14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany AGIK Parallel Session - Session 5: Essential tools for complication management Keynote: My essential tipps & tricks for success in complication management Kambis Mashayekhi, Lahr, Germany Room: West Foyer - Saturday 12:30 Chairmen: Dimitrios Karmpaliotis, Morristown, USA; Kambis Mashayekhi, Lahr, Germany; Andrea Gagnor, Turin, Italy

1. My essential tipps & tricks for
success in complication
management
Kambis Mashayekhi
Heart Center Lahr

2. Affiliation/Financial Relationship
• Consulting Fees/Honoraria
Company
• Abboth, Abiomed, Ashai Intecc, Astra
Zeneca, Biotronik, Boston, Cardinal
Health, Daiichi Sankyo, Medtronic,
Schockwave, SIS, Teleflex,Terumo,
Disclosures
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or
affiliation with the organization(s) listed below.

3. Patel S et al J Invasive Cardiol. 2018
Perforation, mortality, and tamponade are the
three most concerning complications in CTO PCI
Survey of 1,149 cardiologists on CTO PCI

4. Failed CTO cases have a higher
complication rate and higher mortality
3,9 3,6 3,4
4,2
10,3
9,8 10,2
8,6
0,1 0,3 0 0,1
1,5
0,5 0,4 0,2
0
2
4
6
8
10
12
2008-2009 2010-2011 2012-2013 2014-2015
Complication
rate
(%)
Any periprocedural complication, successful cases
Any periprocedural complication, failed cases
In hospital mortality, successful cases
In hospital mortality, failed cases
17,626 procedures enrolled in ERCTO (2008-2015)
Konstantinidis NV et al. ; Circ Cardiovasc Interv. 2018 Oct;11(10):

5. Update from the PROGRESS CTO Registry: 2018
Tajti P. et al, JACC Cardiovasc Interv. 2018
AWE: J-CTO 2.28 ADR: J-CTO 2.86 Retrograde: J-CTO 3.12

6. 4,3
2,1
0,4
1,3
0,6
0,8
1,1
0,3 0,3 0,3
0,1 0,1
0
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Complication
rate
(%)
Retrograde
Antegrade-only
PROspective Global REgiStry for the
Study of CTO interventions
MACCE in retrograde vs. antegrade-only CTO
Karmpaliotis et al. Circ Cardiovasc Interv 2016 Jun
n=539 J-CTO 3,1
n=762 J-CTO 2,5

7. Periprocedural ischaemia during CTO PCI:
Influence of the retrograde approach
Werner et al. Eurointervention 2014 Nov

8. Periprocedural Myocardial Injury in Patients Undergoing
CTO-PCI : Role of Antegrade and Retrograde Crossing
Techniques
Toma et al, EuroIntervention. 2018
antegrade; n=1447
19,4% PMI
retrograde; n=462
44,2% PMI
PMI (elevation of cardiac troponin T [cTnT] >5 x 99th percentile of normal)

9. Complications
Guiding
Catheter
associated
complications
Small vessel
perforations
Vessel
ruptures

10. What is wrong here?

11. GUIDING CATHETER ASSOCIATED AORTIC
INSUFFICIENCY

12. Ipsilateral collaterals in RCA-CTO
After changing the MC
from Supercross to Corsair
Dunning Dissection – Typ I
1) STOP antegrade contrast injection
2) Disconnect your contrast syringe
3) Fix the ostium with a stent

13. Dunning Dissection – Typ I

14. Dunning Dissection- Typ I

15. Iatrogenic Aortic Dissection
1) Wire over AL2 could not be advanced
2) No contrast
3) CHECK IVUS with PING PONG TECHNIQUE

16. Iatrogenic Aortic Dissection

17. Iatrogenic Aortic Dissection
1) STOP antegrade contrast injection
2) Use guideliner to protect the aorto-
coronary ostium if contrast is needed for
distal stenting
3) Fix the ostium with a stent (or even
covered stent)
4) Conservative and no surgical
treatment after fixing the problem!!!

