The document discusses the methodologies for conducting angiograms, emphasizing the importance of a well-structured roadmap for navigating complex coronary cases. It highlights various scores such as the j-cto and castle scores to assess the likelihood of success in retrograde and antegrade interventions. Overall, careful planning is deemed essential for effectively addressing challenges in complex coronary interventions.

1. Plan the approach based on the angiogram
Markus Meyer-Geßner Augusta-Krankenhaus Düsseldorf

2. 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. 3
The roadmap with terra incognita:
Bilateral angiogram
Complete overview (limited collimation)
No panning
Adequate angulations
Start with retrograde injection

4. 4
Retrograd septal via ACVB und RIVP

5. 5
Barriers inside terra incognita
4 C of complexity: Cap, Calcium, Curve, Channel length

6. „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

7. 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. 8
EURO CTO (CASTLE) score= 4C + age + prior CABG

9. 9
EURO CTO (CASTLE) Score
JACC CVI 2019
JACC CVI 2019

10. 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. 11
Retrograde septal PDA-LAD

12. 12
Easy case for beginners – J CTO score 0
Basics: contralateral injection, microcatheter

13. 13
Challenging case for experts - CASTLE score 6
CTO RCA 2007 before CABG

14. 14
Multilevel CTO RCA 2017 10 y post CABG, CASTLE Score 6
Part 1: proximal opening, retrograde via ACVB

15. 15
Part 2: distal opening retrograde via
epicardial channel LCX to PLB

16. 16
CTO RCA 2007 - result 2017

17. 17
A challenge for men and material:
RG3

18. Consensus Paper from Euro CTO Club Eurointervention 2019

19. Conclusion
A carefully performed and analyzed
roadmap is the key for planning the
expedition through terra incognita