Retro style may be fashion

IOANNIS TSIAFOUTIS

INTERVENTIONAL CARDIOLOGIST

RED CROSS HOSPITAL

ATHENS

Retrograde Dissection Re-entry

Retrograde True Lumen

AntegradeDissectionRe-entry

Antegrade True Lumen

4 options to crossing CTOs

Illustration by Dr J C Spratt / VascularPerspectives

IC-185422-AA SEP2013

• Approach from collateral channel

• Usually for RCA and LAD via septals (easier for RCA),

or via Grafts

• Easier to penetrate distal cap than from antegrade

approach

• Be aware with anticoagulation (ACT>350)

W balloon catheter through the channel

Retrograde Approach

Retrograde accessories

• Colateral wires (Fielder FC, XT-R, Sion family, Suoh)

• Externalization wires : RG3, R350

• Guide extensions

• Microcatheters (single and dual lumen)

• Snares

• Perforation tools

Retrograde wires

Sion black Suoh 03

Wire collateral crossing• Septal surfing technique

• Selective contrast injection

Solving Microcatheter problems• Choose guide catheters with good support

• Change the failing mc

• Choose another collateral pathway

• Baloon anchoring

CTO Lesion Crossing

• Retrograde wire escalation

• Retrograde dissection and reentry

CART

Reverse CART

Wire ExternalizationUse of Guide extension or snare

Trapping the micro in the guide

Loading from the tip of the wire or cut it

Retrograde CTO Techniques

CART TechniqueControlled Antegrade and Retrograde Subintimal Tracking

Reverse CARTControlled Antegrade and Retrograde Subintimal

Tracking

Reverse CARTControlled Antegrade and Retrograde Subintimal

Tracking

Reverse CARTControlled Antegrade and Retrograde Subintimal

Tracking

DRAFT TechniqueDeflate, Retract and Advance into the Fenestration Technique

“A novel maneuver to facilitate retrograde wire externalization during retrograde chronic total occlusion percutaneous coronary intervention”

Carlino M, Azzalini L, Colombo A

Catheter Cardiovasc Interv. 2017 Jan;89(1):E7-E12.

IVUS applications in retrograde approach

• Retrograde guidewire crossing

ostial occlusions or bifurcations with blunt stump

• Reverse CART

evaluation of antegrade and retrograde guidewires positions compared with CTO body and optimal balloon sizing for medial disruption

selection of the appropriate position within CTO vessel where to create connection between antegrade and retrograde guidewires

Alfredo R. Galassi et al. JCIN 2016;9:1979-1991

American College of Cardiology Foundation

Alfredo R. Galassi et al. JCIN 2016;9:1979-1991

American College of Cardiology Foundation

1st case

• Pt 70 yrs

With angina with mild exertion

Medical History: Dyslipedemia, Hypertension, ex smoker

Prior MI with no coronography

Coro: Cto dominate LCX, collaterals from right (epicardial)

Jcto score: 1

Progress cto score : 1

The PROGRESS CTO complications score.

Barbara Anna Danek et al. J Am Heart Assoc

2016;5:e004272

© 2016 Barbara Anna Danek et al.

Incidence of periprocedural complications in strata of the PROGRESS CTO complications score.

Barbara Anna Danek et al. J Am Heart Assoc

2016;5:e004272

© 2016 Barbara Anna Danek et al.

Biradial access 6Fr, EBU 3.5, JR4. Antegrade wire escalation Gaia 2nd, Confianza pro12, Hornet 14 , Caravel micro. Single wire – 2 wires parallel technique. Dissection –no reentry

Biradial access 6Fr, EBU 3.5, JR4. Antegrade wire escalation Gaia 2nd, Confianza pro12, Hornet 14 , Caravel micro. Single wire – 2 wires parallel technique. Dissection –no reentry

Epicardial collateral from RCA next choiceSuoh wire, Caravel micro, beating heart surfing

