HKSTENT 2012: 2012/3/3-4 11:47 12:17 CTO Complication
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1 HKSTENT 2012: 2012/3/3-4 11:47 12:17 CTO Complication SATORU SUMITSUJI MD. FACC. Specially Appointed Associate Professor Advanced Cardiovascular Therapeutics, Osaka University Director of Heart Center, Nozaki and Nagoya Tokushukai Hospital
2 Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial Interest /arrangement or affiliation with the organization(s) listed below Affiliation/Financial Relationship Consulting Fees/Honoraria: Company Abbott Vascular Asahi Intec Boston Scientific Cordis, Johnson & Johnson Kaneka Medtronic Terumo AstraZeneca Daiichi-Snakyo/Eli Lilly Sanofi-Aventis Zio software
3 Key points of this talk Introduction of contemporary CTO Understanding CTO specific complications How to deal those complications How to avoid them
4 Stream of CTO-PCI General Detail 1980 s Germination 1990 s Early spreading 2000 s New concept 2010 s More spreading Very few operators Very limited equipment More physician & equipment New concepts (Parallel wire / IVUS guidance) Retrograde approach Image support: CT New Equipment Retrograde approach Image support: CT New Equipment
5 What is the contemporary CTOPCI? Histopathologic aspect Imaging modalities support Developed devices Sophisticated strategies
6 Typical young and aged CTO 1.5 yrs 5 yrs Sumitsuji et al. JACC Intv 2011; 9:941 51
7 Subintima : histopathology vs. IVUS
8 Feature of Subintima
9 Subintimal tracking in antegrade
10 Subintimal tracking in antegrade
11 Subintimal tracking in retrograde
12 Calcium information from CT
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14 My CTO-PCI strategy (2008/4 - ) CTO - PCI Heart CT Antegrade technique Retrograde technique Single wire Parallel wire IVUS entry search Retrograde Wire (w IVUS) Kissing Wire CART Stent reverse CART IVUS guide penetration Success Failure
15 CTO specific complications 2012 general and new complications General Complications Radiation / Renal dysfunction Thrombus trouble More CTO-PCI related Complications Wire perforation intra-cto & distal coronary Device perforation intra-cto Distal embolization Donor artery trouble = thrombus + dissection Retrograde channel perforation
16 Complications in CTO-PCI CIN: contrast induced nephropathy Check used contrast, hydration No definite effective solution Option: minimum Contrast CTOPCI with retrograde approach Radiation dermatitis Check Fluoro time, Air Karma data Dermatologist care, transplantation Radiation pneumonia Respiratory symptom (dry cough) Steroid, never BAL (bronchoalveolar lavage) >> ARDS
17 Thrombus formation Prevention Heparinization Flushing ACT 300sec = 5min means that clot can be made in 15min Treatment Do not push thrombus into coronary Taking all system out Deep consideration of ruling out dissection
18 Problem of no dye injection in case of RETRO or minimum Contrast PCI RGMC:
19 Thrombus due to forgetting Heparin
20 Thrombus due to forgetting Heparin
21 CTO specific complications 2012 general and new complications General Complications Radiation / Renal dysfunction Thrombus trouble More CTO-PCI related Complications Wire perforation intra-cto & distal coronary Device perforation intra-cto Distal embolization Donor artery trouble = thrombus + dissection Retrograde channel perforation
22 Wire perforation intra-cto & distal coronary Prevention Honestly difficult Treatment Intra-CTO Sealing with plaque Prolonged ballooning or Covered stent Distal coronary Coiling Embolization using fat / special material
23 Entry CTO wire perforation Long ballooning (~10min)
24 Intra-CTO wire perforation
25 Intra-CTO wire perforation
26 Intra-CTO wire perforation
27 Intra-CTO wire perforation
28 Intra-CTO wire perforation
29 Intra-CTO wire perforation
30 Distal wire perforaiton
31 Coils and compatible micro-catheter Embolic coils Left : 10mm C, rithg : 20mm Tornade For me personally, compatible and Finecross compatible embolic coils are so important.
32 Device perforation intra-cto Prevention IVUS perforation high risk sign Treatment Prolonged ballooning Covered stent
33 Schema of coronary perforation IVUS image is maybe predictable??? Over-stretching and perforation
34 Type 1: severe eccentric calcified plaque with weak segment in opposite side Post Rotablator Post ballooning 9 in 28 lesions showed type 1 IVUS image.
35 Type 2: severe eccentric fibrous plaque with weak segment in opposite side 8 in 28 lesions showed type 2 IVUS image.
36 Type 3: severe superficial calcium with weak segment in opposite side 4 in 28 lesions showed type 3 IVUS image.
37 Case: without trouble in high risk lesion 76yo Female, AMI anterior Bended calcified lesion with IVUS perforation high risk sign. RGMC:
38 RGMC: dissection
39 How to do for these high risk lesion? Reducing stretch ratio A2 B2 Make dissection Modify plaque Risk of perforation: B1/A1 >>> B2/A2 or B3/A3 B1 A1 A3 B3
40 Distal embolization Prediction & Prevention CT and IVUS high risk sign Distal protection devices Treatment Nitorates Flow support ; IABP
41 3. April, 2010 China Interventional Therapeutics, Beijing, China n=855 Attenuation (+) Attenuation (-) Minus HU (+) 15/ 51 (29.4%) 0/ 58 (0%) Minus HU (-) 1/ 59 (1.7%) 1/ 687 (0.1%) Cardiology of Heart Center, Nozaki Tokushukai Hospital
42 Donor artery dissection Prevention Assessment of donor artery stenosis Treatment Stenting
43 Donor artery dissection
44 Donor artery dissection
45 Donor artery dissection
46 Retrograde channel perforation Prevention Careful angiographic assessment Check difficulty of micro-catheter cross in channel Final selective angiogram Not to be optimistic Treatment Septal channel: leaving in almost all cases Epicardial channel: coiling
47 Channel Perforation (troubled)
48 Channel Perforation (troubled)
49 Channel Perforation (troubled)
50 Channel Perforation (managed)
51 Channel Perforation (managed)
52 Channel
53 Channel
54
55 Channel
56 Channel
57
58
59
60 Long-term (3yrs) mortality in CR/IR group
61 ONE YR MORTALITY AFTER PCI FOR AMI: 1437 PATIENTS Van der Schaaf. AJC 2006;98:1165
62 Impact of CTO within AMI case (2yr survival)
63 Case : ACS+VF > cardiac death (61M) known LAD-CTO + RCA-ACS
64 Case : ACS+HF > Cardiac death (87M) known LAD-CTO + LCX-ACS, RCA severe stenosis
65 CPA case: MVD+AMI, in-hospital CPA 3vesssel occlusions Date_RGMC_Rm_HamaokaTadashi62M_3VesselOcclusion+6moLaterDeath
66 CPA case: 60M died 2vessels almost occlusion
67 CPA case: 91M died 2vessels occlusion, 1vessel severe stenosis
68 CPA case: 60M died 2vessels occlusion
69 CPA case: 75M died 2vessels occlusion, 1vessel severe stenosis
70
71
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73 CTO and CTO complication Nowadays CTO-PCI has became more popular, more reproducible, and more reliable. On the other hand with treating more difficult lesions and patients and with more complicated strategies, we still face problems including complication during CTO-PCI. Good understanding and management of complication increase the level of your CTO-PCI.
74 China New Zealand UAE Thailand JAPAN Malaysia Malaysia Libya Bangladesh
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