18. Aortic dissection – Typ A

19. Aortic dissection
Promus 4,0/16mm
Promus 2x 3,0/38mm
Promus 3,5/28mm

20. Aortic dissection
Quantum Apex 4,5/20mm
After Begraft 4,0/16mm

21. Aortic dissection
1) STOP antegrade contrast injection
2) Use guideliner to protect the aorto-
coronary ostium if contrast is needed for
distal stenting
3) Fix the ostium with a stent (or even
covered stent)
4) Conservative and no surgical
treatment after fixing the problem!!!

22. Aortic dissection – CT after PCI

23. Aortic dissection – CT after 24h

24. Aortic dissection – 6 months follow up

25. Iatrogenic aortic dissection complicating
PCI for CTO
Boukhris M et al. Can J Cardiol. 2015
8 Patients (0,83%) in 956 CTO PCIs

26. Complications
Guiding
Catheter
associated
complications
Small vessel
perforations
Vessel
ruptures

27. Complications in collaterals

28. Complications in collaterals

29. Complications in collaterals
Wire in diagonal is
jailed

30. Complications in collaterals

31. Complications in collaterals

32. Complications in collaterals
1) Never do a superselectiv injection in
damaged collaterals
2) Flushing the fat in the MC is the
major failure mechanism if you want
to embolize with fat
3) Coil the antegrade and retrograde
blood supply, after successful CTO

33. Complications in collaterals

34. Distal Wire Perforation in a STEMI

35. Coronary perforation during CTO PCI
European Multicenter Registry including 1811 patients with 99 perforations (5.5%)
Azallini L, Poletti E, Ayoub M, ……,Mashayekhi K., EuroIntervention 2019

36. Coronary perforation during CTO PCI
European Multicenter Registry including 1811 patients with 99 perforations
(5.5%), totale rate of tamponade (0,9%)
Tamponade: 20%
Death: 5,5%
Azallini L, Poletti E, Ayoub M, ……,Mashayekhi K., EuroIntervention 2019

37. Coronary perforation during CTO PCI
Open CTO Registry including 1000 patients with 89 perforations (8.9%),
totale rate of tamponade (1,0%)
Hirai et al., JACC Cardiovasc Interv. 2019 Jun 19
Tamponade: 23.3%
Death: 20.9%

38. After surgery
“The dry tamponade”
Epicardial Perforation post-CABG

39. 1.8 Fr compatible :
Finecross, Caravel, Corsair, Turnpike
2.4 Fr compatible:
Progreat
Coils and Microcatheters
Axium or Concerto
– ev3
Boston Figure 8-18, or VortX Diamon – 18,
Azur-Terumo,

40. Thrombin

41. Embolization Particles Fat
Alternative to Coils
Thanks to
Manos Brilakis

42. Post-CABG epicardial perforation

43. Post-CABG epicardial perforation

44. Post-CABG epicardial perforation

45. Post-CABG epicardial perforation

46. Epicardial Perforation
Coiling:
1) Pushable coils
2) Compatible MC
Solve the problem immediately!
Do not hesitate!
STOP contrast Injection
Pericardial Effusion?
Post-CABG: hematoma?
How to treat epicardial collateral perforations?
ACT measurement
Protamine only if:
Drainage in the pericardial, or after
successful mechanical embolization
Fat-Embolization/Thrombin:
1) Fat from groin; Fat floats
2) Do no inject it / push it with a
wire!!!
3) Negative suction through MC

47. Complications
Guiding
Catheter
associated
complications
Small vessel
perforations
Vessel
ruptures

48. Antegrade Device Perforation
Good landing zone, >20mm

49. Antegrade Device Perforation

50. Perforation after CrossBoss Retrograde Rescue - CTO
Antegrade Device Perforation

51. Guideliner assisted Revers-CART Final result
Antegrade Device Perforation
1) Long balloon deflation
2) Retrograde “Rescue” CTO
3) Use a guideliner distal of the perforation
for stenting
4) CrossBoss use should be limited to short distal
advancement (<15-20mm) in a straight
segment for performing a controlled dissection
for placing your stingray balloon

52. By courtesy of A. Büttner
RCA CTO post CABG
Retrograde epicardial access LCX to PLB

53. After Kissing wire antegrade wire in true lumen

54. After first stents:
main vessel perforation type III
After 10 stents:
5 x 38mm DES (190mm)
5 x covered stents (19,19,16,16,12mm
RCA CTO post CABG
Retrograde epicardial access LCX to PLB

55. Hematoma with compression of left atrium
→ Hemodynamics: PA syst 40 mmHg; CI 2.0 l/min/m²
Cardiac CT (Day 1)
1) Post-CABG hematoma are the most
life-threatening complications in
CTO-PCI
2) Use of knuckle wire and polymer
jacket wires in unclear vessel routes
are safer, and should be preferred
over stiff penetration wires!!!

