Advanced CTO Techniques Gerald S Werner MD Ph

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Advanced CTO Techniques Gerald S. Werner, MD Ph. D Klinikum Darmstadt, Germany

Advanced CTO Techniques Gerald S. Werner, MD Ph. D Klinikum Darmstadt, Germany

Gerald S. Werner, MD, Ph. D I have no real or apparent conflicts of

Gerald S. Werner, MD, Ph. D I have no real or apparent conflicts of interest to report.

PCI – CTO of the RCA and LCX Male M. K. Age 53

PCI – CTO of the RCA and LCX Male M. K. Age 53

CTO of RCA and LCX Male, M. K. , 53 Risk factors current Smoker

CTO of RCA and LCX Male, M. K. , 53 Risk factors current Smoker Hyperlipidemia Life style (mandatory) Ex-football player (second league), still playing, but since few years as goal keeper, working in office Psychological status Normal

Clinical presentation • since May 2010 feels weaker • no typical chest pain •

Clinical presentation • since May 2010 feels weaker • no typical chest pain • but problems with climbing stairs, shortness of breath (plays now only as goal keeper)

Non-invasive evaluation ECG: small Q waves in inferior leads no classic Q wave infarct

Non-invasive evaluation ECG: small Q waves in inferior leads no classic Q wave infarct sign

Non-invasive evaluation • Echo: Hypokinesia basal wall • Stress-ECG: 125 W without AP, no

Non-invasive evaluation • Echo: Hypokinesia basal wall • Stress-ECG: 125 W without AP, no significant ST changes • Perfusionscan with MRI – EF 46% – Hypokinesia basal and medial and posterolateral – lateral ischemia – subendocardial anterior and lateral late enhancement

Laboratory investigations Hb = 15, 3 g/dl Creatinine = 1, 0 mg/dl Creatinine clearance

Laboratory investigations Hb = 15, 3 g/dl Creatinine = 1, 0 mg/dl Creatinine clearance = 83 ml/min Cholesterol (total) = 175 mg/dl HDL = 43 mg/dl LDL = 95 mg/dl on therapy HBA 1 c 5, 6% CK 153 U/l Troponin I <0, 04 ng/ml

Diagnostic angio 14. 9. 2010

Diagnostic angio 14. 9. 2010

Diagnostic angio 14. 9. 2010

Diagnostic angio 14. 9. 2010

Risk evaluation Euro. SCORE (mortality logistic) = 1. 33% Syntax score = 19

Risk evaluation Euro. SCORE (mortality logistic) = 1. 33% Syntax score = 19

Key issues / Strategy 1. Patient was offered CABG in referring hospital 2. After

Key issues / Strategy 1. Patient was offered CABG in referring hospital 2. After refusal, our strategy 1. PCI of RCA as most important territory and more difficult lesion first 2. LCX as second smaller territory, but with proven ischemia

Coexisting collateral pathways (86% of cases*) *) Werner GS et al. Circulation 2003; 107:

Coexisting collateral pathways (86% of cases*) *) Werner GS et al. Circulation 2003; 107: 1972 -7

STEP 1: RCA • Lesion morphology unfavourable because of length of >6 cm •

STEP 1: RCA • Lesion morphology unfavourable because of length of >6 cm • There is an island of contrast

Material • Bilateral approach highly likely: 90 cm guides: JR 4 SH 7 Fr

Material • Bilateral approach highly likely: 90 cm guides: JR 4 SH 7 Fr and EBU 4. 0 SH, later changed to EBU 3. 5 SH (Launcher, Medtronic) • Microcatheter: Finecross (Terumo) • Initial wire for antegrade probing: Fielder XT (ASAHI Intecc) • Retrograde option: Whisper LS 300 (Abbott Vascular) over Corsair catheter (ASAHI Intecc)

Antegrade wire progress

Antegrade wire progress

Retrograde option, but no wire alignment IVUS: wire exit into the periadventitial space (myocardium)

Retrograde option, but no wire alignment IVUS: wire exit into the periadventitial space (myocardium)

Procedural details • Lab time: 225 min • Fluoro time: 99. 9 min •

Procedural details • Lab time: 225 min • Fluoro time: 99. 9 min • Contrast volume: 850 ml • Precautions: 500 ml Na. Cl infusion during procedure, and continued for 12 hrs

Key issues / Strategy 1. Patient was again offered CABG as principal option 2.

