RBK – Coronary Interventions

Successful transradial retrograde CTO

revascularisation via an epicardial collateral

using a single 6F guideTim Schäufele

Robert-Bosch-Krankenhaus Stuttgart

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Potential conflicts of interest

Speaker's name: Tim Schäufele

I do not have any potential conflict of interest

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Case summary

Demographics: Age: 76 yrs old Gender: female

cvRisk Factors: Hypercholosterolemia Ex smoker Arterial hypertension

Demographics: Age: 76 yrs old Gender: female

cvRisk Factors: Hypercholosterolemia Ex smoker Arterial hypertension

Clinical Presentation and Indication: Stable but recurrent angina despite OMT Significant risk profile

Clinical Presentation and Indication: Stable but recurrent angina despite OMT Significant risk profile

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Medical History 5/2015: de novo angina 9/2015: stable angina on OMT Unknown coronary status No known history of MI

Peripheral vascular disease IIa

Coronary angio

Baseline angiography

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RCA- LAO LCA- RAO/CRAN

Diagnostic Catheter: TIGER II 3.5 5F via right TRA

Baseline angiography

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RCA- LAO LCA- RAO/CRAN

Diagnostic Catheter: TIGER II 3.5 5F via right TRA

Baseline angiography

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RCA- LAO LCA- RAO/CAUD

Diagnostic Catheter: TIGER II 3.5 5F via right TRA

Baseline cMRI

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Normal wallmotion lateral

Severe inducible ischemia Lateral (RCX) Inferolateral (RCA/PLD) NB: not anterior!

<50% myocardial scar

Anatomically 3 VD with functional stenosis in 2 vascular territorries (RCA/RCX)

SYNTAX score 21.3

STS score mortality 1.1%

Anatomically 3 VD with functional stenosis in 2 vascular territorries (RCA/RCX)

SYNTAX score 21.3

STS score mortality 1.1%

Baseline summary and MDT recco

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x

x

x

xx

3MDT Recco: PCI

Strategy

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TRA because of PVD no palpable puls left radial Ipsilateral collaterals only

Brilakis et al JACC 2012

Plan A

Wire escalation Paralell Wire-

Technique

Plan B

Retrograde via epicardial collateral

Externalisation

Plan C

CTO Procedure Step 1 Antegrade/Single Wire

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RAO/CAUD

Guide: EBU 3.5/ 6F via right TRA; FINECROSS; FIELDER XTA;Step-Up: Gaia 2nd

LAO/CAUD

CTO Procedure Step 2 Antegrade/Parallell Wire

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Guide: EBU 3.5/ 6F via right TRA; FINECROSS; FIELDER XTA;Gaia 2nd as parallell wire

LAO/CAUD

RAO/CAUD

CTO Procedure Step 2 Antegrade/Parallell Wire

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Guide: EBU 3.5/ 6F via right TRA; FINECROSS; FIELDER XTA;Gaia 2nd as parallell Wire

LAO/CAUD

RAO/CAUD

Gaia 2nd

CTO Procedure Step 3 Retrograde-search the collateral

14Guide: EBU 3.5/ 6F via right TRA; CORSAIR 150mm; SION black

LAO/CRAN

CTO Procedure Step 4 Retrograde-collateral crossing

15Guide: EBU 3.5/ 6F via right TRA; CORSAIR 150mm; GAIA 2nd (a)

LAO/CRAN

a

CTO Procedure Step 5 Retrograde-Externalisation

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Guide: EBU 3.5/ 6F; CORSAIR 150mm; CONFIANZA pro 9 retro-GAIA 2nd antegrade

RAO/CAUD

Unsuccsessfulattempt to „tip-in“ due to heavylymovingmicrocatheter

Unsuccsessfulattempt to „tip-in“ due to heavylymovingmicrocatheter

Confianza pro 9

Gaia 2nd

Confianza pro 9

Finecross

CTO Procedure Step 5 Retrograde-Externalisation

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Left: Guide: EBU 3.5/ 6F; CORSAIR 150mm; RG3 (left)Right: Guide: EBU 3.5/ 6F; BHW (right)

RAO/CAUD RAO/CAUD

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Was that all?

RCA:SYNERGY 3.0x38 mm; SYNERGY 3.5x20 ml; SYNERGY2.75x12 mm;SYNERGY

4.0x12 mm (left) LAD: SYNERGY 3.5x16 (right) 4 wks later

LAO/CRAN

RAO/CRAN

Procedural Time: 140 minutesCummulative Air Kerma: 3865 mGyDose Area product: 9874 cGycm²

Procedural Time: 140 minutesCummulative Air Kerma: 3865 mGyDose Area product: 9874 cGycm²

@ Follow up 9 months: patient does well, no anginaMed Tx reduced to Statin, ACEI, ASS, CLOPIDOGREL @ Follow up 9 months: patient does well, no anginaMed Tx reduced to Statin, ACEI, ASS, CLOPIDOGREL

CTO Procedure Final Result (FUP 4 Wks)

19RCX: SYNERGY 2.5x28mm; SYNERGY 3.0x8mm ; SYNERGY 2.5x8 mm

RAO/CAUD

Case summary Final/Discussion

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TRA is a valuable option for CTO procedures Ipsilateral collaterals are an elegant way to go Use of single Guiding catheters for externalisation as

a „bail-out“ warrants special attention

TRA is a valuable option for CTO procedures Ipsilateral collaterals are an elegant way to go Use of single Guiding catheters for externalisation as

a „bail-out“ warrants special attention

apropriate patient selection is mandatory MDT provide best patient specific results cMRI is a usefull add- on but cann miss anterior

ischemia

apropriate patient selection is mandatory MDT provide best patient specific results cMRI is a usefull add- on but cann miss anterior

ischemia

My personal take home message: Give 7F TRA at least a try!

Thank you for your attention!

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