56. Day 6 Day 14
Echo
1) Post-CABG hematoma are the most
life-threatening complications in
CTO-PCI
2) Use of knuckle wire and polymer
jacket wires in unclear vessel routes
are safer, and should be preferred
over stiff penetration wires!!!

57. Post-CABG RCA-CTO Preparing for retrograde with 1,25burr
Device entrapment

58. Stocked Rotaburr
Do not pull out entrapped devices
with too much force!

59. 7F AL 0.75, Turnpike and
Confianza 12g Step down after cap penetration → Fielder XT
Rota Complication after Antegrade Wire Escalation

60. Successful antegrade Wiring:
Confianza pro 12 > Fielder XT > Gaia 3rd

61. Entrapment of the
1.75mm burr after the
second rota run
Rota shaft fracture after snaring
maneuver

62. by Manos Brilakis

63. Preparing for pulling the Rotawire with
balloon dilatation proximal to the burr

64. Gently pull back on
the rotawire
while countertraction is applied
on the catheter

65. Broken rotashaft with snare and 1.75mm burr

66. Vessel
perforation
Ellis type III
Knuckle wire goes
into pericard →
Balloon occlusion

67. retrograde guiding catheter changed to
XB 3,5 7Fr
Turnpike MC with selective Injection
for septal connection
Retrograde Rescue CTO PCI

68. Septal wiring
with sion
black

69. cardiac tamponade
Pericardiocenthesis

70. Selective injection at the
distal cap
Knuckling Gladius wire into the
ascending aorta

71. RG3 externalized and Guideliner assisted
stentimplantation performed

72. Implantation of 2 cover stents ( Begraft ) into proximal
RCA after DES implantation

73. Final Result

74. Comparison of patients with/without rotablation in the Bad Krozingen CTO DATABASE:
2789 patients with CTO PCI in stable Angina during 5 years (2015-2019)
CTO with Rotablation CTO without Rotablation
Total number of patients (%) 193 (6.9%) 2596 (93.1%) 2789 (Patients)
Rota 106 (55%)
RotaPro 87 (45%)
History of CABG 60 (33.5%) 417 (16.7%) <0.0001
Procedural time in min. 127 [94-186] 81 [51-126] <0.0001
Fluoroscopy time in min. 54 [35-80] 35 [20-60] <0.0001
Contrast volume in cc 310 [200-400] 260 [190-390] 0.0032
Radiation dose in mGy 1339 [806-2353] 1762 [1231-2555] 0.24
Tamponade 6 (3.1%) 13 (0.5%) <0.0001
In-hospital MI SCAI 24 (12.5%) 142 (5.6%) <0.0001
In-hospital MI 4a 3 (1.6%) 47 (1.8%) 0.80
In-hospital MACCE 8 (4.2%) 72 (2.8%) 0.27
3-year MACCE 45 (23.3%) 554 (21.3%) 0.52

75. Aorto coronary
dissection
1) Stop contrast media
2) Disconnect your contrast syringe
3) Fix the aortocoronary ostium with
a stent (or even cover stent)
4) Use guide extensions
5) Once the entry is fix = conservative,
no surgical treatment
1) Avoid overrotation of
microcatheters and wires
2) Avoid wire kink during
externalization (RG 3)
3) Do not pull hard outside the body
4) Try to trap or better snare out
entrapped devices
Managing CTO Complications
Device
entrapment

76. Perforations
1. STOP to inject contrast
2. Long Balloon deflation
3. Retrograde Rescue
4. Stenting (Coverstent?)
Managing CTO Complications
Antegrade Device
Perforation
After Stenting
Stenting
Collateral
Perforation
1. STOP to inject contrast
2. Long Balloon deflation
3. Ping Pong Technique
4. Coverstent
1. STOP to inject contrast
2. During retrograde wiring:
a. Balloon inflation, Coiling from retrograde
3. After successful CTO:
a. Coiling from ante and retrograde