WHEN, HOW AND WHERE?
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1 CORONARY CHRONIC TOTAL OCCLUSION RETROGRADE APPROACH WHEN, HOW AND WHERE? Ferdinando Varbella Rivoli (Torino) OSPEDALI RIUNITI DI RIVOLI
2 DEFINITION OF CTO 1. DEGREE OF STENOSIS 100% 2. ANTEGRADE FLOW: TIMI 0 = true CTO TIMI 0 + intraluminal or bidi bridging channels = true CTO TIMI 1 = functional CTO
3 DEFINITION TEMPORAL CRITERION Clinical evidence (STEMI) Previous CABG Previous angiogram CTO 3months
4 LAST FRONTIERS CABG 1. CHORNIC TOTAL OCCLUSION 2. MULTIVESSEL DIFFUSE DISEASE 3. LEFT MAIN
5 INSIDE CHRONIC TOTAL OCCLUSION
6 Body of the occlusion CTO MORPHOLOGY Microchannels intraluminal channels neo vascularization Necrotic lipidic core, with organized thrombus Proximal fibrous cap hard and calcified (blunt stump or tapered-dimple stump) Calcifications Distal cap softer
7 Anatomy: extensive neovascularization
8 INSIDE RETROGRADE APPROACH FOR CTO-PCI C
9 1990 First retrograde approach was published Retrograde coronary angioplasty of isolated arterial segments through saphenous vein bypass grafts (Joel K. Kahn MD,Geoffrey O. Hartzler MD, Catheterization and Cardiovascular Diagnosis, Volume 20, Issue 2, pages 88 93, June 1990) 7 case through the vein grafts
10 2011 Fielder XT introduction Corsair clinical start up New retro spring coil wire generation?
11 CTO- PCI RETROGRADE APPROACH PRELIMINARY QUESTIONS : WHEN? 1. HOW COMPLEX IS THE LESION? 2. RETROGRADE OR ANTEGRADE?
12 CTO- PCI RETROGRADE APPROACH SIMPLE : always antegrade first COMPLEX LESIONS consider retrograde tapered Functional Dimple stump Short < 10 mm true CTO Absent stump Long > 20 mm Blunt stump Straight No calcification Tapered stump not ostial side branch No bridging collaterals Ostial side Tortuosity Calcification branch Bridging collaterals
13 CTO- PCI RETROGRADE APPROACH Sianos G for EURO CTO Club Eurointerv pz WHEN TO USE RETROGRADE APPROACH? Success EURO-CTO 28.5% Repeat procedure in previous failed attempts 88% 23.5% Immediately after antegrade failure (if fluoro < 30 minutes) 65.9% 48% Primary strategy in complex CTO 89.3% 1. ostial occlusion 2. extreme tortuosity 3. severe calcification 4. very long occlusion
14 Retrograde approach: WHEN? From Galassi s tips & Tricks
15 Retrograde approach: WHEN? From Galassi s tips & Tricks
16 Retrograde approach: WHEN? From Galassi s tips & Tricks
17 CTO- PCI RETROGRADE APPROACH Corkscrew atrial collaterals
18 CTO- PCI RETROGRADE APPROACH Small perforation
19 CTO- PCI RETROGRADE APPROACH
20 Retrograde approach: WHEN? Ochiai Topic 2006
21 Retrograde approach: WHY? The distal cap is usually softer than the proximal cap
22 Retrograde approach: WHY? Distal fibrous cap: convex shape from the proximal side Ca+ Proximal hard fibrous cap From Noriyuki Ozawa CCI 2006
23 Retrograde approach: WHY? Thinner distal fibrous cap tapered From Noriyuki Ozawa CCI 2006
24 Retrograde approach: WHY? Microchannel or intraluminal connection narrower in proximal part Try to put the wires togheter inside the vessel even if not in the true lumen From Noriyuki Ozawa CCI 2006
25 CTO- PCI RETROGRADE APPROACH HOW COMPLEX IS THE LESION? Retrograde kissing wire (marker wire technique)
26 CTO- PCI RETROGRADE APPROACH HOW COMPLEX IS THE LESION? Retrograde kissing wire (marker wire technique)
27 CTO- PCI RETROGRADE APPROACH HOW COMPLEX IS THE LESION? Retrograde kissing wire (marker wire technique)
28 CTO- PCI RETROGRADE APPROACH RETROGRADE APPROACH HOW?? Collaterali sulla parete libera sono molto tortuosi e pericolosi (intrappolamento perforazione spasmo) Sempre preferire settali (>80%)? Sondaggio con microcath o OTW e contrasto 1 cc in siringa 2 ml luer lock
29 HOW? CTO- PCI RETROGRADE APPROACH 1. KISSING WIRES TECHNIQUE : la guida retrograda viene utilizzata come marker per penetrare attraverso la via anterograda 2. RETROGRADE LESION CROSS : la guida retrograda soffice penetra più facilmente il cappuccio distale dell occlusione. Possibile scambiarla su un pallone OTW lungo > 140 cm con guida stiff. Rientro nel GC ed estrenalizzazione 3. CART C.A.R.T. TECHNIQUE :(Controlled Antegrade and Retrograde subintimal Tracking) se la guida retrograda va subintimale, viene dilatato il pallone OTW retrogrado e si cerca di penetrare con la guida stiff anterograda. 4. REVERSE C.A.R.T. : le due guide ant e retrograda sono subintimali si gonfia un pallone anterogrado subintimale allargando il falso lume, si sostituisce con IVUS Volcano e si cerca di far rientrare la guida retrograda
