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

1. RCA Recanalization in a post CABG patient
Achim Büttner
Universitäts-Herzzentrum
Freiburg - Bad Krozingen, Germany
4th European Live Summit on Retrograde CTO Revascularization

2. Complex CTOs: Patients after CABG
CTOs single operator Bad Krozingen 01/2011 – 09/2013 (n=583)
P<0.001 P<0.001 P<0.001
(n=434) (n=145)
62.7
19%
34%
51
95%
69.3
37% 41%
66
82%
Age (years) Angina CCS
3+4
Retrograde
approach
Fluoroscopy
time (min)
Success rate
No CABG Previous CABG
P<0.001P=0.118

3. Complex CTOs: Patients after CABG
CTOs single operator Bad Krozingen 01/2011 – 09/2013 (n=583)
P<0.001 P<0.001
(n=434) (n=145)
P<0.001
27%
23
18%
1.4%
10%
32
43%
4.1%
LAD-CTO CTO length (mm) Calcium °3 Rotablation
No CABG Previous CABG
P=0.053

4. • Male, 77 years
• Risk factors: Hypertension, hypercholesterolemia
• 1993 Angio: 3VD (LAD 75%, 1st Diag 60%, LCX 100%, RCA 100%)
• 1993 CABG: LIMA on LAD, SVGs on 1st Diag and distal RCA
• 2003, 2007, 2008: Stent implantations both SVGs
• 03/2015: Angina pectoris CCS 3, dyspnoea NYHA III
Echo: Normal LV function
Stress test: Positive 150 watts
CTO of RCA 22 years post CABG
#220921

5. Left coronary artery

6. Right coronary artery (RCA) LAO

7. RCA RAO

8. SVG to 1st Diag

9. SVG to RCA

10. LIMA to LAD

11. Recanalization of RCA
Antegrade
Fielder XT
ConfianzaPro 12
Finecross

15. Retrograde strategy
Collaterals from LAD
via LIMA-Graft ?
Via occluded SVG ?

16. Passage SVG
- Wire Ulimate 3g
- Corsair Microcatheter

18. Retrograde wire
Fielder XTR

19. From retrograde
no entry !
ConfianzaPro12

20. Knuckle technique

22. Reverse CART
2.5mm Balloon
Ultimate (Ø)
Pilot 200 (!)

23. Strategy
Externalization ?
Tip-in ?

24. „Tip-in“ manoeuver in guiding catheter
Antegrade Wire
Meeting point in outer curve
Retrograde Corsair
in antegrade guide

25. Antegrade
BMW Extra Support
Finecross

29. Extra support floppy wire
→ Fielder XTR
(Alternative: Modified CART)

32. Balloon
1.5mm

33. Balloons
2.25mm
3.0mm HP

34. Stent
2.75 x 38mm Everolimus

35. Stent
3.0 x 38mm Everolimus

36. Stent
3.5 x 8mm Everolimus

37. Final LAO

38. Final RAO

39. CTOs after CABG have worse lesion characteristics (calcium)
and are technically demanding
Typical „recanalization modules“ in CTOs post CABG
• Occluded bypass graft as conduit for retrograde guidewires
→ CART, retrograde stent implantation
• Knuckle technique
• Reverse CART
• Tip-in versus externalization (distal anatomy, back-up)
Take home message

40. Complete* (n=750)
Incomplete 1 region (n=444)
Incomplete ≥ 2 regions*(n=191)
Prognosis after PCI late post CABG
*Adjusted HR 1.94 (1.36 – 2.77); p<0.001
Adjusted cumulative mortality and degree of revascularisation
0 1 2 3 4 5
Years