Advanced CTO Techniques Gerald S Werner MD Ph
- Slides: 47
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 interest to report.
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 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 • 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 sign
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 = 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
Risk evaluation Euro. SCORE (mortality logistic) = 1. 33% Syntax score = 19
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: 1972 -7
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 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
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 • 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. 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: Orthogonal roadmap
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
Gradual advancement of Fielder XT
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
Reverse CART and wire externalisation
Step 1 resolved
Changes over time after 4 months Oct 8, 2010 Feb 8, 2011
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. 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
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: 1972 -7
MSCT coregistration
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 (ASAHI)
Negotiating the entry
Loss of contrast filling ->contralateral inj.
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 X 30 mm (Boston Scientific)
DES: Biomatrix Flex 2. 5 x 36 mm
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. 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 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 ?
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