when am i prepared enough for my first retrograde approach?

Kambis Mashayekhi

University Heart center Bad Krozingen

Euro CTO Club 2017: Saturday 7h15-8h30

When am I prepared enough for myfirst retrograde approach ?

Situation in Europe

ESC – Guidelines on Myocardial Revascularisation 2014:

2

Single Operator K.M. (2013-2017)

931 CTO

(95,8% success)

430 single wire (46%)

J-CTO 1,5

Fluoro: 29min

96 Parallel wire / ADR (10,3%)

J-CTO 2,3

Fluoro: 62min

398 retrograde wire (43%)

J-CTO 2,8

Fluoro: 81min

7 data missing

Why do I need retrograde approach?1

Euro-CTO Registry 2013-2016

(n=7523, 32,3%retrograde)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Successrate

Successrate 2013-2016

Antegrade

ADR with CB

Retrograde

92,4%

83,4%85,0%

0

0.5

1

1.5

2

2.5

3

J-CTO

J-CTO Score 2013-2016

Antegrade

ADR with CB

Retrograde

1,87

2,49

2,76

K. Mashayekhi, EuroCTO Registry, TCT 2016

0.60%

1.30%

0.27%0.01%

0.83%

6.20%

0.41%0%

1.50%

4.70%

1.00%

0.16%

Tamponade PE withoutTamponade

PeriinterventionalInfarction

Procedural Death

Complications 2013-2016

Antegrade ADR with CB Retrograde

Am I ready to take the potential risk for

retrograde procedures?


2

4,3

2,1

0,4

1,3

0,6 0,8

1,1

0,3 0,3 0,3 0,1 0,1

0

MACE

MI

Stroke

Pericard

iocente

sis

Re-PCI

Death

Com

plic

atio

n ra

te (%

)

Retrograde

Antegrade-only

PROspective Global REgiStry for the Study

of CTO interventions

MACCE in retrograde vs. antegrade-only CTO

Karmpaliotis et al. Circ Cardiovasc Interv 2016 Jun

n=539 J-CTO 3,1

n=762 J-CTO 2,5

Periprocedural ischaemia during CTO PCI:

Influence of the retrograde approach

Werner et al. Eurointervention 2014 Nov

Periprocedural Myocardial Injury in Patients

Undergoing CTO-PCI : Role of Antegrade and

Retrograde Crossing Techniques

Toma et al, unpublished data 2017

antegrade; n=1447

19,4% PMIretrograde; n=462

44,2% PMI

PMI (elevation of cardiac troponin T [cTnT] >5 x 99th percentile of normal)

Do I have enough support in my hospital?

• Strong backing from the head of the department and the senior consultants

• Motivated and interested Cath-lab team, who believes, that the CTO - operator can handle complex PCI scenarios

• Support from a device company

• Do I need additional support from an experience retrograde CTO operator

3

Do I have enough resources for a retrograde

CTO program?

• Structural resources:– 2 Cath labs

– Institution with >500-750 PCI (50-75 CTO´s / year)

– Cardiac – MRI, Cardiac – CT-scan

• Personal resources:– Experienced internationalist

– CTO- days/week (extra time slots)

• Material and financial resources:– CTO wires, microcatheters, IVUS, rotablator, ACT-measurement

4

Radiation Protection :

• CTO-setting:

• Fluoroscopy: 6 frames/sec

• Angiography: 7,5 frames/sec

Distance to radiation sourceMobile Shield

Patient Shield

Personal Resources

Special requirements:

• Personality structure of the operator ambitious, persistent, mental force, interested in training activities, sharing experiences and open to communicate

• Enough experience in antegrade CTO PCI

• Knowledge about radiation protection

• Able to avoid, but also master complex emergency situations:

Emergency pericardiocentesis

Coiling, Embolization (fat, microspheres)

Experience in the technique of implanting a Cover-Stent (ping pong - guiding technique)

Am I really prepared for the first retrograde

procedures in my institution?

• Clear communication to the Cath lab team and colleges about what is going on today in the lab

• Do I need support from a device company or medical proctor?

