1. 11. Deutscher Allergiekongress 2016 in Berlin
Back and forth
Pierfrancesco Agostoni MD PhD
Giovanni Vescovo MD
HartCentrum
Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim
Antwerp, Belgium
2. 11. Deutscher Allergiekongress 2016 in Berlin
• 80 y.o. gentleman
• CV Risk Factors: hypertension, hypercolesterolemia
Co-morbidities: peripheral vascular disease, COPD
• 1999: CABG (SVG-LAD and jump SVG-RCA-PLCx)
• April 2020: unstable angina and dyspnea: PCI LAD via the SVG. Also
occlusion of CX and RCA and occlusion of the SVG to RCA, bridge from
RCA to PLCx still open. RCA and CX potentially ischemic.
• After PCI LAD, remaining symptoms (dyspnea and angor).
SPECT: inferolateral ischemia. EF: 62%
• Given symptoms and proven ischemia a CTO-recanalization of CX was
planned (scores: J- CTO 4; PROSPECT 3; CASTLE 4; RECHARGE 5)
3. 11. Deutscher Allergiekongress 2016 in Berlin
Baseline Angiogram
CTO mid-Cx – J-CTO 4
Ipsilateral epicardial collaterals OM-PL
4. 11. Deutscher Allergiekongress 2016 in Berlin
Baseline Angiogram
Contralateral epicardial
collaterals from SVG-LAD
RCA occlusion
SVG
occlusion
5. 11. Deutscher Allergiekongress 2016 in Berlin
“Minimalistic hybrid algorithm“* approach:
Direct retrograde approach via ipsilateral epicardial collaterals
Passage of BMW and TurnpikeLP
through ipsilateral collaterals
Set up: single right radial 7F XB4 guiding catheter
Judo 6 guidewire to cross the lesion
Subintimal space achieved (gentle ‘Carlino’)
Reentry in the true lumen with Miracle 12
BMW
wire
Turnpike LP tip
Judo6
wire
Miracle12
wire
*Agostoni, Cathet Cardiovasc Interv, in press
*Zivelonghi, Int J Cardiol, 2019
*Zivelonghi, Cathet Cardiovasc Interv, 2020
6. 11. Deutscher Allergiekongress 2016 in Berlin
Intra-guiding ‘tip-in’
Intra guiding ‘tip-in’ with retrograde
Miracle12 guidewire in antegrade
Supercross microcatheter
Retrograde wiring of the
guiding catheter
Miracle12
wire
TurnpikeLP tip
Supercross tip
7. 11. Deutscher Allergiekongress 2016 in Berlin
From retro to ante
Simultaneous retrograde retrieval of
TurnpikeLP and antegrade advancement
of Supercross over Miracle 12 wire
Then after CTO passage with Supercross,
retrograde Miracle12 retrieval and
antegrade workhorse wire advancement
8. 11. Deutscher Allergiekongress 2016 in Berlin
Predilatation and stenting
After extensive predilatation, 2 DES from ostial LM to distal Cx were implanted
However, the procedure was complicated by the occlusion of the large OM
After predil After 2 DES
OM occlusion
9. 11. Deutscher Allergiekongress 2016 in Berlin
After unsuccesful antegrade attempt to recross the OM with Miracle 12 (guidewire in
sub-intimal space), new ‘reverse’ retrograde approach via ipsilateral collaterals from
PL to OM: Suoh03 guidewire to cross ipsilateral collaterals, TurnpikeLP microcather
up to the occluded OM, then reentry with Gaia3rd. Then again intra-guiding tip-in
Miracle12 subintimal
Suoh03
Turnpike LP tip
Turnpike LP tip
Gaia3
‘Reverse’ retrograde crossing of ipsilateral collaterals
Jailed
wire
10. 11. Deutscher Allergiekongress 2016 in Berlin
Further treatment of the bifurcation
Antegrade Supercross
over retrograde wire
through stent struts
POBA of OM branch
through stent struts
Final kissing balloon
Wire in distal CX
Supercross advancing
11. 11. Deutscher Allergiekongress 2016 in Berlin
Final result
After CX reopening, the RCA was also
reperfused through the patent part of
the SVG graft between PLCx and RCA
Procedure time: 130 min
Fluoro time: 61 min
Contrast: 350 ml
Air Kerma: 1388 mGy
Wires: 8
Microcatheters: 2
Balloons: 3
Stents: 2
12. 11. Deutscher Allergiekongress 2016 in Berlin
Final result
After CX reopening, the RCA was also
reperfused through the patent part of
the SVG graft between PLCx and RCA
Procedure time: 130 min
Fluoro time: 61 min
Contrast: 350 ml
Air Kerma: 1388 mGy
Wires: 8
Microcatheters: 2
Balloons: 3
Stents: 2
