FeaturingCTO

Complex-PCI by Trans-radial Approach

CTOCase review

5 FrenchTRI

CTO of right coronary artery-5 F Launcher guiding Catheter(right Judkins catheter)-Galeo Medium wires

Buddy wire technique

Early angio Late angio

MartialHamon

- 48 years old patient- Recent ACS, dilated on LAD 7 days ago- Excellent LVEF (EF: 75%)- No Q-wave MI- CTO of Right Coronary Artery (RCA) - Planned procedure: RCA desobstructionBy TRA using 5 French guiding catheter

FeaturingCTO

Complex-PCI by Trans-radial Approach

BackgroundPathology

Small vascular channels

(160 to 230 microns diameter)

Connect with proximal part

Non visualized by angiographyNon visualized by angiography

Islands of dense fibrous tissues

1. Early angiogram frequently no entrance visible2. Late angiogram distal opacification seen

Pathology of CTO Lesions

FOCUS

FeaturingCTO

Complex-PCI by Trans-radial Approach

1. Functional vs absolute occlusions2. Duration of occlusion (>3months)3. Morphology at occlusion point(tapered vs abrupt, bridging coll., side branch)4. Lesion length

Predictors of success :

PatientSelection

1. Documented ischemia?2. Vessel importance?3. Alternative solutions?4. Optimal medications?5. Benefit / risk?

Patient :Advanced

PCIPCI

LesionSelection

AMI, CABG, death,perforation, tamponade,excessive contrast load and fluoroscopic

Potential Complications:

FeaturingCTO

Complex-PCI by Trans-radial Approach

1. 5 F provides optimal backup and support (deep cannulation was possible as seen in figures 2 and 3 by gentle clockwise rotation of the guiding catheter, Launcher 5F from Medtronic)

2. Guide wire Galeo M was successful using buddy wire technique (Figure 1, Galeo M wire from Biotronik)

3. Low-profile balloon: 1.25 mm in diameter and 15 mm length from Terumo was used to create the first channel (Figure 2, Riujyn balloon from Terumo)

CTO

5 FrenchTRI

Buddy wire technique Low-profile balloon Long balloon dilation

Fig.1 Fig.2 Fig.3

FeaturingCTO

Complex-PCI by Trans-radial Approach

After balloon inflations After implantation of stentsCTO

5 FrenchTRI

CTO by trans-radial approach and with 5 French guiding catheterIs safe and feasibile in selected cases and with adapted materials

FeaturingCTO

Complex-PCI by Trans-radial Approach

1. Guiding catheters (optimal backup and support)

2. Guide wire support catheter (or over the wire balloon)

3. Guide wire (intermediate and stiffer, tapered and hydrophilic)

4. Interventional devices (low-profile balloons, rotablator, …)

5. Stents and DES (restenosis)

6. IVUS

MaterialSelection

Hydrophilic guidewire Tapered-tip guidewire

Recommendations

FeaturingCTO

Complex-PCI by Trans-radial Approach

Double guide wire technique (buddy wire)

Side branch

Technichalaspects

Vasa vasorum

Side branch

Vasa-vasorum

FeaturingCTO

Complex-PCI by Trans-radial Approach

AdvancedPCIPCI

The lastFrontier

IVUS Guidance (entry site, complex dissection)Contro-lateral access (dual arterial access sites)Stiff wires (penetration wire)Anchorage techniquesRotablator (calcified lesion)

Meticulous review of angiograms+++Keypoints

Advanced specific recommendations: