Modified Reverse CART technique in a near-ostial
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1 Modified Reverse CART technique in a near-ostial RCA CTO Dr. Vincent O.H. Kwok MB BS (HK) FRCP (Lond( Lond, Edin, Glasg) ) FACC FSCAI Consultant Cardiologist & Director Cardiac Catheterization & Intervention Center Hong Kong Sanatorium & Hospital CART= Controlled Antegrade & Retrograde subintimal Tracking
2 Disclosure Statement of Financial Interest I, Dr. On-Hing Kwok, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
3 M/59yr Ex-smoker Case History Hypertension and dyslipidemia Known ischemic heart disease with positive exercise thallium scan showing inferior ischemia 6 years before Defaulted further intervention and treatment Self-medicated with over-the the-counter drug called vessel scavenger c/o increasing exertional dyspnoea and chest discomfort CT angiogram showed near-ostial RCA long-segment total occlusion
4 320 CT Coronary Angiogram
5 Coronary Angiogram 7Fr right femoral approach 6Fr JL4 Diagnostic catheter Left-to to-right collaterals
6 Coronary Angiogram
7 Right Coronary Angiogram Challenges: Near-ostial RCA long- segment total occlusion Faint right-to to-right collateral Blunt occlusion stump Side-branch at entry & exit of total occlusion Advantage: not much calcification
8 Attempt antegrade approach 7Fr AL1.0 SH (90cm) Medtronic guiding catheter Miracle 3 gm loaded on a Finecross microcatheter
9 Failure to traverse through the intra-luminal pathway
10 Still subintimal
11 Retrograde approach 77 Fr Left femoral approach 7Fr EBU 3.5 (90cm) Medtronic Guiding catheter Fielder XT guidewire Finecross microcatheter Selective septal angiogram
12 Selective Septal Angiogram
13 Advancing the Fielder XT
14 Fielder could not advance further Tortuous bend also precluded the advancement of the Finecross microcatheter Corsair micro-channel dilator not available
15 The micro-channel channel was gently dilated with a 1.3x10mm Lacrosse balloon at ATM
16 Finecross was advanced
17 Retrograde wire: Miracle 3 gm Guidewires Kissing inside same subintimal space
18 Subintimal space expanded Spiral dissections more obvious But antegrade and retrograde wires both could not be advanced further
19 Contained perforation Antegrade wire exit through the false lumen A contained perforation/hematoma was noted Patient remained hemodynamically stable
20 CART vs Reverse CART Limitation: almost always require septal channel dilatation Retrograde balloon passage is sometimes difficult even after septal dilatation Passage of long retrograde balloon may damage the septal collaterals, causing septal perforation or hematoma
21 Attempt Reverse CART 2.0x15mm Apex balloon inflated at 6 ATM The contained perforation precluded the use of IVUS as it may expand the spiral dissection/perforation N.B. Solid-state Eagle- Eye IVUS catheter not available
22 Failed to advance the Retrograde wire up, probably because of the tortuous bend Instead, the antegrade wire was retrieved a little and readvanced through the intraluminal pathway following the retrograde wire Risk: Collapsed common subintimal space and created another dissection/expanding distal dissection Alternatives: (Not available) Use of Corsair microcatheter to support the retrograde wire may help advance of the retrograde wire up Use of Snare-wire (Soutenir)
23 Antegrade Finecross catheter advanced down the PLV
24 Diffuse RCA disease
25 No damage done on the Lt System
26 Still a lot of work
27 Triple wires
28 Fixing the bifurcation After aggressive pre- dilatation, the distal RCA-PLV was stented with a 2.5x33mm Xience Prime LL stent. A A 2.25x18mm Xience V stent was deployed at the distal RCA-PDA in a culotte manner Final kissing with 2.5/2.5mm balloons.
29 Xience Prime LL 3.0x33mm
30 Full metal jacket!!
31 Full metal jacket!! 3.5x38mm Xience Prime LL 3.0x38mm Xience Prime LL 3.0x33mm Xience Prime LL All post-dilated up tp 3.5mm
32 Post-dilation with NC balloon 3.5x15mm Voyager NC up to 18ATM
33 Final angiogram (Diagnostic JR 4)
34
35 Pre-PCI PCI vs Post-PCI PCI
36 Sometimes this is how we see ourselves as interventional cardiologists.. CTO Interventions: Never Give Up!
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