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Selecting and performing the first retrograde cases

Evald Hj Christiansen

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Objectives of first retrograde casesSafetyEfficacyLearning

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Optimize your environment

TimeEquipment AvailabilityProctor Lab Discussion

Optimize your environmentExplain to the interventional team the procedural objectives and how they can help. The procedure is more likely to be successful when appropriate time is apportioned & appropriate equipment readily available

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Where retrograde fails

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Where should you start? Optimise case selectionJames add movieto support point 1.Pick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to fail

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Where should you start? Optimise case selectionJames add movieto support point 1.Pick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to fail

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Where should you start? Optimise case selectionPick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to failJames add movieto support point 2.

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Where should you start? Optimise case selectionPick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to fail

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Where should you start? Optimise case selectionPick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to fail

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Where should you start? Optimise case selectionPick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to fail

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Where should you start? Optimise case selectionPick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to fail

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Where should you start? Optimise case selectionPick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to fail

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Where should you start? Optimise case selectionPick a case where you would normally be able to complete by antegrade wiringPick optimum (septal) collateralsMinimize markers of case complexityMaximise back-up supportUse a proctor or at the very least an experienced colleagueEnsure you have time & team supportCheck case inventory before you startBe prepared to fail

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Measuring retrograde complexityEase of collateral Crossing?

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Measuring retrograde complexityEase of collateral Crossing?

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Measuring retrograde complexityEase of collateral Crossing?

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Measuring retrograde complexityEase of microcatheter Crossing?

James add movieto support point bellow

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Measuring retrograde complexityEase of microcatheter Crossing?

James add movieto support point bellow

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Measuring retrograde complexity

Difficulty of distal CTO cap

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Distal cap @ a major bifurcation

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Avoid calcification, angulation and ostial

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Markers of retrograde complexity

The presence of significant calcium is best deferred until higher up the learning curve.

To be navigated they require a higher need for blunt dissection techniques and a high need for back-up support 23

Markers of retrograde complexity

The presence of significant tortuosity is best deferred until higher up the learning curve.

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Markers of retrograde complexity

To be navigated they require a higher need for blunt dissection techniques and a high need for back-up support

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Measuring retrograde complexityDifficulty of proximal CTO cap

TaperedBluntAmbiguous

Images of 3 prox cap blunt to ambiguous

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Markers of retrograde complexity

Proximal cap complexity: Avoid proximal caps associated with significant calcium. .

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Markers of retrograde complexityWhere should you start?Minimize markers of case complexity: avoidCTO length is a poor marker of complexity after attaining retrograde access

Tortuosity /Ca++Distalcap atbifurcation

Poor septalspoor

CTO length is a poor marker of complexity after attaining retrograde access2 images: one of a short RCA CTO, one of a long RCA CTO with otherwise identical features: blunt cap / reconstitution before bifurcation / no calcium / tortuosity

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Markers of retrograde complexityWhere should you start?Minimize markers of case complexity

Short CTO:Retrograde Wire Escalation

CTO length is a poor marker of complexity after attaining retrograde access2 images: one of a short RCA CTO, one of a long RCA CTO with otherwise identical features: blunt cap / reconstitution before bifurcation / no calcium / tortuosity

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Markers of retrograde complexityWhere should you start?Minimize markers of case complexity

Long CTO:Retrograde DissectionRe-entry -> reverse CART

CTO length is a poor marker of complexity after attaining retrograde access2 images: one of a short RCA CTO, one of a long RCA CTO with otherwise identical features: blunt cap / reconstitution before bifurcation / no calcium / tortuosity

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RWEApplicabilityHighLow

Retrograde: choice of strategy

Length20mm

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Strategies Lesion Length >20mmHybrid video registry, Daniels D et al. presented TCT 2013

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Measuring retrograde complexityAdditional factorsPatient tolerability:

Collateral dominanceLeft ventricular function (LVF)Risk of contrast nephropathy (CIN)

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ConclusionUse proctors and attend retrograde coursesSelect cases with interventional septalsStart with LAD to RCA (RCA CTO)Avoid cases with no retrograde stump at cruxAvoid Calcium and Angulations (CT scan)Secure time, equipment and acceptance in your department

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Retrograde iBookdue for launch very soon!

For more info visitwww.ctoibooks.com

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