Adventures with ISR

Colm G Hanratty

ISR Algorithm

• Primary crossboss• )

1st Strategy

• Wire escalation

2nd Strategy

• Retrograde

3rd Strategy

ISR

Clinical Details

• PCI RCA 2003• Symptomatic ISR 2014 (CC II)• Previous failed attempt (February 2014)

Stuck wire

• Wire would not withdraw into corsair• Could pull corsair back on wire• Could pull wire back from stent

• Phoned experienced colleague– Suggested exchange for finecross, or OTW

balloon and retrieve wire through that. Likely problem with corsair tip

Nhancer catheter

Microcatheter: soft, flexible tipUnique locking mechanism to enhance wire control and penetration

Case 2

Index PCI 2008Complicated RCA PCI during PCI for NSTEMI

- Distal edge dissection after stent deployment- Transient loss of flow into PLV

- Difficulties delivering distal stents - DES detached and required to be deployed in proximal vessel

- Prolonged procedure- Eventually, 2 × BMS deployed distally- Good final angiographic result

Follow-Up

• January 2009- CCS I/II angina, reassuring exercise test, medical

therapy increased

• October 2011- CCS III/IV angina, side effects with increased

medical therapy

• December 2011- Failed attempt @ CTO PCI

Attempted CTO PCI Jan 20128F AL1 to RCA (45cm sheath RFA), 6F JL3.5 to LMS (RRA)

Attempted CTO PCI Jan 20128F AL1 to RCA (45cm femoral sheath)

EMPLOYED STRATEGIES– CROSSBOSS- Antegrade wire escalation - Failed - unable to cross proximal cap despite:

- Anchor balloon- Attempted knuckle passage- Highly supportive wires

- Case abandoned – neutral outcome

CTO PCI Oct 20138F AL1 to RCA (45cm sheath RFA), 6F EBU4 to LMS (RRA)

PRIMARY STRATEGY – Retrograde Failed – unable to cross underdeveloped septal collaterals

CTO PCI Oct 20138F AL1 to RCA, 6F EBU4 to LMS (45cm femoral sheaths)

SECONDARY STRATEGY– Antegrade wire escalation - Failed – unable to penetrate proximal cap

CTO PCI Oct 20138F AL1 to RCA, 6F EBU4 to LMS (45cm femoral sheaths)

SUCCESSFUL STRATEGY – Antegrade dissection/re-entry - Penetrated with inflated balloon and 15g wire (ProVia) – “co-axial anchor” - Tracked outside stent in sub-intimal space with polymer jacketed wire (Pilot 200) and Corsair™ support

CTO PCI Oct 2013 Antegrade Dissection and Stingray™ Facilitated Re-entry

Re-entry into distal true lumen - Stingray™ balloon and guidewire

Crossing CTO segment - within sub-intimal space using polymer-jacketed wire (Pilot 200) and Corsair™ support

CTO PCI Oct 2013Predilation and Stenting

- Guideliner™ facilitated stent delivery- Overlapping 2.5 by 38 and 3.0 by 38mm Promus Premier® DES - postdilated 3.0 mm NC balloon

CTO PCI Oct 2013Final Appearance

IVUS demonstrating long sub-intimal stented segment and crushed stent from original procedure in separate sub-intimal tract

Follow Up Angiogram 2014Six Months after Successful PCI

Follow-up angiogram demonstrating widely patent stents and TIMI III flow

Follow Up Angiogram 2014Six Months after Successful PCI

OCT demonstrating good stent apposition and endothelialised struts

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