Patients information

• „This procedure will take at least 2-3h !“

• 2 puncture sides

• Talk also about alternative options

• Radiation exposure

• Bladder catheter

5

Patient selection: Did I choose a technical

”easy looking” retrograde case? 6

J-CTO 4 6 months follow up

Procedural time 302 min., fluoroscopic time 161 min, cumulative radiation dose 37096 uGym2 and amount of contrast was 200cc.

Is this the right patient to start with my first

retrograde CTO?

Do I know at which point in the

procedure I should change from

antegrade to retrograde?

7

x

x

x

x

x

2x

When to change to retrograde?

Subitimale Wire(Confianza Pro)

Subintimal wire position with low antegradereentry chance

Dual Injection

Antegrade CAPRetrograde Landing

Zone

True Lumen SubintimalWire

Tapered Blunt

>3,0mm <3,0mm

J-CTO

<2,0 ≥2,0

Retrograde Wire

Wire based strategy Parallel Wire

ADRIVUS-ADR

Failure

Failure

1.

2.

3.

CTO-Strategy: Subintimal Wire Position

Algorithm for subintimal wire position; K. Mashayekhi 2015

Subintimale Wire

(Confianza Pro)


Do I know how to use a septal dilatator?

Thanks to Nicolas Boudou for the invitation to the great JIF - CTO in Toulouse 2016

8

Do I understand the principals of revers CART?

9

Antegrade Balloon2,5/20mm

Crosair


Trapped retrograde wire


Do I understand the whole

externalization process?10

Wire Externalization Techniques for Retrograde Percutaneous Coronary Interventions of Chronic Total Occlusions, K. Mashayekhi et al. 2017 accepted, EuroIntervention

Do I understand the whole

externalization process?

• Be able to handle complex PCI scenarios (complex bifurcations,

calcified lesions, rotablation)

• Enough experience in basic antegrade techniques (trapping,

parallel wire, MC usage)

• Strong backing from the hole team

• Personal, material and structural resources (2 cathlabs)

• Special knowledge of retrograde techniques

• Support from a high volume CTO (-mentor)

When am I prepared enough for my first

retrograde approach ?

Thank you!

Thank you for your attention!

The best collaterals: Try septal first !!!

• I) Proximal Septal:– Proximal: often to PLA-System

and partial epicardial

• II) Mid Septal:– Generally to the PDA

– Often very tortious before entry to the PDA common

• III) Distal Septal:– Attention regarding sheer

stress

The best collaterals: Try septal first !!!

“Septal tracking” - very complex septal system

epimyocardiale collateral crossing

Ipsilateral RCA-CTO

Ipsilateral RCA-CTO Stuttgart Heart-LIVE 2015

Euro-CTO-Club Registry - Successful strategy

10/2013-10/2016

7523CTO-PCIs

2429 (32,3%)Retrograde Attempts

5094 (67,7%)Antegrade Attempts

2,76 J-CTO-Score83,4% Successrate

1,87 J-CTO-Score

92,4% Successrate

241 (3,2%)ADR with CrossBoss

2,49 J-CTO-Score

85,0 % Successrate


Final Successful Strategy

The Hybrid Algorithm for Treating CTOs in Europe:

The RECHARGE Registry

Joren Maeremans et al., JACC 2016 Nov.

1253 CTO Attempts

AWE

623 (58%)

ADR

192 (18%)

RWE/RDR

260 (24%)



49.00%

23.80%

27.10%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Antegrade wiring Antegrade dissection/re-entry Retrograde

Antegrade wiring Antegrade dissection/re-entry Retrograde

Successful techniques in 1810 lesions

01/2012 – 06/2016

Data from Manos Brilakis 2016

The Hybrid Algorithm for Treating CTOs in Europe:

The RECHARGE Registry

Joren Maeremans et al., JACC 2016 Nov.



J-CTO-Score Validation and Successful Crossing Strategy

Christopoulos et al, Circ Cardiovasc Interv. 2015 Jul

n=650 lesions

CTO-Setting retrograde Approach (rad./fem.)

CTO-Setting retrograde Approach (bifemoral)

when am i prepared enough for my first retrograde approach?

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