CTO in post CABG patients Heinz Joachim Büttner, Germany The Experts “Live” Workshop 2017 Saturday, September 16th, 2017

1. CTO in post CABG patients
- Occluded vein grafts as retrograde guidewire conduits -
Achim Büttner
EUROCTOCLUB Berlin, September 15th – 16th, 2017
Germany

2. Prevalence of CTO in PCI patients
Fefer P et al, (Canadian PCI Registry) JACC 2012;59:991-7
18%
54%
No CABG Previous CABG

3. Mortality benefit of recanalisation success
also for post-CABG patients
Toma A et al. Am J Cardiol. 2016 Dec 1;118(11):1641-1646
Cumulative all-cause mortality until 3 years
Post-CABG failure
Non-CABG failure
Post-CABG success
Non-CABG success

4. CTOs late post CABG: Patients and lesions characteristics
P<0.001 P<0.001
(n=1710) (n=292)
65
19%
30%
18%
68
37%
15%
43%
Age (years) Angina CCS 3+4 LAD CTO Calcium °3
No CABG Previous CABG
P<0.001 P<0.001
Toma A et al. Am J Cardiol. 2016 Dec 1;118(11):1641-1646

5. Davies MJ, Altlas of Coronary Artery Disease 1998
Degeneration of vein grafts
7 – 10 years: Occlusion
Months: Intimal hyperplasia
1 – 7 years: Atherosclerosis + thrombus

6. Case #1: CTO of RCA 22 years post CABG

7. LIMA to LAD

8. SVG to RCA

9. Failure from antegrade
Parralel wires get stuck

10. Passage of SVG
- Wire Ulimate 3g
- Corsair Microcatheter

11. Retrograde wire
Fielder XTR

12. From retrograde
no entry !
ConfianzaPro12

13. Knuckle with
ConfianzaPro12

14. Reverse CART
2.5mm Balloon
Ultimate (Ø)
Pilot 200 (!)

15. Strategy
Externalization ?
Tip-in ?

16. „Tip-in“ manoeuver in guiding catheter
Antegrade Wire
Meeting point in outer curve
Retrograde Corsair
in antegrade guide

17. Antegrade
BHW Extra Support
Finecross

21. Final LAO

22. CTO of LCX: Modified CART via occluded SVG
Antegrade wire
subintimal
RAO caudal
Balloon dilatation over
„SVG-wire“ at anastomosis

23. #232648
Simultaneous injection in LCA and SVG on Diag
RAO caudal
Case #2: CTO of LCX 19 years post CABG

33. Retrograde passage of CTO
via SVG and externalisation (RG3)
A similar case (#3): CTO of LCX 22 years post CABG

41. Case #4 (live 03/2017): CTO of RCA 25 yrs. post CABG

42. Unfavourable collaterals

43. Antegrade wires fail

44. Ultimate Bros 3g / Corsair in SVG

45. Atypical course of SVG: Contrast injection

46. Corsair gets stuck at distal anastomosis

49. Rotablation 1.25 mm burr

50. After balloon dilatation

51. After stent implantation

52. Case #5: CTO of LCX 16 yrs. post CABG

58. LAO caudal

60. After stent implantation

61. • Unfavourable collaterals → SVG useful retrograde guidewire conduit
• Course of SVG is often unpredictable
• Good first choice: Non-tapered intermediate stiff wire (Ultimate 3g)
• Distal anastomosis is usually patent (superselective injection)
• Through an SVG all retrograde techniques are applicable:
including CART (in CTO body)
or modified CART (at distal anastomosis)
• Safe: No touch of healthy vasculature
Conclusions