Key issues / Strategy 1. Patient was again offered CABG as principal option 2. After refusal, our strategy 1. Use MSCT to guide PCI of RCA with coregistration, principal retrograde approach 2. LCX as second smaller territory, but with proven ischemia

MSCT “parallel“ viewing

MSCT “parallel“ viewing

MSCT: Orthogonal roadmap

MSCT: Orthogonal roadmap

Material • Bilateral approach definite: 90 cm guides: JR 4 SH 7 Fr and

Material • Bilateral approach definite: 90 cm guides: JR 4 SH 7 Fr and EBU 3. 5 SH (Launcher, Medtronic) • Start retrograde: Whisper LS 300 (Abbott Vascular) over Corsair catheter (ASAHI Intecc)

Retrograde wire passage attempt

Retrograde wire passage attempt

Gradual advancement of Fielder XT

Gradual advancement of Fielder XT

Antegrade approach towards distal target Antegrade: Fielder XT over Finecross, retrograde Miracle

Antegrade approach towards distal target Antegrade: Fielder XT over Finecross, retrograde Miracle

Antegrade approach towards distal target Antegrade: Confianza Pro 9, retrograde Miracle 3 G

Antegrade approach towards distal target Antegrade: Confianza Pro 9, retrograde Miracle 3 G

Reverse CART and wire externalisation

Reverse CART and wire externalisation

Step 1 resolved

Step 1 resolved

Changes over time after 4 months Oct 8, 2010 Feb 8, 2011

Changes over time after 4 months Oct 8, 2010 Feb 8, 2011

Procedural details • Lab time: 216 min • Fluoro time: 85. 7 min •

Procedural details • Lab time: 216 min • Fluoro time: 85. 7 min • Contrast volume: 230 ml (!) • Precautions: 500 ml Na. Cl infusion during procedure

Key issues / Strategy 1. Patient was again offered CABG as principal option 2.

Key issues / Strategy 1. Patient was again offered CABG as principal option 2. After refusal, our strategy 1. Use MSCT to guide PCI of RCA with coregistration, principal retrograde approach 2. LCX as second smaller territory, but with proven ischemia

RCX at the end of step 1

RCX at the end of step 1

Coexisting collateral pathways (86% of cases*) 4 months later *) Werner GS et al.

Coexisting collateral pathways (86% of cases*) 4 months later *) Werner GS et al. Circulation 2003; 107: 1972 -7

Coexisting collateral pathways (86% of cases*) *) Werner GS et al. Circulation 2003; 107:

Coexisting collateral pathways (86% of cases*) *) Werner GS et al. Circulation 2003; 107: 1972 -7

MSCT coregistration

MSCT coregistration

Material • • Guide: EBU 3. 5 SH 7 Fr (Launcher, Medtronic) Microcatheter Finecross

Material • • Guide: EBU 3. 5 SH 7 Fr (Launcher, Medtronic) Microcatheter Finecross (Terumo) A wire to negotiate the proximal tortuosity Contralateral groin prepared

Negotiating the entry Confianza Pro 9 (ASAHI Intecc) Prowater (ASAHI Intecc) then Fielder XT

Negotiating the entry Confianza Pro 9 (ASAHI Intecc) Prowater (ASAHI Intecc) then Fielder XT (ASAHI)

Negotiating the entry

Negotiating the entry

Loss of contrast filling ->contralateral inj.

Loss of contrast filling ->contralateral inj.

Parallel wiring is not old fashioned… … but requires a lot of patience

Parallel wiring is not old fashioned… … but requires a lot of patience

After ballooning Mini. Trek 1. 2 X 12 mm (Abbott Vascular) Maverick 2. 5

After ballooning Mini. Trek 1. 2 X 12 mm (Abbott Vascular) Maverick 2. 5 X 30 mm (Boston Scientific)

DES: Biomatrix Flex 2. 5 x 36 mm

DES: Biomatrix Flex 2. 5 x 36 mm

Material • • Guide: EBU 3. 5 SH 7 Fr (Launcher, Medtronic) Microcatheter: Finecross

Material • • Guide: EBU 3. 5 SH 7 Fr (Launcher, Medtronic) Microcatheter: Finecross (Terumo) Initial wire: Fielder XT (ASAHI Intecc) Wires: – Prowater; Confianza Pro 9; Whisper ES • Balloons – Mini Trek; Maverick; Quantum Maverick NC • DES (Biomatrix)

Procedural details • Lab time: 163 min (taped case recording) • Fluoro time: 54.

Procedural details • Lab time: 163 min (taped case recording) • Fluoro time: 54. 3 min • Contrast volume: 856 ml • Precautions: 500 ml Na. Cl infusion during procedure, and followed by 100 ml/h for 12 hours

An advanced case because … • … retrograde approach was the only option for

An advanced case because … • … retrograde approach was the only option for the RCA • MSCT helped to verify the correct wire alignement in this case • Patients accept the stepwise approach • Not a single day in rehab, 7 days of sick leave • Which surgeon would have succeeded in complete arterial revascularisation ?

Dear Surgeon …

Dear Surgeon …