CTO in post CABG patients

1. EURO CTO CLUB Toulouse 2018 CTO in post CABG patients Emmanouil S. Brilakis, MD, PhD Minneapolis Heart Institute 15.05 – 15.15 Saturday, September 15, 2018

2. EURO CTO CLUB Toulouse 2018 Disclosure Statement of Financial Interest • Consulting/speaker honoraria: Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Boston Scientific, CSI, Elsevier, GE Healthcare, Medtronic. • Research support: Osprey, Regeneron, Siemens. • Shareholder: MHI Ventures. • Board of Directors: Cardiovascular Innovations Foundation • Board of Trustees: Society of Cardiovascular Angiography and Interventions

3. CTO PCI in prior CABG pts 1. Treat the native vessel instead of SVG* 2. Staged SVG revascularization 3. Strong support 4. Retrograde (triple injection) 5. Wire through tortuosity 6. Reaching the lesion 7. Meticulous lesion modification 8. Watch for perforations

5. SVGs do not do well long-term Median FU: 2.7 years Brilakis et al. Lancet 2018 Target vessel failure

6. Native coronary PCI better than SVG PCI

7. 2010: The “future”: treat native coronary instead of SVG?

8. Candidate for redo CABG? Need for additional revascularization? Corresponding native coronary lesion complex? LIMA to LAD feasible? Consider redo CABG SVG lesion complex? Able to treat native lesion? Native lesion PCI SVG PCI* yes no yes yes no no yes no yes yes no SVG lesion 2018: the “future” is now!

10. Occluded SVG- RCA 81-year-old woman with non-NSTEMI

11. Stent under-expansion despite high pressure balloon inflations

12. 3 weeks later

13. CT-angio

14. Antegrade wire escalation

15. Unable to cross through prior stent • Hornet 14 • Pilot 200 • Gaia 2nd • Gaia 3rd

16. Pilot 200 subintimal (sub-stent) followed by Corsair

17. Stingray wire re-enter distal true lumen exchanged for Pilot 200 “Stick and swap”

18. Pilot 200 into true lumen

19. Procedural time: 249 min Fluoroscopy time: 97.3 min AK Radiation: 2.776 Gray Contrast volume: 149 ml Final Result Conclusions • Native coronary artery PCI is preferred to SVG PCI (esp after SVG occlusion), if feasible • Treating ISR CTOs: sub-stent crossing, re-entry, and crushing stents • Balloon undilatable lesion: subintimal crossing can provide effective treatment

20. “Staged SVG revascularization” Acute SVG failure SVG PCI Native coronary PCI Stage 1 Stage 2

21. Candidate for redo CABG? Need for additional revascularization? Corresponding native coronary lesion complex? LIMA to LAD feasible? Consider redo CABG SVG lesion complex? Able to treat native lesion? Native lesion PCI SVG PCI* yes no yes yes no no yes no yes yes no SVG lesion 2018: the “future” is now! Staged

22. Initial Angiogram: New Severe Lesion Skip Portion SVG Between “OM1” & OM2; Significant ostial LCx disease

23. Attempted Intervention SVG Skip: Unable to cross lesion Patient developed CP/ distal flow OM1 Next step?

24. Emergent CT Coronary Angiogram!!! Identified branch in question to be high takeoff diagonal/ramus Small contrast opacification proximally, small lateral branch open Occlusion ~20mm

25. Patent small branch off occluded vessel Occluded “OM1”- truly high takeoff diag/ramus LAD Severely diseased SVG-Skip OM2

26. Patent small branch of occluded vessel Occluded “OM1” vessel-truly high takeoff diagonal/ramus LA D

27.  Additional views of ongoing occluded vessel

28.  Antegrade wire escalation:  Pilot 200-unsuccessful  Gaia second-unsuccessful  Fielder XT-A-unsuccessful  Gaia third-crossed into distal true lumen & fell into SVG skip portion/not ongoing branch  Corsair, switch to Sion Blue

