Antegrade approach – how to start? Views of a minimalist and a maximalist point of view...

Alexander Ghanem & David Leistner

Antegrade Approach – How to start?

Minimalists‘ versus Maximalists‘ Approaches

17. September 2017

Our aim and its Paradigmata

Minimalists‘ view Maximalists‘ view

“The patient is treated in one attempt by the mostexperienced operator fitted to his lesion complexity.“

Patient

Patient

ProcedureProcedure

Outcome

G. Werner

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding

Outcomes: Angiography

Minimalists‘ Appropriateness List

adopted from Prof. G. Werner, Darmstadt

• Selection of the patient with normal LV-EF

– Symptoms, but „asymptomatic“ patients may beadapted to their limitations by a CTO...

– Ischemic territory should be > 10%

Relationship between mortality and extentof myocardial ischaemia, depending on therapy

Montalescot / Sechtem et al., Eur Heart J 2013;34:2949–3003. Hachamovitch et al., Circulation 2003;107:2900–2907.

OMT / Revascularisation


• Selection of the patient with normal LVF

– Symptoms, but „asymptomatic“ patients may beadapted to their limitations by a CTO...

– Ischemic territory should be > 10%

• In patients with akinesia and ischemic CMP

– Presence of viability tested by MRI

– A grey zone of scar tissue extension remains

Minimalists‘ Appropriateness List

Viability is a Continuum

Wilcox et al, JACC 2015

Baks T et al. JACC 2006;47:721-5

Improvement of LV-Function dependson viability of revascularized myocardium

Adapted from Werner et al. JACC 2006;48:51-8

Collateral blood flow is neversufficient...

Min vs. Max

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


(Retrograde) CTO PCI reduced markely

symptoms (angina and dyspnea)

Boden et al., NEJM 2007

PCI added to optimal medicaltherapy did not improve outcome

Garcia S et al, JACC 2013;62(16):1421 –31

Outcome after incomplete versus complete revascularisation in MVD

Farooq et al., Circulation. 2013; 128: 141-151

Prognosis is significantly related toresidual SYNTAX-Score

SYNTAX Revascularisation Index

Genereux et al., Am J Cardiology, 2015, DOI: 10.1016/j.amjcard.2015.03.056

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


1:0

Min vs. Max

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


CTO-lesion characteristics

Srivatsa et al. JACC 1997;29:955-63

Necrotic Core, Cholesterol, inflammated Tissue

Fibrous-calcific Tissue

Micro Channels

Histological CTO Correlates

De Labriolle et al, Am J Cardiol 2008

Causes of failure of CTO-PCI

CTO Toyohashi Heart Center

Complex PCI, NYC

Development of CTO-PCI procedure

Miracle

Conquest

Parallel wiring

IVUS guidance

Retrograde approach

1995 2000 2005 2010

Fielder XT

Pilot

Fielder FC

SION

MDCT

Corsair

wire, device

imaging modality

wiring technique


Complex PCI, NYC


Miracle

Conquest

Parallel wiring

IVUS guidance

Retrograde approach

1995 2000 2005 2010

Fielder XT

Pilot

Fielder FC

SION

MDCT

Corsair

wire, device

imaging modality

wiring technique

ACS standard

Cross-ItProgress family

RG3

Ultimate

Gaia family

Fielder XT A/R

Wire evolution


Complex PCI, NYC


Miracle

Conquest

Parallel wiring

IVUS guidance

Retrograde approach

1995 2000 2005 2010

Fielder XT

Pilot

Fielder FC

SION

MDCT

Corsair

wire, device

imaging modality

wiring technique

Wire evolution

Microcatheter

Finecross

Improve wire pushabilityConcentrate rotating forcefor better wire control

Superior device passage for the next option

1. 2.

3.

Microcatheter

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


Min vs. Max

1:1

1:0

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


Guiding Backup

BEST OPTION FOR STRENGTHENING A GUIDE:

1. FIRST best maneuver- put the guide in power position or deepseat the guide.

2. SECOND best maneuver – Add a second stiffer wire

3. THIRD best maneuver – change to a stronger guide

4. use the balloon anchoring technique

5. insert a smaller straight inside the current guide (mother &child)

6. remove everything- change the short sheath to a longer one

Guiding Diameter

Ghione et al., Eurointervention 2013

Guiding Diameter

Habit #2: Begin with the End in Mind !

Habit #1: Begin with any End in Mind !

PCI - OPERATORS

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


1:1

1:0

1:2

Min vs. Max

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


Gasparini et al. JACC INTV, 7 (4), 2014.

Vessel Remodelling

Galassi et al., JACC 59 (8) 2012, 711-718.

N=100

Vessel Remodelling

+ 20 - 30%

Galassi et al., JACC 59 (8) 2012, 711-718.

Vessel Remodelling

6-month Follow-up

Gasparini et al. JACC INTV, 7 (4), 2014.

Less is more !

Vessel Remodelling

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


1:1

1:0

1:2

1:3

Min vs. Max

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


Strategy

Patient Selection

StandardizedProtocols

Min vs. Max

Strategy is often about whatyou don‘t do!

Hybrid Approach

pC

dC

Pl

Hybrid Approach

Hybrid Approach4

5

6 6´ 7

4´

4

B 2

Strategic Options


The apparent length of theocclusion is often shorter

than you think !

Bilateral Injection

Maximum Guide Backup

AntegradeFielder XT/A/R orGaia 1 Gaia 2,

Confienza, Progress

Penetration, thenstep down

AntegradeNo stump

IVUS for guidedpenetration?

Reentry-System

Crossboss / Stingray

Distal good target

Parallel with stiffwire

Retrograde

Feasible collateralpathways

Symptoms

ObjectifiedIschemia

Procedure: Wires

Procedure: Guiding


Strategy

Min vs. Max

CTO – PCI always should beplanned and performed

with a maximalist‘s mindset !

Antegrade approach – how to start? Views of a minimalist and a maximalist point of view...

Health & Medicine

Transcript of Antegrade approach – how to start? Views of a minimalist and a maximalist point of view...