CTO and bifurcation: Tips and tricks Gerald S. Werner, Darmstadt, Germany 10th Experts „Live“ CTO Workshop - Day2

1. CTO and bifurcation:
Tips and tricks
Gerald S. Werner, MD, FESC, FACC, FSCAI

2. A bifurcation in a CTO: the
crux of the crux
Gerald S. Werner, MD, FESC, FACC, FSCAI

3. Bifurcation as the central problem of a CTO
• The most frequent problems where a
bifurcation is encountered within a CTO are:
– Bifurcations at the entry into the CTO disguising
the proximal cap of the occlusion
– At the distal end of the occlusion, with the risk of
losing one of the branches in case of subintimal
entry into the cap
– In the middle of a CTO we may have a number of
relevant side branches

4. ERCTO Analysis 2013
• Side branch at the entry into the CTO found in
11.8% of all CTOs
• Success rate only 74.9% without stump as
compared to 92.6% with tapered stump, and
85.4% with blunt stump

5. ERCTO Analysis 2013 and 2017
• Side branch at the entry into the CTO found in
11.8% of all CTOs
• Success rate only 74.9% without stump as
compared to 92.6% with tapered stump, and
85.4% with blunt stump
• 26.1 % side branch at proximal cap
• Success rate 79.0% without stump, vs 88.4%
and 96.1% with blunt or tapered stump in
2017

6. Bifurcation at the beginning of the CTO
• Identify the cap
• Visualize the cap (IVUS)
• Penetrate the cap

7. Bifurcation CTO wiring
Dual lumen applications
Wiring acute angulated
bifurcations

8. 8
Tip end
Position of OTW lumen exit ports
This above data was obtained by company standardized test, which may differ from industry standardized tests.
This above data does not guarantee that all devices have exactly the same performance with the samples used for tests.
The operator needs to be
aware of the differences in
features of the various
dual-lumen catheters.

9. RCA CTO: Strategic options
• Retrograde access
possible
• How likely is it to
pass the retrograde
wire all the way up?
• Antegrade wire
position required
• Antegrade wire
• No entry
• IVUS analysis to inquire
the proximal cap

10. Complex long RCA CTO

11. 2013: 47 year old male: PCI or CABG ?

12. First step: Combined antegrade and retrograde anatomic
reconstruction of the LCX

13. Before second step

14. Bifurcation at the “end” of a CTO
• Besides the problem of the bifurcation itself,
the specific problem to do a CTO with
bifurcation is…
• that most times it comes at the end of an
already lengthy procedure
• that the operator might already be exhausted
• that he thinks he can get away with a single
stent technique (justified by the EBC rules)

15. ERCTO Analysis 2013
• 529 (19.5%) of 2711 patients had a CTO within
or distal of the CTO
• Success rate was 86.6% without, and 90% with
a bifurcation, so no adverse effect
• Single stenting was done in 80.4%

16. ERCTO Analysis 2017
• 1069 (26.1%) of 4101 patients had a CTO
within or distal of the CTO
• Success rate was 88.9 % without, and 90.2 %
with a bifurcation, so no adverse effect
• Single stenting was done in 82.9 %

17. A short RC CTO with diffuse disease of the RCA

18. Full metal required incl. the crux cordis

19. But will this be a sustainable result ?

20. Which is the primary vessel for the bifucation
stenting ?
• If both distal vessels are equally big, choose
the one which is not directly supplied from
the collateral, as you can always recover the
side branch from the retrograde catheter
• Do not jail your RG3
• But do not give up the distal catheter position
before you are satisfied with your bifurcation
stenting

21. 【Case】
50’s year-old male
RCA CTO
J-CTO score 3

22. Ante: 7Fr AL1.0SH via Rt Femoral
Retro: 7Fr EBU3.75SH via Lt Femoral
PCI for RCA

23. Fineduo with Conquest pro12
Gaia3rd
Ante: Parallel wire
Go as far with the antegrade wire as possible as you
need to have a lead for the retrograde wiring

24. Caravel with SUOH03
Retrograde approach

25. Tip injection
Retrograde approach
The stumpless distal bifurcation at the crux is the
worst case: you do not want to loose a branch

26. Caravel with Miracle Neo3
Retrograde approach

27. Ante: Gaia3rd with NC3.0x15mm
Retro: Caravel with Miracle Neo3
Reverse CART

28. Externalization and Stenting

29. Externalization and Stenting

30. Post Stenting
It is sometimes better to leave the crux free and stent
the rest of the RCA, then see what develops

31. Fineduo with SION
Rtecover the other side branch

32. IVUS
Then decide based on the IVUS findings

33. DCB 2.0x20mm

34. Contralateral injection
If you do not see much/any filling from the collaterals
you know, you have good perfusion antegradely

35. POBA 2.0x30mm

36. Final

37. Bifurcation: the crux of the crux in CTO PCI
• Bifurcations are a frequent problem during
the course of revascularizing a CTO
• They must be dealt with like in non-occlusive
lesions
• In some instances we need all the technique
and technology of complex bifurcation
treatment
• Loosing major side branches might be a
Pyrrhus success