8th Experts Live CTO Workshop 2016, September, 30th - October 1st, 20116 in Krakow, Poland

1. RBK – Coronary Interventions
Successful transradial retrograde CTO
revascularisation via an epicardial collateral
using a single 6F guide
Tim Schäufele
Robert-Bosch-Krankenhaus Stuttgart
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2. Potential conflicts of interest
Speaker's name: Tim Schäufele
 I do not have any potential conflict of interest
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3. Case summary
Demographics:
 Age: 76 yrs old
 Gender: female
cvRisk Factors:
 Hypercholosterolemia
 Ex smoker
 Arterial hypertension
Demographics:
 Age: 76 yrs old
 Gender: female
cvRisk Factors:
 Hypercholosterolemia
 Ex smoker
 Arterial hypertension
Clinical Presentation and Indication:
 Stable but recurrent angina despite OMT
 Significant risk profile
Clinical Presentation and Indication:
 Stable but recurrent angina despite OMT
 Significant risk profile
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Medical History
 5/2015: de novo angina
 9/2015: stable angina on OMT
 Unknown coronary status
 No known history of MI
Peripheral vascular disease IIa
Coronary angio

4. Baseline angiography
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RCA- LAO LCA- RAO/CRAN
Diagnostic Catheter: TIGER II 3.5 5F via rightTRA

5. Baseline angiography
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RCA- LAO LCA- RAO/CRAN
Diagnostic Catheter: TIGER II 3.5 5F via rightTRA

6. Baseline angiography
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RCA- LAO LCA- RAO/CAUD
Diagnostic Catheter: TIGER II 3.5 5F via rightTRA

7. Baseline cMRI
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 Normal wallmotion lateral
 Severe inducible ischemia
 Lateral (RCX)
 Inferolateral (RCA/PLD)
 NB: not anterior!
 <50% myocardial scar

8.  Anatomically 3VD with functional stenosis in 2
vascular territorries (RCA/RCX)
 SYNTAX score 21.3
 STS score mortality 1.1%
 Anatomically 3VD with functional stenosis in 2
vascular territorries (RCA/RCX)
 SYNTAX score 21.3
 STS score mortality 1.1%
Baseline summary and MDT recco
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x
x
x
x
x
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MDT Recco: PCI

9. Strategy
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 TRA because of PVD
 no palpable puls left radial
 Ipsilateral collaterals only
Brilakis et al JACC 2012
Plan A
 Wire escalation
 Paralell Wire-
Technique
Plan B
 Retrograde via
epicardial collateral
 Externalisation
Plan C

10. CTO Procedure Step 1 Antegrade/Single Wire
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RAO/CAUD
Guide: EBU 3.5/ 6F via rightTRA; FINECROSS; FIELDER XTA;
Step-Up: Gaia 2nd
LAO/CAUD

11. CTO Procedure Step 2 Antegrade/Parallell Wire
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Guide: EBU 3.5/ 6F via rightTRA; FINECROSS; FIELDER XTA;
Gaia 2nd as parallell wire
LAO/CAUD
RAO/CAUD

12. CTO Procedure Step 2 Antegrade/Parallell Wire
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Guide: EBU 3.5/ 6F via rightTRA; FINECROSS; FIELDER XTA;
Gaia 2nd as parallell Wire
LAO/CAUD
RAO/CAUD
Gaia 2nd

13. CTO Procedure Step 3 Retrograde-search the collateral
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Guide: EBU 3.5/ 6F via rightTRA; CORSAIR 150mm; SION black
LAO/CRAN

14. CTO Procedure Step 4 Retrograde-collateral crossing
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Guide: EBU 3.5/ 6F via rightTRA; CORSAIR 150mm; GAIA 2nd
LAO/CRAN
a

15. CTO Procedure Step 5 Retrograde-Externalisation
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Guide: EBU 3.5/ 6F; CORSAIR 150mm; CONFIANZA pro 9 retro-
GAIA 2nd antegrade
RAO/CAUD
Unsuccsessful
attempt to „tip-in“
due to heavyly
moving
microcatheter
Unsuccsessful
attempt to „tip-in“
due to heavyly
moving
microcatheter
Confianza pro 9
Gaia 2nd
Confianza
pro 9
Finecross

16. CTO Procedure Step 5 Retrograde-Externalisation
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Left: Guide: EBU 3.5/ 6F; CORSAIR 150mm; RG3 (left)
Right: Guide: EBU 3.5/ 6F; BHW (right)
RAO/CAUD RAO/CAUD

17. 18
Was that all?
RCA:SYNERGY 3.0x38 mm; SYNERGY 3.5x20 ml; SYNERGY2.75x12 mm;SYNERGY
4.0x12 mm (left)
LAD: SYNERGY 3.5x16 (right) 4 wks later
LAO/CRAN
RAO/CRAN
ProceduralTime: 140 minutes
Cummulative Air Kerma: 3865 mGy
Dose Area product: 9874 cGycm²
ProceduralTime: 140 minutes
Cummulative Air Kerma: 3865 mGy
Dose Area product: 9874 cGycm²
@ Follow up 9 months: patient does well, no angina
MedTx reduced to Statin, ACEI, ASS, CLOPIDOGREL
@ Follow up 9 months: patient does well, no angina
MedTx reduced to Statin, ACEI, ASS, CLOPIDOGREL

18. CTO Procedure Final Result (FUP 4 Wks)
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RCX: SYNERGY 2.5x28mm; SYNERGY 3.0x8mm ; SYNERGY 2.5x8 mm
RAO/CAUD

19. Case summary Final/Discussion
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 TRA is a valuable option for CTO procedures
 Ipsilateral collaterals are an elegant way to go
 Use of single Guiding catheters for externalisation as
a „bail-out“ warrants special attention
 TRA is a valuable option for CTO procedures
 Ipsilateral collaterals are an elegant way to go
 Use of single Guiding catheters for externalisation as
a „bail-out“ warrants special attention
 apropriate patient selection is mandatory
 MDT provide best patient specific results
 cMRI is a usefull add- on but cann miss anterior
ischemia
 apropriate patient selection is mandatory
 MDT provide best patient specific results
 cMRI is a usefull add- on but cann miss anterior
ischemia
My personal take home message: Give 7F TRA at least a try!

20. Thank you for your attention!
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