4th European Live Summit on Retrograde CTO Revascularization - May 8–9, 2015, in Zurich, Switzerland

1. Is it always
possible to predict
and prevent a
severe
complication?
What would you do in
this case?

2. 4th European Live Summit on Retrograde
CTO Revascularization

3. 4th European Live Summit on Retrograde
CTO Revascularization
• Male, 70 yo
• RF: hypertension, former smoking, dyslipidemia and diabetes
• 03/2014: effort angina
• 06/2014 positive ecg stress test
• 06/2014 CGF -> <50% mid LAD stenosis; 80% prox LCX and mid RCA CTO; LCX PCI with 1 DES
• 07/2014 cardiac stress MRI -> inferior ischemia
• 08/2014 RCA CTO PCI attempt

4. X
X
X
X
X
1X
J-CTO = 1
Category of difficulty: intermediate
Occlusion lenght: >20 mm
Angiographic analysis

5. PROCEDURAL PLANNING
My strategy
4th European Live Summit on Retrograde
CTO Revascularization

6. Evaluation for possible complications:
• dissection (plastic jacket)
• perforation (stiff wires)
Technical considerations:
• proximal cap ambiguity
• very long lesion ≈ 40 mm
• good distal vessel opacification
1° step (antegrade)
Start with an antegrade attempt with an antegrade wire escalation

7. 2° step (retrograde via septal CC)
In case of antegrade failure switch to retrograde approach via septal channels
Technical considerations:
• No clear continuous connection between donor
and recipient (CC0) -> tip injection to identify
suitable CC for retrograde crossing; as alternative
septal surfing with dedicated GWs
• Very long lesion -> high probability of reverse CART
Evaluation for possible complications:
• Septal perforation
• Donor vessel injury
• Thrombosis of donor vessel
• Reverse CART related

8. 3° step (retrograde via epicardial CC)
In case of inability to cross septal CCs switch to retrograde approach throught epicardial CC
Technical considerations:
• Guiding catheter shortening
• Unfavorable collateral -> corkskrew-like
morfology (very tortuous epicardial collateral)
Evaluation for possible complications:
• CC perforation (epicardial)
• Recipient artery ischemia

9. 1° step (antegrade)
Finecross Microcatheter + AWE
Fielder XTA -> UB3 -> Conquest Pro 9
-> Conquest Pro 12
Antegrade inability to cross the
lesion

10. 2° step (retrograde via septal CCs)
No clear continuous connection between donor and
recipient (CC0) -> tip injection to identify suitable CC
for retrograde crossing; as alternative septal surfing
1st
2nd
3rd

11. 2° step (retrograde via septal CCs)
First septal Second septal
Tip injection

12. Second septal Third septal
CC surfing (Sion Black GW)
No way for retrograde septal CCs crossing

13. 3° step (retrograde via epicardial CC)
For epicardial crossing ->
Sion GW with a 90° curve 1 mm from the tip

14. Epicardial crossing

15. .
sudden bradycardia and severe hypotension
No signs of epicardial collateral channel perforation

16. VF -> DC shock followed by asystolia –> immediate CPR
Corsair withdrawal in the mid LAD and then the GW

17. After 15’ of CPR -> recovery of hemodynamic stability
ECHO: no signs of pericardial effusion

18. Xience 3,5 x 18 mm
IABP and cardiac pacing ->
hemodynamic stability
Iatrogenic LM dissection during CPR
LM single DES implantation

19. Final resultFinal kissing balloon

20. What happened?
• This patient had only epicardial collateral via apex from LCA to RCA. No septal,
atrial or PL connections at all
• After successful delivery of a Sion and a Corsair the epicardial collateral collapsed
due to accordion phenomenon and the patient developed acute inferior MI

21. • It’s very difficult to predict whether severe accordion
phenomenon happens or not
• It’s important to check whether there are other
collaterals than apical one
• Even if you replace the Corsair by a Finecross the
accordion phenomenon could improve
• Even a Sion wire can results in similar complication
How to predict and prevent it?

22. What should I do in this case?
Antegrade subintimal crossing?
Wire-based?
(Knuckle wire technique)
Catheter-based?
(CrossBoss device)

23. When?
As an initial strategy
(primary dissection/re-entry)
Good candidate lesion for primary
dissection/re-entry strategy
≥ 20 mm lenght
Large caliber distal vessel
No large branches within the CTO
and at the distal cap
Lack of good “interventional”
collaterals?
After failure of antegrade wire escalation
(inadvertent subintimal crossing) or
failure of the retrograde approach

24. The optimal role and timing of antegrade dissection/re-entry in CTO PCI
continues to be subject of debate
“Hybrid” operators favor early application of antegrade dissection/re-
entry to increase success rate and improve efficiency of the procedure
Other operators argue that dissection/re-entry shuold only be used as a
last resort after other crossing strategies fail, because the long-term
patency of contemporary dissection/re-entry strategies remains
unknown
What would you do in this case?