14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany AGIK Parallel Session - Session 5: Essential tools for complication management LIAB post CABG mit Impella Mohamed Ayoub, Bad Oeynhausen, Germany Room: West Foyer - Saturday 12:00 Chairmen: Dimitrios Karmpaliotis, Morristown, USA; Kambis Mashayekhi, Lahr, Germany; Andrea Gagnor, Turin, Italy

1. Within the past 12 months, I or my spouse/partner have had a
financial interest, arrangement, or affiliation with the
organization(s) listed below:
LIAB Post CABG with Impella
Mohamed Ayoub
Director CHIP and CTO Program
University Heart Center Bad Oeynhausen

2. Within the past 12 months, I or my spouse/partner have had a
financial interest, arrangement, or affiliation with the
organization(s) listed below:
Within the past 12 months, I or my spouse/partner have had a
financial interest, arrangement, or affiliation with the
organization(s) listed below:
Affiliation/Financial Relationship
Consultant, Proctor
Company
BostonScientific,Tel
eflex, Asahi intecc,
Cordis, Terumo
Disclosures

3. Post-CABG CTOs are the most complex CTO
scenarios
• Severe native vessel disease
• Anatomical ambiguity and graft anastomosis changing the vessel
route
• Extensive fibrosis/calcification
• Narrow landing zone
• LIMA as the last remaining patent graft

4. PostCABGprevalencein theliterature
ranged from 7.5% to 36%
Muramatsu Tet al. EuroIntervention 2014
Alessandrino Get al. JACCCI2015
Alaswad Ket al. CCI2015

5. Post CABG CTO
Prevalence of perforation in the Open CTO Registry

6. Learning Objectives
Troubleshooting of
uncrossable lesion
during CTO PCI
Rotational
atherectomy in
the subintimal
space in CTO PCI
Perforations and
how to avoid or
treat them

7. History
• 76-year-old male with known coronary artery disease
• History of CABG (LIMA to LAD, SVG to CX-PL, SVG to Dg) 2008
• Patient referred to our centre for PCI of SVG to RCA or CTO PCI of RCA
• Ejection fraction 37% with preserved viability in MRI
• Clinical presentation: persistent dyspnoea NYHA II

8. MRI: Viability in the RCA Territory

9. Post CABG CTO RCA, J-CTO 4
Retrograde collaterals from LIMA-LAD Calcified blunt proximal cap

10. Post CABG CTO RCA, J-CTO 4
Turnpike spiral MC, Confianze Pro 12, Modified
Carlino technic Guide extension > knuckle wire

11. Post CABG CTO RCA, J-CTO 4
Confirming knuckle position

12. Post CABG CTO RCA, J-CTO 4
Mumba flex MC, Gaia 3rd. subintimal in the RPLD

13. Post CABG CTO RCA, J-CTO 4
After rewiring Gaia 3rd in true lumen in RPLD Balloon uncrossable proximal CAP

14. Post CABG CTO RCA, J-CTO 4
RA with 1.5 burr performed

15. Post CABG CTO RCA, J-CTO 4
Safety check after RA Wiring attemp of PDA using dual lumen MC

16. Post CABG CTO RCA, J-CTO 4
Subintimal wire position at the bifurcation

17. Post CABG CTO RCA, J-CTO 4
IMA to LAD as last remaining vessel

18. Post CABG CTO RCA, J-CTO 4
Balloon dilatation (2.0 mm) of CTO segment Final shot

19. CT scan

21. Outcome
• Patient transferred to the ICU with Impella CP
• CT- scan showed large myocardial hematome
• 15l volume were transferred during 48 hours
• Impella weaned after 72 hours
• Patient discharged at day 7

22. Learning objective 1
Troubleshooting algorithm of uncrossable lesion during CTO:
Increase support
Power-knuckle
Modified Carlino Technique
Laser
External crush
Rotational atherectomy

23. Learning objective 2
Rotational atherectomy in the subintimal space
in CTO PCI:
• Small burr (1.25mm)
• Conventional speeds (160.000 to 180.000 rpm)
• Rota wire needs to be within the vessel
architecture

24. Learning objective 3
Perforation in Post CABG CTO PCI:
1. Prepare coils, covered stents, ping-pong technique etc.
2. Notify the surgeon
3. Treat early
4. Impella supprt might be helpful

25. T H A N K YO U !

26. T H A N K YO U !