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Plan the approach based on the angiogram
Markus Meyer-Geßner Augusta-Krankenhaus Düsseldorf
2
Alexander von
Humboldt,
Born in Berlin 250 years
ago 14th of september
A Pioneer of scientific expeditions through terra incognita
Roadmap of several expeditions
3
The roadmap with terra incognita:
Bilateral angiogram
Complete overview (limited collimation)
No panning
Adequate angulations
Start with retrograde injection
4
Retrograd septal via ACVB und RIVP
5
Barriers inside terra incognita
4 C of complexity: Cap, Calcium, Curve, Channel length
„RECALL“
= 4C + Redo
J Am Coll Cardiol Intv. 2011;4(2):213-221. doi:10.1016/j.jcin.2010.09.024
J-CTO Score 0-5
J Am Coll Cardiol Intv. 2011;4(2):213-221. doi:10.1016/j.jcin.2010.09.024
J-CTO Score: Antegrade wiring success rate and time
8
EURO CTO (CASTLE) score= 4C + age + prior CABG
9
EURO CTO (CASTLE) Score
JACC CVI 2019
JACC CVI 2019
10
From roadmap to expedition plan
J-CTO score 3, CASTLE score 3 – success rate antegrade
<80%
Interventional collaterals -> retrograde septal access
Cap: not tapered
Channel length: >20mm
Calcification: moderate
Collaterals: septals and epicardials, septal approach feasible
11
Retrograde septal PDA-LAD
12
Easy case for beginners – J CTO score 0
Basics: contralateral injection, microcatheter
13
Challenging case for experts - CASTLE score 6
CTO RCA 2007 before CABG
14
Multilevel CTO RCA 2017 10 y post CABG, CASTLE Score 6
Part 1: proximal opening, retrograde via ACVB
15
Part 2: distal opening retrograde via
epicardial channel LCX to PLB
16
CTO RCA 2007 - result 2017
17
A challenge for men and material:
RG3
Consensus Paper from Euro CTO Club Eurointervention 2019
Conclusion
A carefully performed and analyzed
roadmap is the key for planning the
expedition through terra incognita

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Plan the approach based on the angiogram