20GWICC Revascularization of Ostial LAD CTO with Combined Use of Retrograde and Antegrade Wire Techniques LAD CTO Li Weiming, Xu Yawei Revascularization of Ostial LAD CTO with Combined Use of Retrograde and Antegrade Wire Technique LADCTO Department of Cardiology,Shanghai Tenth Peoples Hospital of Tongji University CIT2010-March,2010,Beijing Case History Present History Male,77yr
2 years ago: Chest uncomfortable, CAG showed LAD CTO, and tried to revascularize, but failed; pLCX 90% stenosis, implanted one stent 2 months ago: Exertional chest uncomfortable. CAG showed that LCX was OK, ostial LADwas also occlude, but failed to revascularize again This time: Try to revascularize the LAD using Retrograde Wire Techniques Case History Risk Factors
HBP for several yearsbe controlled well,No DM PE P76bpm,R16bpm,BP132/72mmHg;heart/lung negative Blood biochemistry and main Associated Examinations Laboratory tests:Normal hepatic and renal function.Normal FPG,myocardial necrotic markers and BNP Resting ECGSR68bpm A chest X-ray filmnormal EchocardiographyLight MV regurgitation and decreased LV diastolic function LCX:no in-stent restenosis; LAD:ostial CTO
CAG LCX:no in-stent restenosis; LAD:ostial CTO LCX:no in-stent restenosis; LAD:ostial CTO
CAG LCX:no in-stent restenosis; LAD:ostial CTO CAG 2009.8.6 RCA: dominant and strong artery,no severe stenosis,
well collateral circuIation to dLAD RCALAD CAG 2009.8.6 RCA: dominant and strong artery,no severe stenosis,
weill collateral circuIation to dLAD Try to Revascularize LAD 2009.8.6
GC:6FXB3.5; Microcatheter:2F Progreat; GW:Conquest Pro. It couldnt breakthrough the CTO Try to Revascularize LAD 2009.8.6 Diagnosis CHD, extensive anterior OMI, LAD CTO, 2yr later of LCX stenting, ACS, NYHA 1-2 Hypertension, Very high risk The therapy strategies this time
Medical Therapy CABG PCI Antegrade Wire Crossing Technique Retrograde Wire Crossing Technique Revascularization of LAD 2009.10.9
Pathways of Revascularization Right femoral artery: Pathway of Retrograde Wire Technique for revascularization Left femoral artery: Pathways of CAGand Antegrade Wire Technique Revascularization of LAD 2009.10.9
Instruments be chosen RCA LM/LAD/LCX GC 7F AL1 7F EBU3.75 Retro-wire 0.014Fielder FC 0.009Conquest Pro Ante-wire 0.014Rinato Protection wire RunthroughLCX Micro-catheter 1.8F Finecross LM7F EBU3.75RCA7F AL1 Field FC1.8F FinecrossRCALADLAD Conquest Pro Revascularization of LAD
GC: 7F EBU3.75 (left),7F AL1 (right) Bilateral CAGwell collateral circuIation from RCA to dLAD Revascularization of LAD
GW:0.014Field FC. It retrograded slowly via the septal branch to the distal end of CTO. The tip of GW was confirmed in the true lumen by Angiography via the microcatheter Revascularization of LAD
The GW of Field FC continued to retrograde slowly Revascularization of LAD
But it met resistance in the middle of CTO Revascularization of LAD
Changing the GW to Conquest Pro via microcatheter. Then the GW continued to retrograde slowly Revascularization of LAD
In order to avoid the procedure-related injury,a Runthrough GW was preimplanted as a protection wire and it also was confirmed in the true lumen by bilateral angiography LCX RCA Revascularization of LAD
The GW retrograde, and nearly crossed over the fibrous capof LAD CTO Revascularization of LAD
The GW crossed over the fibrous capof CTO, and entered into the LM at last Revascularization of LAD
The GW reached the LM at last, but it couldnt enter into the GC PCI13 Revascularization of LAD
Antegrade Wire Technique: Under the direction of the retrograde wire,the GW of Conquest Proreached the middle LAD in the support of the microcatheter, and was confirmed in the true lumen 14 Conquest ProLAD Revascularization of LAD
Under the direction of the retrograde wire, the Conquest Pro advanced slowly 15 Revascularization of LAD
Under the direction of the retrograde wire, the Conquest Pro advanced slowly 16 Revascularization of LAD
When the antegrade wire reached the middle LAD, it was changed to the Rinato. The soft wire was sent to the distal LAD later. 20 Revascularization of LAD
The antegrade wire in the distal LAD was confirmed in the true lumen by angiography through the microcatheter 21 Revascularization of LAD
Send the Rinato to the distal LAD, then partly withdrewthe retrograde wire and the microcatheter Revascularization of LAD
Predilatated the CTO of LAD using the small balloon (Firestar 1.510mm) from the distal to the proximal Revascularization of LAD
After predilatation using the small balloon 27 Revascularization of LAD
Multi-predilatation using the bigger balloon 2.7525mm Sprinter Revascularization of LAD
After predilatation using the bigger balloon Revascularization of LAD
One Endeavor DESS1 2.524mm was implanted in the mLAD at 14atm Second Endeavor DESS22.7530mmwas implanted in the middle-proximal LAD 35 Revascularization of LAD
The ostium of LAD was uncovered after two DES having been implanted 41 Revascularization of LAD
S33.518mmwas implanted crossed over the ostial LCX at 14atm Revascularization of LAD
To kiss using the stent balloon3.518mmand the APEX balloon3.015mm The result was satisfied after kissing Revascularization of LAD
The distal LAD showed thin ! dLAD
IVUS IVUS showed thin dLAD itself, and light myocardial bridge in the mLAD. No severe plaque and stenosis. No need of implanting any other stent dLAD Final results S12.524mmS22.7530mm14atmLADS33.518mmLCX14 atm3.518mmAPEX3.015mmLADIVUS Take Home Messages Transradial pathway nearly could complete any PCI procedures, but transfemoral pathway sometimes was much more convenient to the special casePCI need not stick to the operation pathway ! No stump of CTO lesion in the ostial LAD. It seem to see the ostia only in the spider position. Usually it was difficult to find the true lumen of LAD using the antegrade wire technique. After having taken the lessons from the failure and having analyzed the complex lesions of CTO and the well collateral circulation from RCA, to select the retrograde wire technique is a wise choiceClearly analyzing the lesions before PCI is very important PCIPCI LADCTOLADCTORCA Take Home Messages Having successfully revascularized the CTOof this case really benefit from the excellent devices,including the GW of Field FC/Conquest Pro,the GC of EBU3.75 and AL1,the microcatheter of 1.8F Finecross,the 1.510mm Firestar balloon,et alA workman must sharpen his tools if he is to do his work well It is very important for the operator to agilitily apply and proficiently control the guiding wire, the microcatheter,and the balloon Field FC/Conquest ProEBU3.75AL11.8F Finecross1.510mmFirestar Thank you for your attention!
Thank you for your attention!