12th Experts Live CTO The annual Euro CTO meeting September 11th –12th, 2020 - Berlin, Germany

1. Kambis Mashayekhi
Treatment of true CTO Bifurcations
University Heartcenter Freiburg - Bad Krozingen

2. 2
X X X X
X X X X

3. • Take off from the CTO segment (defined as either orifice of SB ≤5 mm proximal or distal-to the entry or outlet-
point or SB ostia within CTO segment by visual estimation)
• SB with a diameter stenosis >50%
• Reference vessel diameter (RVD) >2.0 mm by visual estimation
Definition of a true CTO bifurcation
1. Baystrukov et al., Coronary Artery Disease 2018
2. CHEN et al., Chinese Medical Journal 2012
“True CTO Bifurcations”

4. • 47% (n=254 lesions) including bifurcation lesions <5mm proximal or distal of the CTO 1
• 54,3% (n=182 patients) including bifurcation lesions <5mm proximal or distal of the CTO2
• 26.5% (n=244 lesions) including bifurcation proximal (above the CTO proximal cap), within
the CTO body, and distal (below the CTO distal cap)3
• 33% (n=130 patients) located in the proximal cap, in the distal cap or within the CTO (true
CTO bifurcations)4
Incidence of bifurcations in CTOs
1. CHEN et al., Chinese Medical Journal 2012
2. Baystrukov et al. Coronary Artery Disease 2018
3. Galassi et al. Coronary Artery Disease 2015
4. Ojeda et al. International Journal of Cardiology 2017

5. Technical and Clinical Success Complications in CTO Bifurcations
Lower clinical success and higher complications
in CTO-bifurcations
Galassi et al. Coronary Artery Disease 2015

6. Loss of side branches and clinical Impact
Immediate and clinical outcomes on follow up
Ojeda et al. International Journal of Cardiology 2017

7. Impact on MACE-free survival in case of failure to treat the CTO-bifurcations
Ojeda et al. International Journal of Cardiology 2017

8. Mini Crush vs. Provisional-T-Stenting in CTO Bifurcations
Vitaly I.,…,Mashayekhi K. et al, Coron Artery Dis. 2018 Jan
n=146 (54,3% of the CTOs)

9. Mini Crush superior to Provisional-T-Stenting
in MACCE free survival at 1 year
Baystrukov et al. Coronary Artery Disease 2018

10. Meta-analysis of TVR in 1- vs 2-stents strategy in non-CTO bifurcations
Zimarino M et al, J Am Coll Cardiol Intv 2013
2 stents better 1 stent better

11. Culotte stenting
proximal
Modified T stenting
= TAP
Bifurcations Bad Krozingen – BBK II trial
M. Ferenc et al., EHJ 2016

12. BBK II: Clinical outcome at 1 year
Event Rate (%)
0
P = 0.56P = 0.70
2.0 2.7
15
5
10
Target lesion
failure
0.71.3
Target vessel
MI
Death Stent thrombosis
(definite / probable)
P = 0.32
0.7 0
P = 0.11
12.0
6.7
Culotte
TAP
M. Ferenc et al., EHJ 2016

13. MACE free survival Survival free from TVR
Shao-Liang Chen et al. Circ Cardiovasc Interv. 2017
5-Year Follow-Up Results From a Randomized and Multicenter
DKCRUSH-II Study

14. Technical aspects in treating CTO bifurcations
with the implementation of dual lumen microcatheters

15. Bifurcation Case 1 – RCX CTO

16. Bifurcation Case 1 – RCX CTO
Dual lumen microcathetersAntegrade Wire Escalation

17. Bifurcation Case 1 – after Final-Kissing

18. Bifurcation Case 2 – RCX CTO

19. Bifurcation Case 2 – RCX CTO
Ipsilateral Approach After Tip-In: antegrade Wire in
true lumen

20. Bifurcation Case 2 – Culotte Stenting

21. Technical aspects of bifurcations in post-CABG patients

22. Complex distal Cap Anatomy

23. Complex distal Cap Anatomy

24. Complex distal Cap Anatomy

25. Complex distal Cap Anatomy

26. Complex distal Cap Anatomy

27. Double retrograde for post CABG CTO bifurcation

28. In-Stent-Re-Occlusion retrograde Option via LIMA
Double retrograde for post CABG CTO bifurcation

29. PDA with superselective Injection Preparing the antegrade route
Double retrograde for post CABG CTO bifurcation

30. Antegrade knuckle wire position Epicardial retrograde option via CX
Double retrograde for post CABG CTO bifurcation

31. Retro wire in vein graft Redirecting the wire from the graft to
the PLD branch
Double retrograde for post CABG CTO bifurcation

32. Overlapping knuckle wires
Rendezvous technique; antegrade Gaia
2nd into retrograde MC
Double retrograde for post CABG CTO bifurcation

33. Retrograde puncture into the distal RCA Provision T -Stenting
Double retrograde for post CABG CTO bifurcation

34. Double retrograde for post CABG CTO bifurcation

35. Live Case post-CABG Bifurcation – Turin 2019

36. • The incidence of bifurcation lesion in CTO is around 1/3 of all CTOs
• Loosing important side branches may have impact on long term outcomes
• There are no randomized data about stenting strategy of bifurcation lesions in CTO PCI
• In case of total occlusion of both branches a double retrograde procedure may be
necessary
• IVUS evaluation can help in decision making about the strategy before stenting
• Post-CABG true bifurcation lesions are the most complex scenarios and should be
performed by experienced operators.
Conclusion:

37. CASE 3
Learning from the previous failure

38. Learning from the previous failure (Jan 2017)

39. June 2017: Re-Attempt

40. Different retrograde strategy

41. Triple access tip injection: Understanding the bifurcation

42. Guideliner extended Revers CART and
IVUS controlled puncture towards the PL branch

43. Modified Revers Wiring, or only luck…..

44. Final result

45. Mai 2018
(Follow up after 11 months)
Sept 2018
(Follow up after 16 months)
Follow up of CASE 3

46. Mai 2018
(Follow up after 11 months)
Sept 2018
(Follow up after 16 months)
Follow up of CASE 3