Practical Approach to Chronic Total Occlusions Step-by ...€¦ · Banner University Medical Center...
Transcript of Practical Approach to Chronic Total Occlusions Step-by ...€¦ · Banner University Medical Center...
Practical Approach to ChronicTotal Occlusions Step-by-Step
Techniques – The Antegrade andRetrograde ApproachRetrograde Approach
Scripps 2019
Ashish Pershad MD FACC FSCAI
Banner University Medical Center Phoenix
Which patient with a CTO should we betreating in 2019?-
• Stable CAD patients with anginaand on optimal medical therapy
• Randomized control trial(highest level of evidence)(highest level of evidence)
• Risk of PCI is not higher (deathand MI occurring with equalfrequency in both groups)
Other scenarios for CTO PCI-where there may bebenefit -Pending results of the ISCHEMIA trial
• For Complete Revascularizationin MVD group of patients withSTEMI- RCT LOE 1
• Complete Revascularization inStable CAD patients Syntax 1 vs2- Observational Comparison
How to Approach CTO’s Practically?
4 questions about the Cap
Proximal cap
Ambiguous or unambiguous?
Blunt or tapered?
Side-branch at pCap?
Distal cap
Ambiguous or unambiguous?
Blunt or tapered?
dCap at bifurcation? Side-branch at pCap?
Calcified?
dCap at bifurcation?
Size of distal vessel/diseasebeyond dCap?
Tools for the Trade- Wires andTools for the Trade- Wires andMC’s
WIRE TASKS:
WiringCollaterals
Wiring CTOwith Tapered
Cap
Wiring CTO withBlunt Proximal
Cap
Wiring CTO +Navigating
Calcium
Tapered Proximal CapWire tip tofind loosetissue track
Required Wire Properties
LowTip load
LubricityTapered 0.010” Tip+ Polymer Jacket
Flexibilityin shaft
Wire to tracksoft tissue todistal vessel
Blunt Proximal CapPunctureproximalcap
Wire CTO if short +gooddistal visibility
Required Wire Properties
HeavyTip Load
Tapered WirePenetrative
Wire topenetrateCTO body
Hightorquecontrol
Visible CTO Navigation
Flexibilityin the shaft
Required Wire PropertiesLow-MedTip load
1:1 TorqueResponse
TactileFeedback
Flexibilityin shaft
Flexibilityin the shaft
Collateral Wiring
Required Wire PropertiesHightorquecontrol
Spring CoilHydrophilic Wire
1:1 TorqueResponse
Low TipLoad
Flexibilityin shaft
Atraumatic tip
General Use Ca+ Antegrade
Microcatheters
Channel DilatorsGeneral Use
FinecrossSuperCrossMicro-14
Nhancer Pro
Ca+ Antegrade
Turnpike Spiral
Retro & AntegradeCorsair Pro
TurnpikeTeleport
RetrogradeCorsair XS
CaravelTurnpike LPMamba Flex
Channel Dilators
Principles of ADR- with the Stingray andCross Boss System
• Site of re-entry controllable (to <1 mm)
• Aims to revascularize all distal branches
• Should lead to good run-off
• 1 year outcomes do not appear to bedifferent from other strategies of CTOrevascularization
• CTO proximal RCA
• Non ambiguous proximal cap
• Lesion length about 20mm
• Very good distal target with no
bifurcation at the distal cap
Classic ADR case
bifurcation at the distal cap
• Distal vessel fills via bridging
collaterals and collaterals from Cx to
PLV
1st Limitation of the CrossBoss Catheter-Stiffwith bias to the outer curvature of vessel
2nd Limitation of CrossBoss Catheter-sidebranch seeking
Knuckle Boss Technique Illustration-Sidebranch avoidance & finishing with the Boss
Hematoma Management-101
Following Knuckle wireFollowing CrossBoss
Orientation & Re-entry with StingRaycatheter
Final Angiograms
The Fundamentals of Retrograde CTOTechnique
Gain access in vessel distal to CTOConduits• Septal collaterals• Epicardial collaterals• Bypass grafts
Cross CTO and gain true lumen controlCross CTO and gain true lumen controlproximal and distal Techniques
• Retrograde Wire Crossing (RWE)• Reverse CART (XCART)• Classic CART
PCI • Externalized Wire• Conversion to antegrade system• Safe removal of equipment
Case Example Retrograde Baseline
Retrograde Wire –Septal crossing
Retrograde Wire Escalation
Final Angiograms
@ashishpershad