29.  Twinpass wiring, repeated prolapse into SVG Skip  2 Operator Twinpass to/fro + wiring  Enters ongoing vessel

30. Final Result:  Uncomplicated post-procedural course, D/C’d home  3.5 x 18 Resolute Onyx

32. Strategies for wiring and delivering in tortuous vessels WIRE 1. Bend • >90˚ • Double • “reversed” 2. Type • Composite core • Polymer jacketed • Transitionl ess LESION PREPARATION 1. Predilation • Regular balloon • Cutting balloon • Angiosculpt 2. Atherectomy 3. Laser 4. Wiggle wire – buddy wire 5. Extra support wire STENT 1. Shorter 2. Thin strut 3. Bending 4. Rotaglide Saeed B J Interv Card 2008 STRATEGY 1. Loop at tip 2. Deflection 3. Buddy wires Wiring Delivering Microcatheter 1. Flexible 1. Finecross 2. Caravel 3. Turnpike LP 4. Micro 14 2. Dual lumen 1. TwinPass Torque 3. Distal bend 1. Venture 2. SuperCross SUPPORT 1. Basics 2. Guide extensions 3. Anchor Techniques 4. Support catheters

33. CTO PCI in prior CABG pts: BASICS 1. Femoral access 2. 8 French 45-cm long sheaths 3. Triple injection 4. Guide: – Right grafts: Multipurpose – Left grafts: AL1

36. Getting support: Guide catheter extension

37. “Swan neck” maneuver Mamas et al. CCI 2011

38. “Mother- daughter- granddaughter” Courtesy William Nicholson

40. Additional options = Grafts Grafts Arterial SVGs patent occluded patent occluded Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier 2017

41. PROspective Global REgiStry for the Study of CTO interventions www.progresscto.org 86.6% 86.6% 78.1% 82.0% 70% 80% 90% 2006-2011 2012-2017 No prior CABG Pre Hybrid era Michael, Karmpaliotis, Brilakis, Abdullah, Kirkland, Mishoe, Lembo, Kalynych, Carlson, Banerjee, Lombardi, Kandzari. Heart 2013;99:1515-8 Δ=9.1% P<0.001 PROGRESS CTO Registry 06/2018 Effect of Prior CABG N=1,363 3 US sites Prior CABG: 37% Complications: 1.5% vs. 2.1% Retrograde: 27.1% vs. 46.7% Δ=4.6% P<0.001 Hybrid era N=3486 21 international sites Prior CABG: 32% Complications: 2.5% vs. 3.1% Retrograde: 30% vs. 53% 2012-2018

42. ASSESSMENT Target vessel: RCA Proximal cap: clear Length: ~10 mm Distal vessel: Diseased Collaterals: SVG PLAN 1. AWE 2. Retrograde via SVG 3. ADR

43. Subintimal

44. Pilot 200 Retrograde true to true crossing

45. ? Coil SVG

46. Triple injection first CTO second CTO

47. First Three Dyevert case worldwide! Reduce study

48. The occluded SVG Courtesy William Nicholson

49. BEWARE THE LIMA!!!

50. RCA CTO

51. Difficulty engaging LIMA - Guideliner

52. Dual injection Final result

53. Sion Case 46 www.ctomanual.org

54. Retrograde knuckle past distal cap Case 46 www.ctomanual.org

55. Acute pulmonary edema Procedure stopped: IABP- Impella Case 46 www.ctomanual.org

58. SVG touchdown Courtesy William Nicholson hardesteasiest

59. Challenging wiring to prox. CX (Samurai RC and Caravel)

60. Successful rewiring (Samurai RC, Caravel) Wire position loss (during wire exchange over Caravel MC) and multiple rewiring attempts

61. Venture (Teleflex) McNulty et al. CCI 2005 - Iturbe et al. CCI 2010

62. SuperCross

64. Deflection balloon technique Deflection balloon

66. Focal ISR in mid-RCA (arrowheads), patent radial graft, significant stenosis in OM1

67. Successful balloon delivery Emerge 1.5x20 mm (shaft length 144 cm) and predilation Sion guidewire Emerge balloon GuideLiner V3

72. Wire exchange for Grand Slam Successful stent delivery (2.5 x 16 mm Resolute Onyx)

74. After predilation Case 43 www.ctomanual.org

75. Case 43 www.ctomanual.org

76. Case 43 www.ctomanual.org

77. Wilson et al. CCI 2015;86:407–41 Perforation in the post CABG patient can be a lethal complication – TREAT IT IMMEDIATELY!

78. Riley R, Grantham JA. TCT 2017

CTO in post CABG patients

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