Experts "Live" CTO Workshop 2015 Septemper, 18th – 19th , 2014 in Istanbul, Turkey

1. 0
Recorded Case 1:
Antegrade approach for a long RCA CTO
Dr. Kambis Mashayekhi
Helios-Klinikum-Plauen

2. 1
Medical history:
• 71-year- old men with COPD II
• Current status: progression of dyspnea and angina (NYHA II/CCS II) and
persistent atrial fibrillation
• MRI shows a LVEF of 46%, hypokinesia and viability of the inferior wall
• Adenosine stress perfusion deficiency of the inferior wall
• Proximal occlusion of the right coronary artery with retrograde collaterals via
LAD
• Cardiovascular risk factors:
– Diabetes, arterial hypertension, hyperlipidemia, Ex-Smoker

3. 2
Left coronary system

4. 3
RCA-occlusion with an ipsilateral collateral

5. 4
Complexity:
x
x
x
x
2
x

6. 5
MRI - contractility

7. 6
Adenosin-Stress-MRT

8. 7
Antegrade approach for a long RCA CTO

9. 8
Choice of the guiding catheter size
5F 6F ≥7F
Standard:
1 wire + 1 MC/OTW
✔ ✔ ✔
Parallel-wire-Technik:
2 wires + 1 MC/OTW
✔ ✔ ✔
See-Saw-Technique ✔ ✔
Mother in Child ✔ ✔
Ancor-ballon+ 1 MC ✔ ✔
IVUS guidance ± ✔
Retrograde CART, reverse Cart,
Knuckle wire, usw....
✔ ✔

10. 9
Choice of the guiding catheter size
6F-Guide 8F-Guide
• A) Monorail-Balloon + Finecross
• B) 2xFinecross
• C) Monrail-Balloon + Valet Microkatheter(Volcano)
• D) Valet Microkatheter + Finecross
• A) Stingray + OTW-Balloon
• B) 2xCorsair + 1 Monorail-Balloon
• C) 2xCorsair + 1 IVUS
• D)1x Corsair + 1 Venture + 1 IVUS

11. 10
Choice of the guiding catheter size
5F 6F ≥7F
Standard:
1 wire + 1 MC/OTW
✔ ✔ ✔
Parallel-wire-Technik:
2 wires + 1 MC/OTW
✔ ✔ ✔
See-Saw-Technique ✔ ✔
Mother in Child ✔ ✔
Ancor-ballon+ 1 MC ✔ ✔
IVUS guidance ± ✔
Retrograde CART, reverse Cart,
Knuckle wire, usw....
✔ ✔
6F radial EBU 4,0
7F femoral AL1 SH

12. 11
What is the best strategy for this anatomy?
Antegrade:
Single Wire
Parallel Wire
IVUS controlled dissection reentry
Primary dissection reentry (Bridge point)
Retrograde:
Contrallateral or Ipsilateral case
Revers CART

13. 12
What is the best strategy for this anatomy?
Antegrade:
Single Wire
Parallel Wire
IVUS controlled dissection reentry
Primary dissection reentry (Bridge point)
Retrograde:
Contrallateral or Ipsilateral case
Revers CART

14. 13
First Angiogram

15. 14
CTO-Strategy: When to go retrograde?
Dual Injection
Antegrade CAP
Retrograde Landing
Zone
True
Lumen
Subtinitmal
Wire
Tapered Blunt
>3,0mm <3,0mm
J-CTO
<2,0 ≥2,0
Retrograde
Wire
Parallel
Wire
ADR
IVUS-ADR
Failure
Failure
1.
2.
3.

16. 15
CTO-Strategy: When to go retrograde?
Dual Injection
Antegrade CAP
Retrograde Landing
Zone
True
Lumen
Subtinitmal
Wire
Tapered Blunt
>3,0mm <3,0mm
J-CTO
<2,0 ≥2,0
Retrograde
Wire
Parallel
Wire
ADR
IVUS-ADR
Failure
Failure
1.
2.
3.
RETROGRADE STRATEGY
1. Direct Wiring
2. Antegrade Wiring (retrograde Marker Wire)
3. Contemporary Revers CART
4. IVUS controlled retrograde Wiring
5. IVUS controlled Revers CART

17. 16
Antegrade approach for a long RCA CTO

18. 17
Treatment strategy for this vessel
• 1) DES with stent landing zone distal of the
bifurcation in the PDA
• 2) DES with stent landing zone just in front of the
bifurcation
• 3) DES+DEB at the bifurcation side
• 4) Scaffolds
• 5) IVUS

19. 18
Antegrade approach for a long RCA CTO

20. 19
1 year follow-up

21. 20
Thank you!