14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany AGIK Parallel Session - Session 4: The 101 of the global consensus approaches Impulse: Indicators for the necessity of a retrograde approach Bernward Lauer, Jena, Germany Room: West Foyer - Saturday 8:45 Chairmen: Harald Lapp, Bad Berka, Germany; Jaroslaw Wójcik, Lublin, Poland; Tommaso Gori, Mainz, Germany

1. Klinik für Innere Medizin I / Kardiologie
Indicators for the necessity of a
retrograde approach
September 2nd 2022
Bernward Lauer
Ltd. Oberarzt der Klinik für Innere Medizin I
Universitätsklinikum Jena

2. I, Bernward Lauer, DO NOT have a financial
interest/arrangement or affiliation with one or more
organizations that could be perceived as a real or
apparent conflict of interest in the context of
the subject of this presentation
Disclosure Statement of Financial Interest

3. Necessity of a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
I have found no literature on this specific topic
So I will present my personal view

4. Indication for CTO recanalization
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• myocardium in the CTO territory is viable
• patient is symptomatic
• complete revascularization is necessary
• (post) ACS
• CCS
√
√
√
(√)
NECESSITY OF RETROGRADE APPROACH
if the indication is correct, every (reasonable)
effort has to be done to achieve the goal

5. Necessity of a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• always antegrade approach first
• after failed antegrade attempt

6. proximal CTO of the RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

7. antegrade wire „somewhere“
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

8. attempt of antegrade wire passage
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

9. antegrade wire passage in RVD
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

10. antegrade wire passage in RVD
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
PTCA in proximal RCA

11. after PTCA proximal RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

12. antegrade wire does not reach distal lumen
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

13. placing stent in proximal RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

14. placing stent in proximal RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
inflating stent in proximal RCA

15. preliminary final result
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

16. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
preliminary final result after 3 days

17. Searching for collaterals
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
3 days later

18. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Retrograde wire in collateral 1

19. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Retrograde wire in collateral 2

20. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Searching for another collateral

21. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Injection in collateral 3

22. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Wire passes collateral 3

23. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Control of wire position in distal RCA

24. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Wire in distal RCA after correction

25. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Retrograde wire goes in RVD

26. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Retrograde wire goes in proximal RCA

27. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Injection in RCA

28. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
retrograde wire in aorta

29. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
retrograde wire in aorta retrograde wire in guiding
catheter

30. 71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
final result

31. Necessity of a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• always antegrade approach first
• after failed antegrade attempt
• ostial CTO

32. CTO of the RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Zimmermann

33. ACVB auf PLA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

34. Wire passage in distal RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

35. Wire passage in distal RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Retrograde recanalization

36. Retrogtrade wire before guiding catheter
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

37. Retrograde wire in aorta
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

38. Retrograde wire in guiding catheter
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

39. Retrograde wire in guiding catheter
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Antegrade PTCA

40. Final result
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

41. Necessity of a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• always antegrade approach first
• after failed antegrade attempt
• CTO at bifurcation
• ostial CTO

42. CTO at bifurcation (RCA)
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Schumann

43. CTO at bifurcation (LCA)
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

44. retrograde wire passage of collaterals
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

45. retrograde recanalization of CTO
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

46. retrograde wire in RVD
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

47. retrograde wire in proximal RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

48. retrograde wire in proximal RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
retrograde wire in guiding catheter

49. final result
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

50. Necessity of a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• always antegrade approach first
• after failed antegrade attempt
• CTO at bifurcation
• ostial CTO
• Ca at proximal cap

51. RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Karsten

52. LCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

53. LCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

54. LCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
LAD
RCX
LAD
RCX
LAD
RCX

55. LCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
RCX RCX
Ca Ca

56. LCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

57. Necessity of a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• always antegrade approach first
• after failed antegrade attempt
• CTO at bifurcation
• ostial CTO
• Ca at proximal cap
• poor distal target

58. LCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Röder

59. RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

60. antegrade failed
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

61. rapid switch to retrograde, quick wire passage
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

62. retrograde wire did not pass
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

63. reverse CART
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

64. retrograde wire did not pass
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

65. reverse CART 2
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

66. retrograde wire passes
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

67. retrograde wire in guiding catheter
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

68. final result
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

69. Threshold for a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• localization of collaterals
Threshold rises
septal < epicardial < atrial

70. Threshold for a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• localization of collaterals
Threshold rises
septal < epicardial < atrial
depending on the experience of the operator

71. Threshold for a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• localization of collaterals
• quality of collaterals

72. excellent collateral
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer
Kirchner

73. retrograde wire in collateral
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

74. retrograde wire in distal RCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

75. retrograde wire subintimal
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

76. antegrade wire passage
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

77. antegrade wire passage
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

78. antegrade wire passage
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

79. control of wire position
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

80. antegrade PTCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

81. after antegrade PTCA
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

82. final result
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

83. Threshold for a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• localization of collaterals
• quality of collaterals
• post CABG
• in theory: less risk (for tamponade) etc
• but be careful (especially in the RCA)

84. Why are we doing this ?
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

85. THEREFORE
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86. THANK YOU
FOR YOUR ATTENTION
71. Seminarwoche Innere Medizin kompakt, August 2022, Bernward Lauer

87. Necessity of a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• always antegrade approach first
• after failed antegrade attempt
• CTO at bifurcation
• ostial CTO
• Ca at proximal cap
• poor distal target
• always antegrade approach first

88. Necessity of a retrograde approach
ESC Guidelines, 4th Universal Definition of Myocardial Infarction 2018
14th Expert Live CTO, Mainz, September 2022, Bernward Lauer
• always antegrade approach first
• after failed antegrade attempt
• CTO at bifurcation
• ostial CTO
• Ca at proximal cap
• poor distal target
• always antegrade approach first