Injection from micro

A Gaia 3rd successfully passed retrogradely and an RG3 was externalized through a Guide extension (Guidezilla).A guide extension was used through EBU to facilitate the ext

Two DES Promus 3.0x18mm. 2.5x20mm71.5 min Fluoroscopy time, 21079 cGy/cm2 DAP. Progress Cto compl score: 4

•2nd casePt male 82 yrs with nSTEMIMedical history: MI, DM, Hypertension, PADEF:40%Coro : diffused disease , prox,mid LAD long lesionCto RCA

7Fr transradially bilateral, EBU 3.5 for LCA and AL1 for RCA. First we fix prox-mid LAD

Rca cto: gap<20mm,Jcto score: 1, Progress cto score:1

7Fr transradially bilateral, EBU 3.5 for LCA and JR4 for RCA. First we fix prox-mid LAD

After a 10 minutes try for antegrade true to true lumen with Fielder Xt, Pilot 200 we tried retro with Sion black septal surfing, micro Corsair failed and switched to Caravel that went easily

Gaia 2nd,3rd failed but a Pilot 150 succeeded to pass retro. The micro was driven inside the guide with wire trapping and RG3 was externalized

After dilatations we finished the PCI with stenting (Resolute 2.75x30mm,2.75x30mm,2.5x18mm)

Prox –mid LAD, Retro cto RCA :52 min fluoroscopy time , DAP 12250cGy/cm2. Progress cto complication score :4

ImprovedProcedural Success Rate

10

0

20

30

80

70

60

50

40

90

100

2003.3 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014.6

Retrograde Corsair

75%

97%86%

IRIS CTO Registry, AMC data 2016

Brilakis ES, JACC Interv 2015;8:245-53, A Report from theNCDR

Pro

ced

ura

l S

uccess

(%)

MA

CE

(%

)

Large Volume Experiences Can Make a

Better Success and Lower MACE

4.3

2.1

Multicenter US Registry, Circ Cardiovasc Interv 2016;9: e003434

MACE Myocardial infarction

Retrograde approach Antegrade approach

P<0.05

1.1

But, Retrograde Approach

Increased In-Hospital MACE

P<0.05

0.3

Cu

mu

lative

Incid

en

ce

(%)

The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention: Update From the PROGRESS CTO Registry

Tajti P, Karmpaliotis D, Alaswad K3, Jaffer FA, Yeh RW, Patel M, Mahmud E, Choi JW, Burke M, Doing AH, Dattilo P, Toma C, Smith AJC, Uretsky B, Holper E, Wyman RM, Kandzari DE, Garcia S, Krestyaninov O, Khelimskii D, Koutouzis M, Tsiafoutis I, Moses JW, Lembo NJ, Parikh M, Kirtane AJ, Ali ZA, Doshi D, Rangan BV, Ungi I, Banerjee S, Brilakis ES

JACC Cardiovasc Interv. 2018 Jul 23;11(14):1325-1335

“2,733 CTO interventions in 2,677 patients

Overall technical and procedural success was 88% and 86% respectively and in-hospital major complications rate was 2.9%.

The prevalence of in-hospital MACE in retrograde cto was 5.86%”

CORONARY

1. Vessel closes

• Dissection

• Embolization

• Spasm

• Pseudolesion

2. Vessel Leaks

• Perforation

3. “Wrong place”

• Equipment loss

Be ready to manage complications

HEART

1. MI

2. Arrhythmia -

arrest

3. Tamponade

OTHER

1. Access

2. Thromboembolic

3. Contrast

• Nephropathy

• Allergies

4. Radiation

Brilakis ES. Manual of coronary CTO interventions 2nd edition. Elsevier2017

• Red Cross Hospital cath lab Athens

1st Cardiological Dpt 2nd Cardiological Dpt

Dr Tsiafoutis Ioannis Dr Koutouzis Michael

110 cases

Success 80%

Now participating in SHINE-Cto trial

Retro is not a party at all but may be the solution if you choose right and be well prepared!