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Georgios Sianos - RETROGRADE STEP BY STEP APPROACH
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Transcript of Georgios Sianos - RETROGRADE STEP BY STEP APPROACH
Georgios Sianos, MD, PhD, FESCAristotle University
AHEPA University Hospital
Thessaloniki, Greece
A’ Cardiology DepartmentAHEPA University Hospital
Aristotle Universityof Thessaloniki
RETROGRADE STEP BY STEP APPROACH
CART techniqueThe novelty in 2005
Targeted collateral crossing
Septal collateral dilatation (1.25-1.5 mm long OTW balloons at max 4 atm)
Connection of the subintimal spaces
The Continuum of CTO PCI
Dissection Reentry
Antegrade
Retrograde
Adoption of only 1 or 2 of these limbs will limit the patients that can be treated on the basis of coronary anatomy
Septal surfing technique
Fielder FC, SION, SION blue
Selective contrast injection
Microcatheter inner lumen size matters
SION black, Fielder XT-R, SUOH
Wire collateral crossing
Microcatheter Collateral crossing
Microcatheter inner lumen matters
Microcatheter selection
Corsair, Caravel, Finecross, Turnpike, Turnpike LP
Solving MC crossing problems
Choose guiding catheters with good backup support
Change the failing MC
Ballooning by small balloon with low pressure
Balloon anchoring
Select another retrograde channel
CTO lesion crossing
Retrograde Wire Escalation (RWE)
Retrograde wire crossing
Retrograde Dissection and Reentry (RDR)
CART
Reverse CART
Stent facilitated
Guideliner facilitated
Guide extension facilitated
RetrogradeDissectionRe-entry
(RDR)
RetrogradeWire Escalation
(RWE)
AntegradeDissectionRe-entry
(ADR)
AntegradeWire Escalation
(AWE)
CTO CROSSING`Wire Options To Crossing CTOs
Courtesy J Spraat
Sequence of Wire Selection in Contemporary CTO Techniques
(Antegrade and Retrograde)
Soft (<1gf)-tapered-polymeric-composite core GWs (Fielder XT-A/R) for soft tissue tracking (passive wire control)
Intermediate stiff (2-6 gf)-tapered-composite core GWs (GAIA family) for hard tissue tracking (active wire control)
Stiff (>9gf)-tapered GWs (Confianza pro / Progress 200T) for calcified tissue penetration
Retrograde wire externalization
MC and wire in the antegrade GC
Dedicated wires (RG3)
Snares
Tip in methods
Male 55 years old Presented with unstable angina Risk Factors:
- Dyslipidemia - Ex-smoker- ID diabetes- COPD
Non Invasive testing.- Exercise test positive for myocardial ischemia- 2D ECHO: hypokinesia of inferior wall, EF 55%
Patient refused CABGSYNTAX score 21.5
CASE
Male 62 years old Presented with stable angina class III Risk Factors:
- Dyslipidemia - Ex-smoker- ID diabetes
Normal LV function EF 65%CTO LAD Previous failed attempt to recanalise the LAD
CASE
The retrograde technique represents a breakthrough in CTO recanalisation with success rates exceeding 90% in complex CTOs and it has comparable complication rates with contemporary antegrade techniques.
Current evidence suggests that they should be reserved for second attempts after antegrade failure, or as strategies of choice in very complex CTOs where the expected antegradesuccess rate is <50%.
CONSENSUS ON THE RETROGRADE APPROACH
Recent trends in practice suggest implementation of the retrograde techniques after short antegrade failures (aimed at reducing procedure duration, contrast consumption and radiation exposure), but until more data become available this approach should be reserved for very experienced operators.
Retrograde techniques should be reserved for very experienced antegrade operators (>300 CTOs & >50 per year).
A minimum of 50 retrograde procedures (25 as second operator and 25 as first under supervision) are required before a cardiologist becomes an independent retrograde operator.
CONSENSUS ON THE RETROGRADE APPROACH
Think first retrograde when…
Truly aorto-ostial occlusionsGood interventional collateralsProximal cap - ambiguous anatomy or not crossed
antegradeLong lesion with undefined CTO coursePoor distal vessel opacificationVessel reconstitutes at a distal bifurcationRepeat attempts Tandem CTOs Post GABG patientsContrast Sparing
But above all when you are well trained…….
Cath LAB set up trained supporting personnel (assistants, technicians & nurses) Dual catheter injections Vigilant ACT monitoring (Cave donor artery
complications) CTO TOOLBOX
Long sheaths GC (short/end) GC extensions Wires full spectrum and dedicated for channel tracking
(SION family, XTR) and externalisation (RG3) Microcatheters (Corsair, Finecross) Syringes for tip injections Dual lumen MC ( Twinpass, Crusade) Snares Coils
IMAGING (IVUS, MSCT)
Retrograde Set up