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CTO Recanalization - CTO Recanalization - Effect of the Retrograde Approach Valeri Gelev Valeri Gelev

CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

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Page 1: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

CTO Recanalization -CTO Recanalization -Effect of the Retrograde Approach

Valeri GelevValeri Gelev

Page 2: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

No conflict of interest regarding this presentation.

Page 3: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Rational for CTO Recanalization

• Symptom control• Angina• Angina• CHF• Fatigue

• Improve LV function• Improve LV function• Regional• Global

• Survival• Improved tolerance of AMI• Complete revascularization• Complete revascularization• Ischemic Risk

Page 4: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Development of CTO Techniques

Single wire

Parallel wireParallel wire

IVUS guided

STAR

Retrograde

STAR

Antegrade SCTs

Dissection & Reentry

20

00

20

00

20

01

20

01

20

05

20

05

20

04

20

04

20

08

20

08

Page 5: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

CTO-PCI Success Ratein Toyohashi Heart Center

100

in Toyohashi Heart Center

64.9

71.374 73.5

7984.2 86.3

92.4 92.2 91.6 91.5 92.6

80

100

%

64.9

40

60

0

20

01999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Page 6: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

European Registry Update

Retrograde approach improve success rate ofCTO PCI

European Registry Update

Sianos G, CTO Summit, NY, 2015

Page 7: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Numbers of Retrograde Procedures Success RateEuropeEurope

Galassi, A.R. et al. J Am Coll Cardiol. 2015; 65(22):2388–400.

Page 8: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

SummarySummary

Japanese CTO PCI Expert Registry

SummarySummary

Japanese experts frequently chose the bidirectional approach as the primary

strategy (27.9%), especially for more complex CTO lesions, with a technicalstrategy (27.9%), especially for more complex CTO lesions, with a technical

success rate of about 90%.

For intermediate CTO lesions (J-CTO score < 2), experts mainly performed For intermediate CTO lesions (J-CTO score < 2), experts mainly performed

the antegrade approach alone, with a very high success rate (more than 95%).

However, for RBA, the success rate decreased to less than 80%.

The experts frequently used the parallel wiring and IVUS-guided penetration

in antegrade approach, with high technical success (75.0%–88.9%).

Severe lesion calcification was a strong predictor of failure.

Etsuo Tsuchikane CTO Summit New York 2017

Page 9: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

PROspective Global REgiStry for the Study of CTOinterventions

www.progresscto.org

5/2012 to 2/201716 centers, 2,102 lesionsTechnical success: 88%Major complications: 2.6%

•Appleton Cardiology, WI•Baylor Heart and Vascular Hospital, TX•Columbia University, NY•Central Arkansas VAMC, AR•Dallas VAMC/UTSW, TX•Henry Ford Hospital, MI•Massachusetts General Hospital, MA Major complications: 2.6%•Massachusetts General Hospital, MA•Medical Center of the Rockies, CO•Minneapolis VAMC, MN•Minneapolis Heart Institute, MN•PeaceHealth St. Joseph MC, WA•Piedmont Heart Institute, GA•San Diego VAMC and UCSD, CA•St Luke’s Mid America Heart Institute, MO Successful technique

0.6% mortality, 0.9% MI0.9% pericardiocentesis, 0.2% stroke

0.1% CABG, 0.3% re-PCI

•St Luke’s Mid America Heart Institute, MO•Torrance Medical Center, CA•UPMC Medical Center, PA

Antegrade wiring

Antegrade dissection/re-entry

Retrograde77.1%80.00%

100.00%

Antegrade

Antegrade DR

Successful technique

49%

24%

27%

77.1%

34.3%39.5%

20.00%

40.00%

60.00%

80.00%

Retrograde

24%

0.00%

20.00%

Techniques Used

Emmanouil S. Brilakis CTO Summit New York 2017

Page 10: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

January 2010Starting our experience withStarting our experience with

Retrograde Approach

George Sianosand

Alexander DoganovAlexander Doganov

DuringSecond Retrograde CTOSecond Retrograde CTO

Workshop

Page 11: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

• When to Consider Retrograde Approach

• In difficult anatomy

• To achieve fast and predictable result in• To achieve fast and predictable result innot that complex cases with goodretrograde options, while preserving theretrograde options, while preserving theanatomy of the vessel

Page 12: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

CTO Complexity – J CTO score

• Blunt tip/none or unclear tip: 53.7%• Calcification*: 33.7%• Calcification*: 33.7%• Bending*: 8.5%• Occlusion length>20mm: 61.7%• Re-try lesion: 11.6%

*Score was counted based on judgment more thanIn difficult CTOs (J-CTO score 2), successful

antegrade wiring of the CTO within 30 minutes

35.4%40%

50%

*Score was counted based on judgment more than“moderate” grade for calcification and bending

In difficult CTOs (J-CTO score 2), successfulantegrade wiring of the CTO within 30 minutes

of fluoroscopy time can be accomplished inless than 50%

15.0%

35.4%

31.5%

18.2%20%

30%

40%less than 50%

0%

10%

Easy (0) Intermediate (1) Difficult (2) Very difficult (>3)

Page 13: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

When to Consider Retrograde Approach

• Abrupt occlusion with a large side branch• Ambiguous anatomy of proximal cap and

vessel course.vessel course.• Length of CTO 20mm• Bending in the CTO body• Severe Calcifications• Severe Calcifications• Poor distal landing zone or bifurcation• Previous failed attempt

Interventional collaterals presentInterventional collaterals present• Dependent on the experience of the operator• Absent in 20-30 % of cases

Page 14: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

RCA CTO – J CTO score 0-1Primary Retrograde ApproachPrimary Retrograde Approach

Page 15: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

RCA CTO

Retrograde crossing with Sion over Corsair Ultimate through distal cap

Page 16: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

RCA CTO

Antegrade wiring with Ultimate Reverse CART with 2,5/15 balloonUltimate wire exchanged with Pilot 150

Page 17: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Final result after 3DES

RCA CTO Final result and Procedural Details

Final result after 3DES

AntegradeAttempt

RetrogradeAttempt

Procedural time 118 min. 90 min.Procedural time 118 min. 90 min.

