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

1. How to handle with Iatrogenic Aortic
Dissection Complicating CTO PCI
Marouane Boukhris, MD*
Alfredo R Galassi, MD, FESC, FACC, FSCAI
Department of Clinical and Experimental Medicine
University of Catania, Italy
*Faculty of Medicine of Tunis, Tunisia

2. Case 1
66 year-old male Risk factors: DM type II, smoking, hypertension, dyslipidemia
CABG for 3-VD: LIMA on LAD, SVG on OM1, RCA CTO not treated
Subsequent PCIs
Symptoms: Angina (CCS II-III)
Imaging tests: Preserved LVEF, ischemia of inferior wall
RCA ostial CTO lesion

3. Case 1
Septal collaterals (CC2 & CC1)
Tortuous screw like epicardial collaterals (CC2)
66 year-old male Risk factors: DM type II, smoking, hypertension, dyslipidemia
CABG for 3-VD: LIMA on LAD, SVG on OM1, RCA CTO not treated
Subsequent PCIs
Symptoms: Angina (CCS II-III)
Imaging tests: Preserved LVEF, ischemia of inferior wall

4. Retrograde Approach
Corsair (Asahi)
Sion guidewire (Asahi)
LM: EBU 4
RCA: AL 2

5. Bilateral Injection
LM: EBU 4
RCA: AL 2
Iatrogenic Aortic Dissection
Involvement of RCA into the dissection

6. Causes
 Guiding catheter trauma  Balloon rupture
 Contrast mean injection:
wedged catheter
 Retrograde projection of
RCA dissection
Iatrogenic Aortic Dissection

7. Probably not!
Would you consider
surgery?

8. A Fielder FC (Asahi) was subintimally pushed and reentry was achieved
Management of Iatrogenic Aortic Dissection

9. Xience (Abbott) 3.5x28 mm
Balloon dilation and DES implantation in RCA ostium
Management of Iatrogenic Aortic Dissection

10. Management of Iatrogenic Aortic Dissection
Result after several dilatations with balloons.
Persistence of contrast in the aortic root and mid RCA dissection

11. Afterwards two other DES were implantated
Xience (Abbott)
3.0x33 mm
Xience (Abbott)
2.75x28 mm

12. Due to persistence of flow towards dissection
a covered stent was implanted more proximal
Jostent Stent Graft (Abbott)
4x19 mm

13. Final Result
Angiographic success of RCA CTO revascularization
Absence of contrast in aortic root

14. S1
S2
S1
Stent in sub-intimal space
Compressed true
lumen
S2
Aorta lumen
IVUS

15. Medio-intimal aortic root dissection
(approx 35 mm)
Stent inserted at the ostium of the
RCA projecting 8.9 mm in the
Valsalva’s sinus
2-D Echocardiography
Dunning Class II

16. MSCT (within 24h)
MSCT unenhanced scan examination
shows dislocation of intimal calcification
with an eccentric double lumen

17. Almost total resolution of the dissected
thrombosed lumen
1-month MSCT

18. Total resolution of the dissection
6-month MSCT

19. Case 2
Mid- RCA CTO
63-year old woman Risk factors: hypertension, dyslipidemia
Symptoms: Angina CCS III, Dyspnea NYHA II
2D echo: LVEF 45% with inferior hypokinesia
Septal collaterals CC2 and CC1 from LAD

20. Reverse CART Attempt
Corsair (Asahi)
Sion retrograde (Asahi)
Fielder XT R antegrade (Asahi)
Guidezilla guiding extension (Boston)

21. Suddenly……
Hemodynanic instability
Donor artery (LM) thrombosis

22. Cardiac Arrest
Cardiac ressuscitation & DES implantation in LM

23. Restoration of Hemodynamic Stability
Iatrogenic aortic dissection probably due to
catheter trauma during rescussitation

24. Antegrade Approach
Finecross (Terumo)
Fielder XT R (Asahi)

25. Result after 5 DES implantation

26. Ostial stenting
DES
3.5 x 15 mm

27. Final Result
Angiographic success of RCA CTO revascularization
Absence of contrast in aortic root

28. CT Angiogram (within 24h)
Aortic dissection limited to the right sinus
Dunning Class I

29. Dunning et al. CCI 2000
Dunning Classification
Dunning class I
Dunning class II
40mm
Dunning class III

30. PCI of CTO lesionsCoronary angiography or PCI
Dunning et al.
CCI 2000
Nunez-Gil et al.
Circulation 2015
Shorrock et al.
CCI 2014
Boukhris et al.
Can J Card 2015
Incidence
0.02%
(9 cases/43143)
0.06%
(74 cases/108 083)
1.8%
(6 cases/336)
0.83%
(8 cases/956)
LocationDunningclasses
100
0
0
20
40
60
80
100
Right Left
56.8
41.9
0
20
40
60
80
100
Right Left
100
0
0
20
40
60
80
100
Right Left
87,5
12,5
0
20
40
60
80
100
Right Left
44.5
33.3
22.2
0
20
40
60
80
100
I II III
60.8
33.3 20.6
2.7
0
20
40
60
80
100
I II III N/A
25
75
0
0
20
40
60
80
100
I II III
Not specified
-More extensive atherosclerosis burden in CTO patients
-Procedures requiring more “agressive” manipulations
-The use of 2 guiding catheters
-The hemodynamic force vector is directed to the right side
convexity of the ascending aorta

31. PCI of CTO lesionsCoronary angiography or PCI
Dunning et al.
CCI 2000
Nunez-Gil et al.
Circulation 2015
Shorrock et al.
CCI 2014
Boukhris et al.
Can J Card 2015
ManagemetShort&mid-
termoutcome
Long-termoutcome
12.5
0
20
40
60
80
100
cardiac death
0
0
20
40
60
80
100
further complications
Not available
0
66.7
33.3
0
20
40
60
80
100
Conservative stenting Surgery
48.6 47.3
4.1
0
20
40
60
80
100
Conservative stenting Surgery
16,7
66,6
16,7
0
20
40
60
80
100
Conservative stenting Surgery
0
100
0
0
20
40
60
80
100
Conservative stenting Surgery
16.7
0
20
40
60
80
100
cardiac death
2.7
0
20
40
60
80
100
cardiac death
22.2
0
20
40
60
80
100
cardiac death
51.2 months
0
0
20
40
60
80
100
further complications
31.5 months
Not available

32. Boukhris et al. Can J Cardiol 2015
8 cases / 956 CTO PCI ( 0.83%)

33. Take Home Messages
- Assessment of patient’s symptoms and hemodynamic status
- In absence of hemodynamic instability or severe symptoms, the
procedure can be continued
- Balloon inflation +/- Ostial stenting in order to seal the entry point (DES or
covered stent)
- Generally, no need for protamine administration or antiplatelet agents
interruption
- Urgent (within 24h) aortic imaging (TEE or CT angiogram) to assess the
extension of the dissection into aorta

34. Take Home Messages
Patching up the coronary
problem + “wait & see”
Cardiac surgery
Dunning class I
Dunning class II
40mm
Dunning class III
- A second comparative aortic imaging should be performed before discharge.
- Further control at 1 month might be indicated