30 HOW? CTO- PCI RETROGRADE APPROACH Retrograde crossing Kissing wires technique Guida Whisper MS 300 mm retrograda marker pallone OTW retrogrado C.A.R.T. technique M. Ochiai Controlled Antegrade and Retrograde subintimal Tracking
31 2- RETRO WIRE FALSE LUMEN IVUS IVUS 1- ANTERO WIRE TRUE LUMEN COMPRESSED 3- ANTEGRADE IVUS GUIDED FALSE LUMEN Reverse CART IVUS guided RETRO WIRE in FALSE LUMEN 65,5% ( 19/29) Success rate subintimal IVUS technique (personal data Tsuchikane, Japan TRUE LUMEN CTO club 2010) ANTERO WIRE IVUS 97% Overall procedure success
32 HOW? CTO- PCI RETROGRADE APPROACH Corsair retrograde, reversecart technique IVUS guided
33 HOW? CTO- PCI RETROGRADE APPROACH Corsair retrograde, reversecart technique IVUS guided
34 HOW? CTO- PCI RETROGRADE APPROACH Corsair retrograde, reversecart technique IVUS guided
35 HOW? CTO- PCI RETROGRADE APPROACH
36 HOW? CTO- PCI RETROGRADE APPROACH retrograde crossing Retrograde: Conquest 9 su pallone Ryujin OTW 148 mm Antegrade: Miracle 3 su catetere guida AL 2 6 F
37 INSIDE NEW NEVICES FOR RETROGRADE CTO-PCI
38 CTO- PCI RETROGRADE APPROACH HOW? 3.7 gr 1.6 gr Tip load: 3.7 g Support: 5.3 g 0.8 gr Tip load: 1.6 g Support: 5.3 g Tip load: 1 2 g Tip load: 1.2 g Support: 5.5 g
39 CORSAIR CORSAIR MICROCATHETER
40 Facilitating CROSSABILITY into tortuous vessels (such as collateral channels as well as highly stenosed lesions) Providing STRONG GUIDEWIRE backup support in complex cases.
41 CTO- PCI RETROGRADE APPROACH Antegrade Corsair Retrograde Corsair Wires antegrade and retrograde
42 New dedicated wire from Japan Septal/Epicardial p Channel Selection Spring coil!!! Rdi Radiopaque length :3cm3 Coating length :28cm(Full coating) Tip load :0.7g
43 New dedicated wire from Japan Externalization
44 RACCOMANDATIONS : WHERE AND WHO 1. CENTER REQUIREMENTS 2. OPERATOR S EXPERTISE
45 CTO- PCI RETROGRADE APPROACH RACCOMANDATIONS CENTER REQUIREMENTS availability of high quality digital image intensifier sufficient variety of guiding catheters and wires (dedicated wires) IVUS and Rotablator are welcome additions (so is MSCT) all angiographers must understand that CTO require dedicated acquisitions with multiple views and lung runs or super selective injections EuroClub Eurointerv. 2007; M Ochiai Circulation 2007; J. Grantham (JACC Interv 2009)
46 CTO- PCI RETROGRADE APPROACH ANNO 2009 Philps Integris 5000 del 2001 > procedure.
47 CTO- PCI RETROGRADE APPROACH Philps Allura FLAT PANEL 2010
48 CTO- PCI RETROGRADE APPROACH RACCOMANDATIONS CENTER REQUIREMENTS at the beginning cross referral of complex CTO to experienced laboratory (do not leave untreated or send to surgery) high volume of PCI and dedicated CTO program developed program of proctorship with guest operators complex CTO must performed or directly supervised dby super specialists EuroClub Eurointerv. 2007; M Ochiai Circulation 2007 ; J. Grantham (JACC Interv 2009)
49 CTO- PCI RETROGRADE APPROACH MOchiaiin M. in RIVOLI (TO) Sept 2010 Nov 2010
50 CTO- PCI RETROGRADE APPROACH RACCOMANDATIONS OPERATOR S EXPERTISE high operative volume, at least two years PCI experience at least 30 CTO-PCI as a part of the 200 angioplasty package required personal caseload > 50 CTO per year as CTO are 10-15% of total PCI ( large volume laboratory with more than 1000 PCI cases/year can provide competency to no more than 2 operators) Begin from simple to complex CTO EuroClub Eurointerv. 2007; M Ochiai Circulation 2007 ; J. Grantham (JACC Interv 2009)
51 CTO- PCI RETROGRADE APPROACH OPERATOR S EXPERTISE AND INDICATION National Cardiovascular Data Registry ACC-NCDR PCI 5% CTO LOW VOLUME INTERMEDIATE VOLUME HIGH VOLUME PCI/YR n operators <75 (n 1388) (n 941) >200 (n 301) CABG when CTO 19,1% 15.9% 14% (p ) Predictor of CTO-PCI attempt O.R O.R O.R. 1 Grantham J.A. JACC Intevention 2009
52 CTO- PCI RETROGRADE APPROACH CTO-PCI for expert operators but must not be a niche (5% of PCI) Training and training more and more to enlarge indications Grantham J.A. JACC Intevention 2009
53 CTO- PCI RETROGRADE APPROACH TEACHING AND LEARNING TOGHETER
54 STARHOTEL MAJESTIC Turin
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