X ray time 57 min. 35 min.

Contrast Volume 450 ml 330 ml

Retrograde Approach, even in not that complex cases,provides the opportunity to achieveContrast Volume 450 ml 330 ml

# of CTO wires 4 4

provides the opportunity to achievefast, predictable success, sparing the anatomy

of the vessel.

Failure Success

Page 18: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

CTO Experience

National Heat Hospital 2002 - 2005

2006 117

National Heat Hospital

2007 159

2008 154National Heat Hospital 2008 154

2009 81

Emergency Center "Pirogov 2010 - March2013 164

Tokuda Hospital March2013-2016 238Tokuda Hospital March2013-2016 238

Page 19: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

235Antegrade

only235

403 Antegrade/Retrograde

only

[CATEGORY NAME]

16,5%16,5%

[CATEGOR[CATEGORY NAME]

83,5%

Page 20: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

JCTO Score

1.231.4

0.96

1.23

1

1.2

0.4

0.6

0.8

0

0.2

0.4

Antegrade/Retrograde

Antegradeonly

Page 21: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Success Rates for CTO RecanalizationSuccess Rates for CTO Recanalization

[VALUE]%90

[VALUE]%

[VALUE]%

60

70

80

30

40

50

60

0

10

20

30

0

Antegrade/Retrograde

Antegradeonly

Antegrade/Retrograde

Antegradeonly

Page 22: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

J-CTO scores in Antegrade and Retrograde Patients

1.49

1.4

1.6

Success rate ~90%

1.18

1

1.2

1.4Success rate ~90%

0.4

0.6

0.8

0

0.2

RetrogradeAntegrade

Page 23: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

The Impact of the Retrograde Approach

Gives you the opportunity:To threat more complex CTO casesIn a more predictable mannerIn a more predictable mannerWith higher success rates

Additionally(something which is no measurable):Additionally(something which is no measurable):• Increases your knowledge: anatomy, pathology, technology and

devices…• Improving your skills – retrograde procedures are very demanding• Improving your skills – retrograde procedures are very demanding• Acquire new techniques – trapping, wire externalization, tip in tip,

randevouz…• Developing a new mind-set, useful not only in CTO recanalizations.• Developing a new mind-set, useful not only in CTO recanalizations.

Page 24: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Male 47y; Admitted with ACS w/o ST elevationAug. 2007 – ACS – Severe ostial LAD stenosis - dedicated bifurcation stentAug. 2007 – ACS – Severe ostial LAD stenosis - dedicated bifurcation stentNov. 2007 – instent restenosis - ACB x 2 LIMA –LAD; SVG - RIM

Normal nonNormal nondominant RCA

High grade stenosis of LCx after the origin of RIM

Page 25: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Patent LIMA – LAD and SVG - RIMPatent LIMA – LAD and SVG - RIM

Page 26: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

PCI Procedure

Wires in LAD and RIM

Right radial access6F EBU

Impossible to wire the LCx because ofImpossible to wire the LCx because ofunfavorable angle- any type of wires ( 4 different types)- after predilatations at the carina site 2,5/15- after predilatations at the carina site 2,5/15- using a double lumen catheter – “Crusade”

Page 27: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

PCI Procedure

Retrograde approachRetrograde approachAdditional left radial access 7F AL 1,5 for SVGCorsair 150 cmRunthrough wire retrograde successfullyRunthrough wire retrograde successfullypassed

Page 28: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

PCI Procedure

Corsair couldn’t follow the wire

Exchange with OTW 1,5/15

Retrograde dilatation at the ostiumof Cx

Successful antegrade wiring of CxSuccessful antegrade wiring of Cx

Page 29: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

PCI ProcedureFinal ResultFinal Result

Procedural DetailsProcedural DetailsX-ray time - 70 min

Antegrade attempt – 49 minRetrograde pass - 2 min

Procedural time - 110 minContrast amount – 450 ml

Page 30: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Another example…..

Page 31: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Another example…..

Peripheral Angio of Right Leg

Page 32: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

After failed antegrade attempt, no clear vessel course.Retrograde attempt - unable to get in the true lumen retrogradly,Retrograde attempt - unable to get in the true lumen retrogradly,probably due to aneurysmatical changes at the proximal cup.

Page 33: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Retrograde attempt - Stent Facilitated Reverse CARTOver the antegrade wire, a balloon expandable coronary stent wasimplanted with the proximal part of the stent deployed in the poplitealimplanted with the proximal part of the stent deployed in the poplitealartery while distal part expanded in the subintimal space.

Page 34: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Verification of the proper passage of the retrograde wire trough the stent

Page 35: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Final result after externalization and balloon angioplasty, achieving a“straight line” to the foot with rapid recovery of the patient.“straight line” to the foot with rapid recovery of the patient.

Page 36: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,

Retrograde approach is vital component of a CTOprogram, increasing the success rates even in veryprogram, increasing the success rates even in verycomplex anatomy.

The retrograde concept creates a different mind-setand skills-set which improves the overalland skills-set which improves the overallperformance of the interventional cardiologist.

Page 37: CTO Recanalization - Effect of the Retrograde ApproachRetrograde Attempt Procedural time 118 min. 90 min. X ray time 57 min. 35 min. Contrast Volume 450 ml 330 ml Retrograde Approach,