Post on 18-Feb-2021
Antegrade vs Retrograde DecisionAntegrade vs. Retrograde Decision‐Making: Hybrid ThinkingMaking: Hybrid Thinking
Junbo Ge, MD,FACC, FESC, FSCAI, FAPSIC
Department of Cardiology,
Zhongshan Hospital, Fudan University
Shanghai Institute of Cardiovascular DiseasesShanghai Institute of Cardiovascular Diseases
Update from the "Retrograde Summit"p gYamane M. CTO Summit, 2013, NY
N=1166 cases (2009-11 in 27 centers)
Primary Retrograde Approach (716)
Immediately After Failed Antegrade (450)
Successful GW collateral channel cross
pp ( ) g ( )
f82.3% (960/1166)
Retrograde Success:
Change to Antegrade Approach (252)
Retrograde Success: 87.3% (838/960)
Success 58.3% Success 58.3% Failure/Halt /CMX
15.5% (181)Overall Success 84.5%
( 985/1166)
(147/252(147/252)
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Hybrid Approach is common in
complex CTO‐PCI!p
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Indication of Retrograde approaches
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Hybrid ApproachAnatomy Dictates StrategyAnatomy Dictates Strategy
Th F Q tiThe Four Questions1. Is the Proximal cap well defined or ambiguous?2 Quality of the distal target2. Quality of the distal target3. Suitability of “interventional” collaterals4. Lesion length < or > 20mm
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Ad Hoc Strategy for CTO PCI
Antegrade techniqueTapered stump
Short CTO segment
Antegrade technique as first strategy
Angiographic viasualization of microchannels
Absence of calcification in CTOAbsence of calcification in CTO segment
Retrograde technique Long CTO segment (>40mm)
Easy retrograde collateral routeas first strategy
Easy retrograde collateral route
Severe calcification in CTO segment
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Case 1:Male, 60 yrs, Recurrent Chest Pain for 4 mons
021567
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
021567
Antegrade vs. Retrograde Decision‐Making: Hybrid
Attempted to open CTO with the antegrade approach but failed
Thinking and Changing Course
Attempted to open CTO with the antegrade approach, but failed.
7FEBU 3 757FEBU 3.75
Crosswire NT
2.0F Progreat
021567
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Retrograde GW could not access into the antegrade GC
0215676F JR4 GC; 2.0F Progreat MC; Fielder GW
Antegrade vs. Retrograde Decision‐Making: Hybrid
R l Wi T i T h i
Thinking and Changing Course
Reversal Wire Trapping Technique
021567Amplatz Goose Neck(ev3, Plymouth, Minnesota)
Antegrade vs. Retrograde Decision‐Making: Hybrid
R l Wi T i T h i
Thinking and Changing Course
Reversal Wire Trapping Technique
021567
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
021567
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Runthrough GWRunthrough GW
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Antegrade vs. Retrograde Decision‐Making: Hybrid
Fi l R l
Thinking and Changing Course
Final Result
021567
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Dose this statement hold true?
Antegrade approach should be always tried in all g pp yCTO‐PCI, if its failed, then choose retrograde
approach!
Maybe not!Maybe not!
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Indication of Retrograde Approachas a Primary Procedureas a Primary Procedure
• Antegrade wiring seems very difficult in terms ofanatomical factors (complex CTO)
Th i h i ibl d i ll l• The patient has visible and continuous collaterals
• The donor vessel is healthy (or can be treated)• The donor vessel is healthy (or can be treated)
• Re‐attempt after previous failurep p
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Case 2:Male, 54 yrs, SA for 3 mons (CTOCC 2009)
022638(2)First attempt with antegrade approach was failed.
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
CC 1-2 from L to R
022638(2)
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Fielder FC + Corsair
022638(2)
Antegrade vs. Retrograde Decision‐Making: Hybrid
Att ti Ki i Wi T h i b t f il
Thinking and Changing Course
Attempting Kissing Wire Technique, but failure
Fielder FC – Crosswire NT 022638(2)
Antegrade vs. Retrograde Decision‐Making: Hybrid
R CART T h i
Thinking and Changing Course
Reverse CART Technique
Conquest Pro
Ryujin plus 1.5* 15mm @ 6-10atm Ryujin plus 2.5*15mm @ 6-10atm 022638(2)
Antegrade vs. Retrograde Decision‐Making: Hybrid
R CART T h i
Thinking and Changing Course
Reverse CART Technique
Apex 3.5* 20mm @ 8atm 022638(2)
Antegrade vs. Retrograde Decision‐Making: Hybrid
300 Fi ld FC
Thinking and Changing Course
300cm Fielder FC
Ryujin 2.5*15mm @ 6-10atm 022638(2)
Antegrade vs. Retrograde Decision‐Making: Hybrid
Final Res lts
Thinking and Changing Course
Final Results
022638(2)
Antegrade vs. Retrograde Decision‐Making: Hybrid
Wh ill thi CTO ith t d
Thinking and Changing Course
Who will reopen this CTO with antegrade approach firstly?app oac st y
018760Case 3: Female, 65 yrs, chest pain for 2 mons
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Tip Injection
Ch l Dil t Fielder FC018760
Channel Dilator Fielder FC
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Retrograde GW could not access into the JR4 GC
018760Miracle 3+ Channel Dilator
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Retrograde wire trapping technique
018760
Advanced Channel Dilator into the root of aorta and changed Miracle 3 GW to Fielder FC (300cm)
Amplatz Goose Neck(ev3, Plymouth, Minnesota)
Antegrade vs. Retrograde Decision‐Making: Hybrid
B k E d b ll i MC l
Thinking and Changing Course
Back-End ballooning + MC reversal
018760Ma’sla Just(2.5*15mm)
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Final Result
018760
Antegrade vs. Retrograde Decision‐Making: Hybrid
h k d hThinking and Changing Course
Change Course: Ad hoc or Stage?
IF large amount of contrast used
IF long period of fluoro time spent
IF the operator and/or patient exhausted
IF the equipment is insufficient
Stage procedure may be reasonable!
Antegrade vs. Retrograde Decision‐Making: Hybrid
Thinking and Changing Course
Take home message
• Changing course is common in some complex
CTO‐PCI.
• Hybrid strategy can increase success of CTO‐
PCI Th CTO h ld lPCI. The CTO expert operator should learn to
be versatile and be ready to adopt differentbe versatile and be ready to adopt different
techniques during the same proceduretechniques during the same procedure.