Kỹ thuật để mở các tổn thương tắc nghẽn mạn tính mẹo để tối ưu kết quả và giảm thiểu biến chứng

Double injection technique Case Presentation... Double injection technique Case Presentation... Special Guide wires for CTO• Hydrophilic coated wires – Whisper, Choice PT, Pilot, Terumo

VNCC 2016, Hanoi

“Tips & Tricks to Open CTO”

Wasan Udayachalerm, MD, FAPSIC

Cardiac center King Chulalongkorn Memorial Hospital

2

10 Tips for CTO intervention

1 Good preparation for CTO

2 Guiding techniques to have good back up support

3 Contra-lateral injection (Mandatory for accurate

identification of the lesion)

4 Using Microcatherter(s)

5 Guide wire(s) selection & shaping

6 Good techniques : Antegrade & retrograde

7 Passing the lesion after the wire pass !!

8 Others techniques

9 prevent & prepare to solve complication(s)

10 Thinking & mentality!!

3

Tip 1 : The Good Preparation

• Sufficient baseline angiographic images of the entire coronary artery anatomy

• Deliberate planning of the primary technical approach

– Anatomic considerations

– Non-coronary variables

• renal function

• prior attempts

• overall health of the patient

• Biplane system if possible

• Review of Cath Lab inventory - do you have everything you need on the shelf and in the room?

• Stopping rules - x-ray dose and contrast volume

Tip 2 : Guiding Techniques

• XB for LCA and AL1/XB RCA for RCA

• 7 or 8 Fr guiding may be better

• Use both passive & active back up

• Deep seated techniques with careful

manipulation

• Mother & child/ guiding extension

techniques

• Sheathless guiding for bigger lumen (TRI)

or new virtual sheath

VNCC 2016, Hanoi

Tip 3 : Contra-Lateral Injection

Contra-Lateral Injection

Case Presentation

A 48 y/o woman, having atypical anginal chest pain with positive EST at low work load ( with chest pain )

Double injection technique

Case Presentation

Double injection technique

Case Presentation

Double injection technique

Case Presentation

Double injection technique

Case Presentation

•Wire performance characteristics influence choice

•Performance characteristics affect suitability in

varying clinical situations

•Wire choice should be based on performance

requirements for each procedure

Science & Art - Selection of Guidewire in a Case

The selection of guidewire is influenced by:

Vessel take Off

Special Guide wires for CTO

• Hydrophilic coated wires

– Whisper, Choice PT, Pilot, Terumo NT,

Shinobi

• Cross-IT family, Progress

• Asahi Guide wire

– Miracle & Conquest family

• Special wire for retrograde approach

– Fielder FC, Fielder XT, Sion, Sion Blue

Wire Shaping

•Easy to make re-entry

•Small false lumen

•Large false lumen

•Difficult to make re-entry

•True lumen

Creation of Re-entry

Tips 6 : Good Techniques

SLIDING TECNIQUE:

This technique, a common

technique for crossing functional

occlusions or very narrow lesions,

benefits from using lubricious a

polymer sleeved guide wire

DRILLING TECNIQUE:

The guide wire is advanced using gentle movements Straight tip guide wires facilitate tactile feedback and steerability Step up with stiffer guide wires

PENTRATING TECNIQUE:

Penetrating the obstruction aiming at the target

The direction of the guide wire is more precisely controlled Tapered tip guide wires permit higher penetrating forces

21

Antegrade Wiring Techniques

• Usually the first strategy

• Wire choosing : hydrophilic vs hydrophobic

• Single wire technique (+ microcatheter for

guide wire support and directional stability)

• Wire manipulation

– Sliding or gliding, Drilling & Penetrating

• If single wire failed :

– 2 wires technique(s) : Pararelle wire, Se-Saw wire – Go retrograde (if possible)

