This document discusses the minimalist versus maximalist approaches to chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
The minimalist view is to treat the patient in one attempt using the most experienced operator for their lesion complexity. The maximalist view is to use all available tools and strategies to fully revascularize the patient.
The document outlines considerations for patient selection, procedural strategies like bilateral injection and maximum guide support, and tools like intravascular ultrasound (IVUS) and re-entry devices. It emphasizes that CTO PCI should always be planned and performed with a maximalist mindset to optimize outcomes.
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Max vs Min CTO Approach
1. Alexander Ghanem & David Leistner
Antegrade Approach – How to start?
Minimalists‘ versus Maximalists‘ Approaches
17. September 2017
2. Our aim and its Paradigmata
Minimalists‘ view Maximalists‘ view
“The patient is treated in one attempt by the most
experienced operator fitted to his lesion complexity.“
Patient
Patient
ProcedureProcedure
Outcome
G. Werner
5. Minimalists‘ Appropriateness List
adopted from Prof. G. Werner, Darmstadt
• Selection of the patient with normal LV-EF
– Symptoms, but „asymptomatic“ patients may be
adapted to their limitations by a CTO...
– Ischemic territory should be > 10%
6. Relationship between mortality and extent
of myocardial ischaemia, depending on therapy
Montalescot / Sechtem et al., Eur Heart J 2013;34:2949–3003.
Hachamovitch et al., Circulation 2003;107:2900–2907.
OMT / Revascularisation
7. adopted from Prof. G. Werner, Darmstadt
• Selection of the patient with normal LVF
– Symptoms, but „asymptomatic“ patients may be
adapted to their limitations by a CTO...
– Ischemic territory should be > 10%
• In patients with akinesia and ischemic CMP
– Presence of viability tested by MRI
– A grey zone of scar tissue extension remains
Minimalists‘ Appropriateness List
29. Guiding Backup
BEST OPTION FOR STRENGTHENING A GUIDE:
1. FIRST best maneuver- put the guide in power position or deep
seat the guide.
2. SECOND best maneuver – Add a second stiffer wire
3. THIRD best maneuver – change to a stronger guide
4. use the balloon anchoring technique
5. insert a smaller straight inside the current guide (mother &
child)
6. remove everything- change the short sheath to a longer one
53. Strategic Options
adopted from Prof. G. Werner, Darmstadt
The apparent length of the
occlusion is often shorter
than you think !
Bilateral Injection
Maximum Guide
Backup
Antegrade
Fielder XT/A/R or
Gaia 1 Gaia 2,
Confienza,
Progress
Penetration, then
step down
Antegrade
No stump
IVUS for guided
penetration?
Reentry-System
Crossboss /
Stingray
Distal good target
Parallel with stiff
wire
Retrograde
Feasible collateral
pathways