CTO PCI failure – When to try again?
Bernward Lauer, Jena, Germany
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
1. Klinik für Innere Medizin I / Kardiologie
CTO PCI failure - when to try again
11th Experts Live CTO
13. - 14.09.2019
Prof. Dr. Bernward Lauer
Ltd. Oberarzt der Klinik für Innere Medizin I
Universitätsklinikum Jena
2. CTO PCI Failure
Antegrade: ca. 30 - 40 %
Retrograde: ca. 10 - 20 %
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
Retry ?
3. When to retry after CTO PCI Failure
• Retry: yes or no ?
• At what time ?
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4. Retry yes or no ?
If the indication for CTO - PCI is correct, the patient has the
right to receive optimal treatment with maximal commitment
and dedication from the treating physician
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
5. Retry yes or no ?
If the indication for CTO - PCI is correct, the patient has the
right to receive optimal treatment with maximal commitment
and dedication from the treating physician
Correct indication
• ischemic symptoms under OMT
• > 10 % ischemic myocardium
• complete revascularisation to achieve residual Syntax - Score
< 8
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CTO PCI FAILURE
6. Retry yes or no ?
If the indication for CTO - PCI is correct, the patient has the
right to receive optimal treatment with maximal commitment
an dedication from the treating physician
„Yes“ is the default answer
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
7. Retry yes or no ?
If the indication for CTO - PCI is correct, the patient has the
right to receive optimal treatment with maximal commitment
an dedication from the treating physician
„Yes“ is the default answer,
except when not
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8. Are there other therapeutic option ?
CTO PCI Failure EuroCTO - Meeting Berlin 2019
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9. Are there other therapeutic option ?
CTO PCI Failure EuroCTO - Meeting Berlin 2019
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72 y, male, atypical chest pain since 1 year, stress-induced
myocardial ischemia anterior, no scar
ECG: sinus rhythm, HR 58/min, normal QRS
Echo: normal LV - function (EF >65%)
10. Are there other therapeutic option ?
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LAD CTO
11. Are there other therapeutic option ?
CTO PCI Failure EuroCTO - Meeting Berlin 2019
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LAD CTO, collaterals from the RCA
Course of LAD not clear
Still unclear after CT scan
12. Are there other therapeutic option ?
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
13. Are there other therapeutic option ?
CTO PCI Failure EuroCTO - Meeting Berlin 2019
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Unable to cross CTO antegrade or retrograde via RD I
14. Are there other therapeutic option ?
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Unable to cross CTO antegrade or retrograde via LAD
15. Are there other therapeutic option ?
CABG
MIDCAB LIMA -> LAD + RD
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16. Are there other therapeutic option ?
No !
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17. What was the reason for CTO PCI failure ?
• Long procedure
• Operator and/or patient is tired/exhausted after several
hours
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
18. What was the reason for CTO PCI failure ?
• Long procedure
• Operator and/or patient is tired/exhausted after several
hours
• High volume of contrast medium
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CTO PCI FAILURE
19. What was the reason for CTO PCI failure ?
• Long procedure
• Operator and/or patient is tired/exhausted after several
hours
• High volume of contrast medium
• Complications/problems
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
20. What was the reason for CTO PCI failure ?
• Long procedure
• Operator and/or patient is tired/exhausted after several
hours
• High volume of contrast medium
• Complications/problems
• perforation, dissection (unintended), hemodynamic
instability
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
21. What was the reason for CTO PCI failure ?
• Long procedure
• Operator and/or patient is tired/exhausted after several
hours
• High volume of contrast medium
• Complications/problems
• perforation, dissection (unintended), hemodynamic
instability
• Operator/equipment has reached his (technical) limits
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
22. What was the reason for CTO PCI failure ?
• Long procedure
• Operator and/or patient is tired/exhausted after several
hours
• High volume of contrast medium
• Complications/problems
• perforation, dissection (unintended), hemodynamic
instability
• Operator/equipment has reached his (technical) limits
• equipment limited in stock
• no further idea how to proceed
• no retrograde experience
• etc.
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
23. What was the reason for CTO PCI failure ?
• Long procedure
• Operator and/or patient is tired/exhausted after several
hours
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CTO PCI FAILURE
• Give doctor and patient a rest and a good sleep
• Try to imagine other intervention strategies
• Other wires
• Other guiding catheters (more back-up)
• Other vascular access (femoral ?)
• Additional material (GC extensions)
2nd attempt in a few days
24. What was the reason for CTO PCI failure ?
• Long procedure
• Operator and/or patient is tired/exhausted after several
hours
• High volume of contrast medium
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CTO PCI FAILURE
• Good hydration
• Give kidney a rest
2nd attempt, when creatinine has reached the
initial values
25. What was the reason for CTO PCI failure ?
• Complications/problems
• perforation, dissection (unintended), hemodynamic
instability
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CTO PCI FAILURE
• Perforation: reverse anticoagulation; check for PE, echo,
2nd attempt after few weeks
26. What was the reason for CTO PCI failure ?
• Complications/problems
• perforation, dissection (unintended), hemodynamic
instability
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
• Perforation: reverse anticoagulation; check for PE, echo,
2nd attempt after few weeks
• Dissection: let edema/hematoma resolve
2nd attempt after few weeks
27. What was the reason for CTO PCI failure ?
• Complications/problems
• perforation, dissection (unintended), hemodynamic
instability
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
• Perforation: reverse anticoagulation; check for PE, echo,
2nd attempt after few weeks
• Dissection: let edema/hematoma resolve
2nd attempt after few weeks
• Hemodynamic instability: intensiv care, rethink
risk/benefit-ratio
2nd attemp probably after a few days
28. What was the reason for CTO PCI failure ?
• Operator/equipment has reached his (technical) limits
• equipment limited in stock
• no further idea how to proceed
• no advanced (e.g. retrograde) experience
• etc.
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CTO PCI FAILURE
• Extend your equipment
29. What was the reason for CTO PCI failure ?
• Operator/equipment has reached his (technical) limits
• equipment limited in stock
• no further idea how to proceed
• no advanced (e.g. retrograde) experience
• etc.
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
• Extend your equipment
• Talk with colleagues (e.g. EuroCTO - club members)
30. What was the reason for CTO PCI failure ?
• Operator/equipment has reached his (technical) limits
• equipment limited in stock
• no further idea how to proceed
• no advanced (e.g. retrograde) experience
• etc.
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
• Extend your equipment
• Talk with colleagues (e.g. EuroCTO - club members)
• Send patient to Experts (some of them you find here)
31. What was the reason for CTO PCI failure ?
• Operator/equipment has reached his (technical) limits
• equipment limited in stock
• no further idea how to proceed
• no advanced (e.g. retrograde) experience
• etc.
CTO PCI Failure EuroCTO - Meeting Berlin 2019
CTO PCI FAILURE
• Extend your equipment
• Talk with colleagues (e.g. EuroCTO - club members)
• Send patient to Experts (some of them you find here)
• Take part in CTO courses
32. Why are we doing all this ?
CTO PCI Failure EuroCTO - Meeting Berlin 2019