LEFT MAIN LAD CHRONIC TOTAL OCCLUSION RECANALISATION IN POST CABG PATIENT

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Left Main Lad Chronic Total Occlusion Recanalisation In Post Cabg Patient Sergey Furkalo - National Institute Surgery and Transplantology Kiev, Ukraine Case Competition - 11th Experts Live CTO The annual Euro CTO meeting September 13th –14th, 2019 - Berlin, Germany

11. Deutscher Allergiekongress 2016 in Berlin
LEFT MAIN – LAD CHRONIC TOTAL OCCLUSION RECANALISATION
IN POST CABG PATIENT
Sergey Furkalo
National Institute Surgery and Transplantology
Kiev, Ukraine

11. Deutscher Allergiekongress 2016 in Berlin

11. Deutscher Allergiekongress 2016 in Berlin
CLINICAL FEATURES
Patient 79 y.o. male, presented with progressive angina.
HYSTORY: 2016 non Q-wave MI in antero-lateral area.
-Hypertensive, non smoker, EF-56%, anterior hypokinesia.
-2016 CABG with LIMA LAD graft, venous bypasses to RCA and D1.
- 06.2019 Diagnostic coronarography: LM CTO, LIMA to LAD occluded, venous grafts to RCA
and D1 patent. D1 75% ostial stenosis. LAD opacification through venous graft to D1.
- JCTO score 3 (retry CTO, calcium, blunt stamp), GFR – 56 ml/min.
Previous CTO attempt: 06.2018 – not successful. 07.2019 – not successful attempt CX CTO
recanalization with creation subintimal pass.

11. Deutscher Allergiekongress 2016 in Berlin
Previous СХ recanalization attempt (2 weeks before)

11. Deutscher Allergiekongress 2016 in Berlin
Double femoral approach: EBU 3,75-
7F (LM) & AR 2-7F (D1 graft) Ostial D1 critical stenosis

11. Deutscher Allergiekongress 2016 in Berlin
1. AWE not successful (Gaia 2,Gaia 3, CP 12)
2. Retrograde approach via D1 graft

11. Deutscher Allergiekongress 2016 in Berlin
1.Retrograde - Hyperion AL 1.5, Guideliner 6F
RWE (Gaia 2 Gaia 3, CP12, CP8-20). 2.Externalisation

11. Deutscher Allergiekongress 2016 in Berlin
1.LM-LAD Dilatation 2. Double lumen catheter for LAD wire crossing and stenting

11. Deutscher Allergiekongress 2016 in Berlin
Final result with good LM stent apposition

11. Deutscher Allergiekongress 2016 in Berlin
CONCLUSIONS
1. In CTO patients after CABG, unstable manifestation of the disease not
uncommon.
2. In patient with proximal LAD stenosis/occlusion additional D1 bypass grafting
not recommended in case of high volume retrograde flow to LAD
3. The possibility of complete revascularization may in some cases be limited.
4. Venous grafts can be a good way for retrograde approach.
5. CTO in bypassed arteries are characterized by calcification and significant
difficulties for recanalization both antegrade and retrograde.
6. IVUS control mandatory for LM CTO interventions.
7. Venous graft embolization at the discretion of the operator

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LEFT MAIN LAD CHRONIC TOTAL OCCLUSION RECANALISATION IN POST CABG PATIENT

1. 11. Deutscher Allergiekongress 2016 in Berlin LEFT MAIN – LAD CHRONIC TOTAL OCCLUSION RECANALISATION IN POST CABG PATIENT Sergey Furkalo National Institute Surgery and Transplantology Kiev, Ukraine

2. 11. Deutscher Allergiekongress 2016 in Berlin

3. 11. Deutscher Allergiekongress 2016 in Berlin CLINICAL FEATURES Patient 79 y.o. male, presented with progressive angina. HYSTORY: 2016 non Q-wave MI in antero-lateral area. -Hypertensive, non smoker, EF-56%, anterior hypokinesia. -2016 CABG with LIMA LAD graft, venous bypasses to RCA and D1. - 06.2019 Diagnostic coronarography: LM CTO, LIMA to LAD occluded, venous grafts to RCA and D1 patent. D1 75% ostial stenosis. LAD opacification through venous graft to D1. - JCTO score 3 (retry CTO, calcium, blunt stamp), GFR – 56 ml/min. Previous CTO attempt: 06.2018 – not successful. 07.2019 – not successful attempt CX CTO recanalization with creation subintimal pass.

4. 11. Deutscher Allergiekongress 2016 in Berlin Previous СХ recanalization attempt (2 weeks before)

5. 11. Deutscher Allergiekongress 2016 in Berlin Double femoral approach: EBU 3,75- 7F (LM) & AR 2-7F (D1 graft) Ostial D1 critical stenosis

6. 11. Deutscher Allergiekongress 2016 in Berlin 1. AWE not successful (Gaia 2,Gaia 3, CP 12) 2. Retrograde approach via D1 graft

7. 11. Deutscher Allergiekongress 2016 in Berlin 1.Retrograde - Hyperion AL 1.5, Guideliner 6F RWE (Gaia 2 Gaia 3, CP12, CP8-20). 2.Externalisation

8. 11. Deutscher Allergiekongress 2016 in Berlin 1.LM-LAD Dilatation 2. Double lumen catheter for LAD wire crossing and stenting

9. 11. Deutscher Allergiekongress 2016 in Berlin Final result with good LM stent apposition

10. 11. Deutscher Allergiekongress 2016 in Berlin CONCLUSIONS 1. In CTO patients after CABG, unstable manifestation of the disease not uncommon. 2. In patient with proximal LAD stenosis/occlusion additional D1 bypass grafting not recommended in case of high volume retrograde flow to LAD 3. The possibility of complete revascularization may in some cases be limited. 4. Venous grafts can be a good way for retrograde approach. 5. CTO in bypassed arteries are characterized by calcification and significant difficulties for recanalization both antegrade and retrograde. 6. IVUS control mandatory for LM CTO interventions. 7. Venous graft embolization at the discretion of the operator

11. 11. Deutscher Allergiekongress 2016 in Berlin CONCLUSIONS 1. In CTO patients after CABG, unstable manifestation of the disease not uncommon. 2. In patient with proximal LAD stenosis/occlusion additional D1 bypass grafting not recommended in case of high volume retrograde flow to LAD 3. The possibility of complete revascularization may in some cases be limited. 4. Venous grafts can be a good way for retrograde approach. 5. CTO in bypassed arteries are characterized by calcification and significant difficulties for recanalization both antegrade and retrograde. 6. IVUS control mandatory for LM CTO interventions. 7. Venous graft embolization at the discretion of the operator

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