LAD-CTO (5Th Attempt)

CTO Toyohashi Heart Center

Learning From Cases of CCT 2015

Case 3: LAD-CTO (5th Attempt)

Etsuo Tsuchikane, MD, PhD

Toyohashi Heart Center Nagoya Heart Center Gifu Heart Center CTO Toyohashi Heart Center

Disclosure

Within the past 12 months, the presenter or their spouse/partner have had a financial interest/arrangement or affiliation with the organizations listed below.

Physician Name Company/Relationship Etsuo Tsuchikane, MD, PhD Boston Scientific, Japan Consultant Asahi Intecc, Japan Consultant CCT2015

CCT2015 PCI Live Case Transmission Rakuwakai Marutamachi Hospital

Marutamachi Case 1

70’s male Target Lesion: Ostial LAD(CTO)

Diagnosis ■ OMI Prior intervention ■ ’06 AMI (RCA) ’06.9 CABG (LITA to LAD, Ao-RA-OM) ‘07 LITA occlusion ’11,’12, ’13, ‘14 PCI to LAD (unsuccess) Coronary risk factor ■ Dyslipidemia DM, HT eGFR ■ 53 Syntax score ■ 28.5 Latest CAG findings ■ ‘14.11.10 ostial LAD 100% RAO Caudal View LV EF ■ 46%(UCG) J-CTO score ■ 4 CTO Toyohashi Heart Center

Ostial LAD CTO, 5th Attempt CTO Toyohashi Heart Center

The 1st Attempt (2011/4/14) CTO Toyohashi Heart Center

The 2nd Attempt (2012/2/24) CTO Toyohashi Heart Center

The 4th Attempt (2014/4/11) CTO Toyohashi Heart Center

MDCT CTO Toyohashi Heart Center

The 5th Attempt (2015/10/29)

I decided to use IVUS to identify the LAD ostium from Dx. CTO Toyohashi Heart Center

SION Black was stuck… CTO Toyohashi Heart Center

Pilot 200 was advanced towards Dx. CTO Toyohashi Heart Center

With knuckle formation CTO Toyohashi Heart Center

Retrograde injection CTO Toyohashi Heart Center

Small balloon dilatation CTO Toyohashi Heart Center

IVUS examination from Dx CTO Toyohashi Heart Center CTO Toyohashi Heart Center

LAD

LCx wire CTO Toyohashi Heart Center

Start retrograde approach CTO Toyohashi Heart Center

Retrograde tip injection CTO Toyohashi Heart Center

Antegrade wiring CTO Toyohashi Heart Center

But looks strange… CTO Toyohashi Heart Center

Parallel wiring with GAIA3rd CTO Toyohashi Heart Center

Caravel MC followed the wire! CTO Toyohashi Heart Center

Knuckle wiring with SION Black CTO Toyohashi Heart Center

2.5mm antegrade balloon CTO Toyohashi Heart Center

Reverse CART with retrograde SION Black CTO Toyohashi Heart Center

Successful wire externalization CTO Toyohashi Heart Center

Final angiogram Careful analysis of angiogram / MSCT In-stent restenosis

Yes Consider use of CrossBoss as Proximal cap ambiguity IVUS guided entry primary crossing strategy

No Yes No

Poor quality distal vessel or Yes Interventional collaterals present bifurcation at distal cap

No Yes No

Antegrade wire Retrograde approach based approach If suitable re-entry zone Features favoring early use of KWT Dissection Reentry Parallel wiring and/or dissection re-entry (crossboss-stingray) • Ambiguous course in CTO • Length >20 mm • Tortuous CTO segment IVUS guided wiring • Heavy calcification • Previous failed attempt

Consider stopping if >3 hours, 3.7 x eGFR ml contrast, Air Kerma > 5 Gy unless procedure well advanced CTO Toyohashi Heart Center

Take Home Message

 Pre-procedural MDCT imaging and Procedural IVUS imaging are indispensable for complex CTO cases.  Knuckle wiring is a promising technique to track inside the vessel. But do never over-push!

 Please follow the Asian-Pacific CTO-PCI algorithm. CTO Toyohashi Heart Center

17th CTO Club

June 17-18, 2016, Nagoya, Japan