Should we revise our hybrid algorithms? Long RCA CTO and distal cap at a major bifurcation GEORGIOS SITAFIDIS MD EAPCIM CONSULTANT INTERVENTIONAL CARDIOLOGIST UNIVERSITY HOSPITAL OF LARISSA GREECE Case Competition - 11th Experts Live CTO The annual Euro CTO meeting September 13th –14th, 2019 - Berlin, Germany

1. Should we revise our hybrid
algorithms?
Long RCA CTO and distal
cap at a major bifurcation
GEORGIOS SITAFIDIS MD EAPCIM
CONSULTANT INTERVENTIONAL CARDIOLOGIST
UNIVERSITY HOSPITAL OF LARISSA GREECE

3. Case History

4. Dual Injections

5. The set up was Right Femoral 7F JR4
Right Radial 6F EBU 3.5

6. Tapered proximal cap, occlusion length >20mm,
tortuosity present, CC1&CC2 septal collaterals
from LAD to PDA, distal cap at bifurcation

7. Strategy
 Short attempt with antegrade wire
escalation deescalation if failed
 Immediate switching to retrograde approach
with good interventional collaterals to PDA
in order to preserve both branches of the
bifurcation.
 During the procedure intravascular imaging
is being considered ( IVUS ).
 If the aforementioned strategic plan
unsuccessful than ADR with stingray balloon
but I may loose one of the branches so not
the best option.

8. Workhorse wire supported by microcatheter
exchanged for Fielder XT

9. Antegrade microcatheter Finecross with Fielder
XT and anchoring balloon. Less supportive
guide due to some ostial disease

10. Fielder XT replaced by Gaia 2

11. Crossing wire to PL branch Gaia second

12. Gaia second exchanged for Sion Blue ES
and predilatation with 1.25x10mm balloon

13. Dual lumen microcatheter

14. Gaia second exchanged for an extra support
workhorse wire and after predilatation with
1.25x10mm balloon dual lumen microcatheter for
wiring and preserving the PDA

15. PDA is wired and secured & predils were done

16. Crossover Stenting

17. Crossover stenting and positioning with
retro injections

18. POT

19. Watch out ! Guides are entangled

20. More proximal predilatation and second stent ( of
course the anchoring balloon withdrawn )

21. Second Stent

22. RePOT

24. After IVUS multiple postdils were performed
and the ostium was not stented

25. Some concentric fibrofatty plaque but big MLA
at the proximal segment and left untreated

26. Deep vessel wall injury

27. Final Result

28. Final Result

29. Final Result

31. I DID NOT FOLLOW THE CONSENSUS
DOCUMENT BUT THE FINAL RESULT
WAS REWARDING