Elements of CTO PCI. Ashish Pershad, MD FACC Heart and Vascular Center of AZ & Banner Good Samaritan Medical Center

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1 Elements of CTO PCI Ashish Pershad, MD FACC Heart and Vascular Center of AZ & Banner Good Samaritan Medical Center

2 Disclosures Consultant- Bridgepoint Medical Systems Speakers Honorarium- WL Gore Inc. & Abbot Vascular Inc. and Medtronic Inc.

3 Rules for Diagnostic Angiography-Dissemination to Referring Physicians Use the lowest magnification (10 or 25cm) Promote dual cusp angiography (8fr sheath will allow 2 4Fr diagnostic catheters through same access) and obtain multiple orthogonal views Dissuade panning to allow for careful assessment of collaterals Start the injection in donor vessel; wait 2 secs and then inject CTO vessel Stay on the cine pedal until contrast clears the recipient vessel Educate referring physicians

4 Angiographic Evaluation of Proximal Cap Is the cap tapered or blunt? Are there bridging collaterals in proximity to the cap? Are there side branches near the cap? Suitability of using proximal side-branches to anchor for additional support Extent of calcification of the cap Proximal vessel tortuosity and disease

5 Angiographic Evaluation for CTO Procedure Planning Assessment of disease in the collateral vessel if retrograde approach is being considered If diseased then order of RX of donor vessel and CTO needs to be sorted out before index procedure Previous bypass insertion sites which might make anatomy ambiguous If collaterals are from dual sources then a third access site may be necessary for visualization of retrograde filling of a CTO

6 Common Interventional Collateral Patterns and Views Septal perforator branches from the LAD to RCA and vice versa RAO cranial for entry and RAO or RAO caudal for exit angle Epicardial vessels Customized views Saphenous Venous Bypass grafts PS: The clue to filling of the dominant collateral is the frame by frame filling pattern

7 Collateral Prioritization

8 Epicardial Collaterals-Suggested Angiographic Views OM/PL and Diagonal donors to OM branches- LAO and RAO cranial projections Proximal OM to RCA- RAO and AP caudal projections Regardless, in virgin chest orthogonal views of epicardial collaterals is critical because perforation is potentially catastrophic- (tamponade and need for coiling both feeders to treat tamponade)

9 2012 Algorithm for Crossing CTOs Brilakis, E. S. et al. J Am Coll Cardiol Intv 2012;5: Copyright 2012 American College of Cardiology Foundation. Restrictions may apply.

10 Evaluating the Diagnostic Angiogram in the Context of the Hybrid Algorithm Proximal cap anatomy Ambiguous or well defined Lesion length <20mm or >20mm Suitability of interventional collaterals Usable or not Quality of the target vessel Good or not

11 LAD occlusion Septal perforator branches from the LAD to RCA and vice versa-rao cranial for entry and RAO or RAO caudal for exit 1

12 LAD Occlusion Epicardial collateral from the RCA RV marginal branch to the LAD apex 2

13 LAD Occlusion Epicardial collateral from the Diagonal to the LAD 3

14 LAD occlusion Conus branch from the proximal RCA to the proximal LAD 4

15 RCA occlusion LAD collaterals from the septals to the PDA 1

16 RCA Occlusion Epicardial collateral from the Circumflex artery (LA branch or PL branch to the PL branch of the RCA) 2

17 RCA occlusion RCA epicardial homocollateral from the proximal RCA to the PDA 3

18 RCA Occlusion LAD collateral from the proximal LAD to the proximal RCA (conus branch) 4

19 RCA Occlusion LAD apical collateral to the RV branch; Rarely to the PDA 5

20 Circumflex Occlusion Epicardial PLB from the RCA collateral to the proximal CX artery 1

21 Circumflex Occlusion Epicardial collateral from OM1 to OM 2 or to OM 3 2

22 Circumflex Occlusion Epicardial collateral from diagonal to OM1/ OM 2 or OM 3 3

23 Diagonal Artery to OM collateral (epicardial)

24 Diagonal Artery to OM collateral (epicardial)

25 LAD/CX to RCA collateral-pda and PLA

26 LAD Septal TO PDA

27 LAD Septal to PDA

28 RCA to LAD collateral

29 RCA to RCA collateral

30 The Base of Operations the model for effectiveness and efficiency Antegrade Goal Move gear safely and quickly to distal cap to focus on true lumen entry or Move gear beyond distal cap to focus on reentry Retrograde Goal Move gear safely and quickly to proximal cap for true lumen entry or reverse CART (dissection connection) Mobile, not fixed, base Move up and down vessel as circumstances dictate

31 Myth and Obsession with True Lumen Safety concerns about using the subintimal space Safety-durability concerns about implanting DES in the subintimal space Presumed theoretical improvement in vessel healing when stenting the true lumen

32 However???? All devices that have attempted to stay true to true have failed (Frontrunner and Safecross being examples) Even presumed true to true wire passage has been shown to be through the subintimal space ( in and out ) in 30-50% of the time by IVUS analysis

33 Antegrade Dissection and Reentry Techniques Uncontrolled 1. STAR (subintimal tracking and re-entry) 2. MiniSTAR 3. Carlino s Contrast enhanced MiniSTAR 4. LAST Controlled Reeentry Stingray Balloon and Guide wire

34 Antegrade Dissection Techniques CTO True lumen STAR/Mini STAR/Contrast STAR reentry True lumen LAST redirection True lumen Bridgepoint reentry

35 Stingray Animation

36 Re-entry Zone Management Common error is enlarging the subintimal space bycontrast injections -hydraulic dissections large loops-knuckle management dilatation of the space with larger than required balloons-hematoma expansion All these 3 maneuvers need to be consciously avoided

37 Successful Reentry Maneuver through proximal port directed inferiorly

38 StingRay Fenestration Demonstation

39 Loss of Distal Visibility-Blind Stick In the absence of retrograde interventional collaterals or if antegrade hematoma results in loss of distal visibility-a <blind stick> may be needed Solutions include: 1. Thompson Technique 2. Straw Technique 3. Modified Straw Technique

40 Conclusions Antegrade wire escalation, antegrade dissection reentry, and retrograde wire escalation and dissection reentry techniques are complimentary and necessary for full spectrum CTO PCI Careful collateral review and assessment is essential for success Using the hybrid approach and base of operations concept- goal has shifted from true lumen obsession to true lumen control proximal and distal to the CTO The subintimal space in the CTO body itself can be a friend and not a foe- Trust the Knuckle