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Retro style may be fashion
IOANNIS TSIAFOUTIS
INTERVENTIONAL CARDIOLOGIST
RED CROSS HOSPITAL
ATHENS
Retrograde Dissection Re-entry
Retrograde True Lumen
AntegradeDissectionRe-entry
Antegrade True Lumen
4 options to crossing CTOs
Illustration by Dr J C Spratt / VascularPerspectives
IC-185422-AA SEP2013
• Approach from collateral channel
• Usually for RCA and LAD via septals (easier for RCA),
or via Grafts
• Easier to penetrate distal cap than from antegrade
approach
• Be aware with anticoagulation (ACT>350)
W balloon catheter through the channel
Retrograde Approach
Retrograde accessories
• Colateral wires (Fielder FC, XT-R, Sion family, Suoh)
• Externalization wires : RG3, R350
• Guide extensions
• Microcatheters (single and dual lumen)
• Snares
• Perforation tools
Retrograde wires
Sion black Suoh 03
Wire collateral crossing• Septal surfing technique
• Selective contrast injection
Solving Microcatheter problems• Choose guide catheters with good support
• Change the failing mc
• Choose another collateral pathway
• Baloon anchoring
CTO Lesion Crossing
• Retrograde wire escalation
• Retrograde dissection and reentry
CART
Reverse CART
Wire ExternalizationUse of Guide extension or snare
Trapping the micro in the guide
Loading from the tip of the wire or cut it
Retrograde CTO Techniques
CART TechniqueControlled Antegrade and Retrograde Subintimal Tracking
Reverse CARTControlled Antegrade and Retrograde Subintimal
Tracking
Reverse CARTControlled Antegrade and Retrograde Subintimal
Tracking
Reverse CARTControlled Antegrade and Retrograde Subintimal
Tracking
DRAFT TechniqueDeflate, Retract and Advance into the Fenestration Technique
“A novel maneuver to facilitate retrograde wire externalization during retrograde chronic total occlusion percutaneous coronary intervention”
Carlino M, Azzalini L, Colombo A
Catheter Cardiovasc Interv. 2017 Jan;89(1):E7-E12.
IVUS applications in retrograde approach
• Retrograde guidewire crossing
ostial occlusions or bifurcations with blunt stump
• Reverse CART
evaluation of antegrade and retrograde guidewires positions compared with CTO body and optimal balloon sizing for medial disruption
selection of the appropriate position within CTO vessel where to create connection between antegrade and retrograde guidewires
Alfredo R. Galassi et al. JCIN 2016;9:1979-1991
American College of Cardiology Foundation
Alfredo R. Galassi et al. JCIN 2016;9:1979-1991
American College of Cardiology Foundation
1st case
• Pt 70 yrs
With angina with mild exertion
Medical History: Dyslipedemia, Hypertension, ex smoker
Prior MI with no coronography
Coro: Cto dominate LCX, collaterals from right (epicardial)
Jcto score: 1
Progress cto score : 1
The PROGRESS CTO complications score.
Barbara Anna Danek et al. J Am Heart Assoc
2016;5:e004272
© 2016 Barbara Anna Danek et al.
Incidence of periprocedural complications in strata of the PROGRESS CTO complications score.
Barbara Anna Danek et al. J Am Heart Assoc
2016;5:e004272
© 2016 Barbara Anna Danek et al.
