2014 in Madrid, Spain

1. • P.R., 58 y, F
• Previous Medical History: Hypercholesterolaemia, Hypertension, Family history
of CAD, One year before pt developed CCS Class 2 Angina: angiography showed
SVD with previous failed attempt of recanalisation (anterograde and retrograde)
• Medication: Bisoprolol 10 mg od, Isosorbide Mononitrate 60 mg od, Nicorandil 30
mg bd, Lansoprazole 30 mg od, Lisinopril 5 mg od, Aspirin 75 mg od, statin
intolerance
• ECG: SR 68 bpm with normal tracing
• Blood test: Hb 131 g/L, PLT 214 10^9/L, INR 0.9, Creatinine 65 mmol/L, GFR 81
mL/min, Cholesterol 5.5 mmol/l
• Echocardiogram: LV normal size, hypokinetic inferoposterior wall. EF 55%
Carlo Di Mario, Roberta Serdoz
Royal Brompton Hospital
Imperial College London, UK
Branch Occlusion in CTO Recanalisation

2. No Stump, 5 cm long Occlusion ending in Bifurcation,Werner 1 Septal C
Previous Unsuccessful attempt anterograde and retrograde (distal vessel not rea
Bifemoral approach with 45 cm femoral sheats 7 Fr EBU 4.0 8 Fr JR 4.0

3. Confianza 12 was used to penetrate the
proximal cap
Further progress with a Gaia Second wire
supported by a Corsair 135 cm.
ANTEROGRADE APPROACH
Multiple wires did not enter the distal cap

4. Sion wire reached the occlusion distal
cap; Corsair skrewed trough the
collateral branch
RETROGRADE WIRING (fourth collateral attempted)
Tip injection

5. ANTEROGRADE CROSSING: NO REVERSE CART NEEDED
Ultimate wire enters the 3rd segment of the
RCA. Retrograde Corsair withdrawn to start
reverse CART but the anterograde Ultimate
easily enters the PDA with intraluminal
position confirmed by tip injection and soft
wire insertion
Resolute Integrity 3.0/38 mm positioned
with retrograde injection

6. DES Implantation in mid RCA
Result after stent ………
NC Sprinter 2.0/25 mm

7. Dissection in PDA
Resolute Integrity 2.25/30 mm
in position

8. The Ultimate wire supported by a
Corsair that entered the dissected
PL branch; wire is exchanged for a
Fielder XT wire that reaches the
distal vessel under retrograde
injection forming a small loop
PL branch wiring
Tip injection confirms the intraluminal
position of the Corsair

9. Resolute Integrity 2.25/26
mm in PL branch
Kissing Balloon with Stent
Delivery Balloon & 3.0/12
mm in main vessel
DES implantation in PL branch

10. Final result with wires in
place
Kissing Balloon with 1.5 /15
& 2.0/25 mm
Second wire into another terminal branch of PL

11. Final Result

12. Conclusion
• The reconstitution of the distal RCA at the crux
is one of the most difficult targets for
anterograde recanalisation
• Retrograde approach is favoured when feasible
but does not ensure salvage of both branches
• Creative solutions involving subintimal wiring
can be preferrable to the persistance of
occlusion of part of the original target vessel
Branch Occlusion in CTO Recanalisation