Experts "Live" CTO Workshop 2015 Septemper, 18th – 19th , 2014 in Istanbul, Turkey

1. Basics of CTO PCI:
“Reading the angiogram
of a CTO patient”
V Martin Yuste, MD, PhD
H Clinic. Barcelona. Spain

2. Background
• 9.4 – 5.7 % of all PCI
• Long, expensive, complex procedures
• Low success rate.
• Negative contribution to the making
decision process about treatment
– Mono-vessel disease medical treatment
– Multivessel disease CABG regardless if the
other lesions can be easily treated by PCI

3. WHY IS A GOOD ANGIOGRAM
SO IMPORTANT?
• 1. Contributes to the correct diagnostic of CTO
• 2. Helps us to select the lesion suitable for PCI
and to inform the patient about the success rate
of this particular CTO PCI
• 3. Can help us to plan the CTO PCI procedure
– Antegrade/retrograde
– The best collaterals to go through
– Material…

4. 1. Diagnostic
TIMI 0
DURATION > 3 MONTS

5. 2. Lesion selection
Morino et al JACC CI 2011; 4:213-21

6. 2. Lesion selection
J-CTO scoring and wire crossing
Morino et al JACC CI 2011; 4:213-21

7. 3. How to plan the
procedure

8. 3. How to plan the
procedure
• A) Proximal vessel
• B) Proximal cap of CTO
• C) CTO body
• D) Distal cap of CTO
• E) Quality of distal vessel
• F) Collateral channel

9. A) Proximal vessel

10. B) Proximal cap of CTO
• Blunt or tapered
• Calcification
• Side branch

11. C) CTO body

12. D) Distal cap of CTO

13. E) Distal vessel quality

14. E) Collateral channel
• Epicardial
– Conus branch-LAD
– RV branch-LAD
– RV-PD branch
– PD branch-apex LAD
– RCA PL branch-Dx branch
– RCA PL branch-LCX /OM
branch
– LCX OM/PL branch
– Dx-OM/PL blanch
– Dx to Dx
• Atrial
– SN branch-AV node artery
– RCA AC branc – LCX AC
bracnh
• Septal
– Septal to septal
– AM branch-septal-LAD
– RCA PD branch /PL
branch-septal-LAD

15. Epicardial collateral LAD

16. Epicardial collateral RCA

17. • Se deben elegir en función de:
• A) Type of septal
• B) corkscrew – like morphology
• C) Flexible/rigid
• D) excessive bend of channel
• E) channel size (CC)
• F) Side branch of septal channel
• G) angle between septal and main branch at
origin and destination
Angiographic characteristics of collaterals
we need to analyze on the angiogram

18. A) Type of septal branch anatomy

19. B) Corkscrew-like morphology

20. Clasificación de la tortuosidad
• Mild. Straight vessel
or slightly curved
• Moderate. Curves
less angulated than
90º. A/D >2
• Severe. Corkscrew
appearance. A/D < 2

21. Flexible Rigid
C) Flexible/rigid

22. D) Bend of channel

23. CC0: no continuous
connection between
donor and recipient artery
CC1: continuous, threadlike
connection (<0.4mm)
CC2: continuous, small side
branch-like size
(>0.4mm)
E) Channel size (Collateral Connection
Grade)

24. F) Side branch of septal channel

25. G) Angle between septal and main branch at
origin

26. …and destination

27. • Just a “normal” angiogram isn’t enough to
plan our strategy when we face a CTO
PCI
• There are a lot of details to analyze before
coming to the cath-lab
CONCLUSIONS

28. Thank you for your attention