Biradial access 6Fr, EBU 3.5, JR4. Antegrade wire escalation Gaia 2nd, Confianza pro12, Hornet 14 , Caravel micro. Single wire – 2 wires parallel technique. Dissection –no reentry
Biradial access 6Fr, EBU 3.5, JR4. Antegrade wire escalation Gaia 2nd, Confianza pro12, Hornet 14 , Caravel micro. Single wire – 2 wires parallel technique. Dissection –no reentry
Epicardial collateral from RCA next choiceSuoh wire, Caravel micro, beating heart surfing
Injection from micro
A Gaia 3rd successfully passed retrogradely and an RG3 was externalized through a Guide extension (Guidezilla).A guide extension was used through EBU to facilitate the ext
Two DES Promus 3.0x18mm. 2.5x20mm71.5 min Fluoroscopy time, 21079 cGy/cm2 DAP. Progress Cto compl score: 4
•2nd casePt male 82 yrs with nSTEMIMedical history: MI, DM, Hypertension, PADEF:40%Coro : diffused disease , prox,mid LAD long lesionCto RCA
7Fr transradially bilateral, EBU 3.5 for LCA and AL1 for RCA. First we fix prox-mid LAD
Rca cto: gap<20mm,Jcto score: 1, Progress cto score:1
7Fr transradially bilateral, EBU 3.5 for LCA and JR4 for RCA. First we fix prox-mid LAD
After a 10 minutes try for antegrade true to true lumen with Fielder Xt, Pilot 200 we tried retro with Sion black septal surfing, micro Corsair failed and switched to Caravel that went easily
Gaia 2nd,3rd failed but a Pilot 150 succeeded to pass retro. The micro was driven inside the guide with wire trapping and RG3 was externalized
After dilatations we finished the PCI with stenting (Resolute 2.75x30mm,2.75x30mm,2.5x18mm)
Prox –mid LAD, Retro cto RCA :52 min fluoroscopy time , DAP 12250cGy/cm2. Progress cto complication score :4
ImprovedProcedural Success Rate
10
0
20
30
80
70
60
50
40
90
100
2003.3 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014.6
Retrograde Corsair
75%
97%86%
IRIS CTO Registry, AMC data 2016
Brilakis ES, JACC Interv 2015;8:245-53, A Report from theNCDR
Pro
ced
ura
l S
uccess
(%)
MA
CE
(%
)
Large Volume Experiences Can Make a
Better Success and Lower MACE
4.3
2.1
Multicenter US Registry, Circ Cardiovasc Interv 2016;9: e003434
MACE Myocardial infarction
Retrograde approach Antegrade approach
P<0.05
1.1
But, Retrograde Approach
Increased In-Hospital MACE
P<0.05
0.3
Cu
mu
lative
Incid
en
ce
(%)
The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention: Update From the PROGRESS CTO Registry
Tajti P, Karmpaliotis D, Alaswad K3, Jaffer FA, Yeh RW, Patel M, Mahmud E, Choi JW, Burke M, Doing AH, Dattilo P, Toma C, Smith AJC, Uretsky B, Holper E, Wyman RM, Kandzari DE, Garcia S, Krestyaninov O, Khelimskii D, Koutouzis M, Tsiafoutis I, Moses JW, Lembo NJ, Parikh M, Kirtane AJ, Ali ZA, Doshi D, Rangan BV, Ungi I, Banerjee S, Brilakis ES
JACC Cardiovasc Interv. 2018 Jul 23;11(14):1325-1335
“2,733 CTO interventions in 2,677 patients
Overall technical and procedural success was 88% and 86% respectively and in-hospital major complications rate was 2.9%.
The prevalence of in-hospital MACE in retrograde cto was 5.86%”
CORONARY
1. Vessel closes
• Dissection
• Embolization
• Spasm
• Pseudolesion
2. Vessel Leaks
• Perforation
3. “Wrong place”
• Equipment loss
Be ready to manage complications
HEART
1. MI
2. Arrhythmia -
arrest
3. Tamponade
OTHER
1. Access
2. Thromboembolic
3. Contrast
• Nephropathy
• Allergies
4. Radiation
Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier2017
• Red Cross Hospital cath lab Athens
1st Cardiological Dpt 2nd Cardiological Dpt
Dr Tsiafoutis Ioannis Dr Koutouzis Michael
110 cases
Success 80%
Now participating in SHINE-Cto trial
Retro is not a party at all but may be the solution if you choose right and be well prepared!