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Antegrade approach – how to start? Views of a minimalist and a maximalist point of view combattants
- 1. Alexander Ghanem & David Leistner Antegrade Approach – How to start? Minimalists‘ versus Maximalists‘ Approaches 17. September 2017
- 2. Our aim and its Paradigmata Minimalists‘ view Maximalists‘ view “The patient is treated in one attempt by the most experienced operator fitted to his lesion complexity.“ Patient Patient ProcedureProcedure Outcome G. Werner
- 5. Minimalists‘ Appropriateness List adopted from Prof. G. Werner, Darmstadt • Selection of the patient with normal LV-EF – Symptoms, but „asymptomatic“ patients may be adapted to their limitations by a CTO... – Ischemic territory should be > 10%
- 6. Relationship between mortality and extent of myocardial ischaemia, depending on therapy Montalescot / Sechtem et al., Eur Heart J 2013;34:2949–3003. Hachamovitch et al., Circulation 2003;107:2900–2907. OMT / Revascularisation
- 7. adopted from Prof. G. Werner, Darmstadt • Selection of the patient with normal LVF – Symptoms, but „asymptomatic“ patients may be adapted to their limitations by a CTO... – Ischemic territory should be > 10% • In patients with akinesia and ischemic CMP – Presence of viability tested by MRI – A grey zone of scar tissue extension remains Minimalists‘ Appropriateness List
- 8. Viability is a Continuum Wilcox et al, JACC 2015
- 9. Baks T et al. JACC 2006;47:721-5 Improvement of LV-Function depends on viability of revascularized myocardium
- 10. Adapted from Werner et al. JACC 2006;48:51-8 Collateral blood flow is never sufficient...
- 11. Min vs. Max Symptoms Objectified Ischemia Procedure: Wires Procedure: Guiding Outcomes: Angiography
- 13. (Retrograde) CTO PCI reduced markely symptoms (angina and dyspnea)
- 14. Boden et al., NEJM 2007 PCI added to optimal medical therapy did not improve outcome
- 15. Garcia S et al, JACC 2013;62(16):1421 –31 Outcome after incomplete versus complete revascularisation in MVD
- 16. Farooq et al., Circulation. 2013; 128: 141-151 Prognosis is significantly related to residual SYNTAX-Score
- 17. SYNTAX Revascularisation Index Genereux et al., Am J Cardiology, 2015, DOI: 10.1016/j.amjcard.2015.03.056
- 21. Srivatsa et al. JACC 1997;29:955-63 Necrotic Core, Cholesterol, inflammated Tissue Fibrous-calcific Tissue Micro Channels Histological CTO Correlates
- 22. De Labriolle et al, Am J Cardiol 2008 Causes of failure of CTO-PCI
- 23. CTO Toyohashi Heart Center Development of CTO-PCI procedure Miracle Conquest Parallel wiring IVUS guidance Retrograde approach 1995 2000 2005 2010 Fielder XT Pilot Fielder FC SION MDCT Corsair wire, device imaging modality wiring technique Complex PCI, NYC Conquest Parallel wiring IVUS guidance Retrograde approach 1995 2000 2005 2010 Fielder XT Pilot Fielder FC SION MDCT Corsair wire, device imaging modality wiring technique ACS standard Cross-It Progress family RG3 Ultimate Gaia family Fielder XT A/R Wire evolution
- 24. Complex PCI, NYC Conquest Parallel wiring IVUS guidance Retrograde approach 1995 2000 2005 2010 Fielder XT Pilot Fielder FC SION MDCT Corsair wire, device imaging modality wiring technique Wire evolution
- 26. Improve wire pushabilityConcentrate rotating force for better wire control Superior device passage for the next option 1. 2. 3. Microcatheter
- 29. Guiding Backup BEST OPTION FOR STRENGTHENING A GUIDE: 1. FIRST best maneuver- put the guide in power position or deep seat the guide. 2. SECOND best maneuver – Add a second stiffer wire 3. THIRD best maneuver – change to a stronger guide 4. use the balloon anchoring technique 5. insert a smaller straight inside the current guide (mother & child) 6. remove everything- change the short sheath to a longer one
- 30. Guiding Diameter Ghione et al., Eurointervention 2013
- 31. Guiding Diameter
- 32. Habit #2: Begin with the End in Mind !
- 33. Habit #1: Begin with any End in Mind ! PCI - OPERATORS
- 36. Gasparini et al. JACC INTV, 7 (4), 2014. Vessel Remodelling
- 37. Galassi et al., JACC 59 (8) 2012, 711-718. N=100 Vessel Remodelling + 20 - 30%
- 38. Galassi et al., JACC 59 (8) 2012, 711-718. Vessel Remodelling
- 39. 6-month Follow-up Gasparini et al. JACC INTV, 7 (4), 2014. Less is more ! Vessel Remodelling
- 42. Strategy is often about what you don‘t do!
- 43. Hybrid Approach
- 45. Hybrid Approach 4 5 6 6´ 7 4´
- 46. 4 B 2
- 53. Strategic Options adopted from Prof. G. Werner, Darmstadt The apparent length of the occlusion is often shorter than you think ! Bilateral Injection Maximum Guide Backup Antegrade Fielder XT/A/R or Gaia 1 Gaia 2, Confienza, Progress Penetration, then step down Antegrade No stump IVUS for guided penetration? Reentry-System Crossboss / Stingray Distal good target Parallel with stiff wire Retrograde Feasible collateral pathways
- 54. Symptoms Objectified Ischemia Procedure: Wires Procedure: Guiding Outcomes: Angiography Strategy Min vs. Max CTO – PCI always should be planned and performed with a maximalist‘s mindset !