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CTO PCI failure – When to try again?
- 1. Klinik für Innere Medizin I / Kardiologie CTO PCI failure - when to try again 11th Experts Live CTO 13. - 14.09.2019 Prof. Dr. Bernward Lauer Ltd. Oberarzt der Klinik für Innere Medizin I Universitätsklinikum Jena
- 2. CTO PCI Failure Antegrade: ca. 30 - 40 % Retrograde: ca. 10 - 20 % CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE Retry ?
- 3. When to retry after CTO PCI Failure • Retry: yes or no ? • At what time ? CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 4. Retry yes or no ? If the indication for CTO - PCI is correct, the patient has the right to receive optimal treatment with maximal commitment and dedication from the treating physician CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 5. Retry yes or no ? If the indication for CTO - PCI is correct, the patient has the right to receive optimal treatment with maximal commitment and dedication from the treating physician Correct indication • ischemic symptoms under OMT • > 10 % ischemic myocardium • complete revascularisation to achieve residual Syntax - Score < 8 CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 6. Retry yes or no ? If the indication for CTO - PCI is correct, the patient has the right to receive optimal treatment with maximal commitment an dedication from the treating physician „Yes“ is the default answer CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 7. Retry yes or no ? If the indication for CTO - PCI is correct, the patient has the right to receive optimal treatment with maximal commitment an dedication from the treating physician „Yes“ is the default answer, except when not CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 8. Are there other therapeutic option ? CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 9. Are there other therapeutic option ? CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE 72 y, male, atypical chest pain since 1 year, stress-induced myocardial ischemia anterior, no scar ECG: sinus rhythm, HR 58/min, normal QRS Echo: normal LV - function (EF >65%)
- 10. Are there other therapeutic option ? CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE LAD CTO
- 11. Are there other therapeutic option ? CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE LAD CTO, collaterals from the RCA Course of LAD not clear Still unclear after CT scan
- 12. Are there other therapeutic option ? CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 13. Are there other therapeutic option ? CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE Unable to cross CTO antegrade or retrograde via RD I
- 14. Are there other therapeutic option ? CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE Unable to cross CTO antegrade or retrograde via LAD
- 15. Are there other therapeutic option ? CABG MIDCAB LIMA -> LAD + RD CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 16. Are there other therapeutic option ? No ! CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 17. What was the reason for CTO PCI failure ? • Long procedure • Operator and/or patient is tired/exhausted after several hours CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 18. What was the reason for CTO PCI failure ? • Long procedure • Operator and/or patient is tired/exhausted after several hours • High volume of contrast medium CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 19. What was the reason for CTO PCI failure ? • Long procedure • Operator and/or patient is tired/exhausted after several hours • High volume of contrast medium • Complications/problems CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 20. What was the reason for CTO PCI failure ? • Long procedure • Operator and/or patient is tired/exhausted after several hours • High volume of contrast medium • Complications/problems • perforation, dissection (unintended), hemodynamic instability CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 21. What was the reason for CTO PCI failure ? • Long procedure • Operator and/or patient is tired/exhausted after several hours • High volume of contrast medium • Complications/problems • perforation, dissection (unintended), hemodynamic instability • Operator/equipment has reached his (technical) limits CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 22. What was the reason for CTO PCI failure ? • Long procedure • Operator and/or patient is tired/exhausted after several hours • High volume of contrast medium • Complications/problems • perforation, dissection (unintended), hemodynamic instability • Operator/equipment has reached his (technical) limits • equipment limited in stock • no further idea how to proceed • no retrograde experience • etc. CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE
- 23. What was the reason for CTO PCI failure ? • Long procedure • Operator and/or patient is tired/exhausted after several hours CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Give doctor and patient a rest and a good sleep • Try to imagine other intervention strategies • Other wires • Other guiding catheters (more back-up) • Other vascular access (femoral ?) • Additional material (GC extensions) 2nd attempt in a few days
- 24. What was the reason for CTO PCI failure ? • Long procedure • Operator and/or patient is tired/exhausted after several hours • High volume of contrast medium CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Good hydration • Give kidney a rest 2nd attempt, when creatinine has reached the initial values
- 25. What was the reason for CTO PCI failure ? • Complications/problems • perforation, dissection (unintended), hemodynamic instability CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Perforation: reverse anticoagulation; check for PE, echo, 2nd attempt after few weeks
- 26. What was the reason for CTO PCI failure ? • Complications/problems • perforation, dissection (unintended), hemodynamic instability CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Perforation: reverse anticoagulation; check for PE, echo, 2nd attempt after few weeks • Dissection: let edema/hematoma resolve 2nd attempt after few weeks
- 27. What was the reason for CTO PCI failure ? • Complications/problems • perforation, dissection (unintended), hemodynamic instability CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Perforation: reverse anticoagulation; check for PE, echo, 2nd attempt after few weeks • Dissection: let edema/hematoma resolve 2nd attempt after few weeks • Hemodynamic instability: intensiv care, rethink risk/benefit-ratio 2nd attemp probably after a few days
- 28. What was the reason for CTO PCI failure ? • Operator/equipment has reached his (technical) limits • equipment limited in stock • no further idea how to proceed • no advanced (e.g. retrograde) experience • etc. CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Extend your equipment
- 29. What was the reason for CTO PCI failure ? • Operator/equipment has reached his (technical) limits • equipment limited in stock • no further idea how to proceed • no advanced (e.g. retrograde) experience • etc. CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Extend your equipment • Talk with colleagues (e.g. EuroCTO - club members)
- 30. What was the reason for CTO PCI failure ? • Operator/equipment has reached his (technical) limits • equipment limited in stock • no further idea how to proceed • no advanced (e.g. retrograde) experience • etc. CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Extend your equipment • Talk with colleagues (e.g. EuroCTO - club members) • Send patient to Experts (some of them you find here)
- 31. What was the reason for CTO PCI failure ? • Operator/equipment has reached his (technical) limits • equipment limited in stock • no further idea how to proceed • no advanced (e.g. retrograde) experience • etc. CTO PCI Failure EuroCTO - Meeting Berlin 2019 CTO PCI FAILURE • Extend your equipment • Talk with colleagues (e.g. EuroCTO - club members) • Send patient to Experts (some of them you find here) • Take part in CTO courses
- 32. Why are we doing all this ? CTO PCI Failure EuroCTO - Meeting Berlin 2019
- 33. THEREFORE ! CTO PCI Failure EuroCTO - Meeting Berlin 2019
- 34. Thank you for your attention CTO PCI Failure EuroCTO - Meeting Berlin 2019
- 35. Thank you for your attention CTO PCI Failure EuroCTO - Meeting Berlin 2019