Case Presentation

•A 72y/o woman, post CABG for 8 yrs with 2 x PCI in

LAD and LCx with angina and CTO RCA

Case Presentation

Case Presentation

Case Presentation

Case Presentation

27

Retrograde Wiring Techniques

• Select channel & injection of contrast via

microcatheter

• Use small balloon or channel dilater

• Guide wire : Sion, fielder family, whisper MS and wire shaping

• When retrograde wire pass into distal true lumen: Connect between the channels

Strategies for Retrograde

Approach

• Use retrograde wire as a marker then facilitate antegrade wire passing

• Real retrograde passing of guide wire

– How to connect between antegrde and

retrograde channels

Techniques to Connect between the

Chanels

• If successful crossing with retrograde wire

– Kissing wire technique

– Trapping of retrograde wire

– Exchange to 300 cm wire or Snaring of

retrograde wire

• If retrograde wire fails to cross

– CART or reverse CART technique

– SIAM kissing technique

to the distal true lumen

CTO

CART for Retrograde approach

Tip 7 : After the Wire Pass…….!!

• Still only a half way!!

• Try to pass microcatheter and exchange stiff wire to soft wire

• If microcatheter couldn’t pass, try small balloon

• Tornus, anchoring technique, laser

• Try to pass rota wire  Rotablator

Tip 8 : Others Techniques

• CTA for previous failed PCI

• Knuckled wire technique

• IVUS guided

Identification of the Entry Point by IVUS

Tip 9: Prevent & prepare for Cx

• Basic safety procedures

• What can happen, it will happen

• When complication(s) happen, act like a

“DUCK”

Case Presentation

A 64 y/o man, with angina & syncope post PCI in LAD

and LCx with failed PCI in RCA (perforation)

Case Presentation

Case History

• A 65 Y/o male patient with angina on exertion

• Risk factors : HTN & dyslipidemia

• Positive EST at low work load

RCA

LCA

Case summary

• High risk CAD patient

• Osteal LAD lesion (trifurcation LM)

• Total occlusion of mid LAD

• Total occlusion of mid RCA

• Patient strongly refuse surgery!!

PCI for LAD-CTO

After balloon dilatation

What will you do next?

A Repeat PCI with bigger balloon

B Stent graft in LAD

C Try to redirect the wire in LAD & stent

D Consult surgery

E Others

After waiting for 15 minutes

Forgiven complication!!

2nd procedure

PCI for RCA-CTO

Change to AL1 guiding

Retrograde wiring

Retrograde wire pass into aorta

Antegrade wire easily pass!!

Final result for RCA

3rd procedure

RCA

PCI for LAD

Final results

A 65 Y/O male with angina on Exerton

Anchoring balloon in RV branch

A 65 Y/O male with angina on Exerton

Final results

FU 3 years later

A 47 Y/O male with angina on Exertion

Retrograde wire into antegrade

guiding

Kissing microcathers

A 65 Y/O male with angina on Exerton

After stenting

After stent graft

Complications During PCI for

SIAM Technique

technique

Advantages of the technique

 Usually success after failed regular antegrade

and retrograde appoach

 Less contrast used

 Need only 1 extra microcatheter and 1 guide

wire

 Less injury to distal vessel by the guide wire

 No major dissection before stenting

 Usually in the true lumen (side branch always

preserve after the procedure)

 Easily changing guide wire

Limitations

 May be difficult to manipulate guide wire into

contralateral microcatheter

 In some cases, microcatheter may not be able

to pass the lesion

 Needs skilled operator (esp for retrograde

approach)

Tip 10 : Good Mentality & Thinking

Conclusions

• In an environment of increased scrutiny of all PCI procedures, CTO treatment will be under the microscope and compelling clinical

rationales are necessary

• Meticulous attention to the angiogram in

planning and during the procedure is mandatory

• Comfort with a variety of wire and “bailout”

techniques are vital

Conclusions

• It’s all about decision making

• PCI of CTO: indication, risk benefit ratio

• Antegrade vs retrograde

• When to abandon the planned procedure?

Misuse version 2

• 6 hour procedures

• All about the operator and not the patient

• Huge radiation doses to patient

• Inability to give up

• Risks increase late into a procedure