4th European Live Summit on Retrograde CTO Revascularization - May 8–9, 2015, in Zurich, Switzerland

1. Break through the wall- RCA ostial CTO
Markus Meyer-Geßner Augusta-Krankenhaus Düsseldorf
Altbier Altstadt/ Rheinpromenade
4 th European Live Summit on Retrograde CTO Revascularization Zürich 8.-9.5.15

2. 111
111 Jahre Augusta-Krankenhaus in Düsseldorf, 1904-2014

3. 3
Case1: Mr. MJ, 55a , CTO RCA ostium without stump
AP CCS III, treadmill: inferior ischemia, Echo: normal LVF
Creatinin 1,5 mg/dl, GFR 49 ml/min

4. 4
No guide for antegrade work (JR 3,5 8F, JR 4 8F, IMA 7F)

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Retrograde via 1. septal branch
Sion crosses in PDA, Corsair 150 cm stucks in septum

6. 6
Sion goes far, IMA 7F is near, no breakthrough
170ml contrast used, GFR 49 ml/min,still a lot of work
-> second attempt with refined strategy

7. 7
„Exophytic ostial calcium block, CTO channel filled by calcium,
length 35mm“ -> not encouraging!
Before 2. attempt: CT scan -> anatomy of ostium/CTO channel?

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Patient still symptomatic after 3 months-> we try it
key to success: septal cross with microcatheter
Sion, Finecross 150cm

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Selective injection: multisegmental occlusion, short ostial part
Ultimate 3 g crosses

10. 10
Finecross stucks at tip of guide

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Change to RG3 in aorta Snare in brachiocephalic trunc

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„Balloon battle“
19 balloons, ruptures, finally child in mother

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Concertina effect at ostium, correction by additional stent
Procedure time 209min, fluoro 86,4 min, AK 2474 mGy, contrast 90ml
4 stents, 3,5/100 mm

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Similar case: Antegrade system from right radial approach
Retrograde system in aortaNo passage in antegrade guide

15. 15
Snaring
Quattro Pro Elite Snare 35 mm in
brachiocephalic trunc
Change to RG3

16. Conclusions
 RCA ostial CTO: short or absent stump and high degree of calcification
 Limited or no antegrade option, retrograde approach mostly needed
 CT-scan tells not always the complete truth, retrograde injection is helpfull
 Differential use of microcatheter sometimes necessary for collateral crossing
 Child in mother system facilitates stent crossing in severe calcification
 RG3 may easily be catched by a large snare in brachiocephalic trunc from right
radial and femoral access

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Final Conclusion
It´s challenging to break the wall
Heinz Rühmann in „A man goes through the wall“ (1959)

18. Altbier Altstadt/ Rheinpromenade
Thank You
Break through the wall- RCA ostial CTO– 2 cases
Markus Meyer-Geßner Augusta-Krankenhaus Düsseldorf
4 th European Live Summit on Retrograde CTO Revascularization Zürich 8.-9.5.15