Angiogram- how to record, analyse

and prepare to the intervention

Dr Alexandre AVRAN Arnaud Tzanck Institute Nice

Which questions we have to answer

1) define the CTO as well as possible

- JCTO score (level of difficulty)

- proximal cap

- length

- calcification

- bending

- other

- bifurcation before or after

- stent

- microchanel or bridging collaterals

2)Which strategy seems to be the best as first one

(antegrade, retrograde or ADR)

- Hybrid algorithm (can help)

- proximal cap

- length

- quality of collateral circulation

- landing zone or distal cap

Which questions we have to answer

PROXIMAL CAP

objectif to avoid

different projectiononly one shot because it’s

occluded

answer tapered, blunt or no

stump

Does this only projection can

define proximal cap?

chanel or bridging ?

LENGTH

To avoid Objectif

short angio enough long acquisition

LENGTH

Objectif

Use same projection from RCA and LC

CALCIFICATION

Objectif

fluoro without contrast

Use calcification and different

projection as a roadmap

even if it’s proximal

occlusion

COLLATERALS

1) From where ?

2) Are they interventional ?

3) Which one is the safer one:

septal, epicardial, atrial,

bypass?

4) tortuous?

5) size Werner classification

6) angle and location of entry

A world of questions

COLLATERALS

which septal seems to be

the promising one in case of

retrograde strategy

Prefer long shot and low magnification

Don’t follow collaterals

Prefer low magnification

Avoid panning

and cable

Prefer long acquisition

long acquisition

with low magnification

Focus on connexion without moving

Best projection for septal

connexionRAO cranial to define first part

and LAO cranial for the connexion

point

sometime the only

antegrade injection is not

enough to define our

strategy

Angiogram is always improve

with our bilateral injection

Conclusion

At the end of your angiogram you are able to

decide how managing your CTO case

1) is this case is feasible by me or need a

proctor or refer the patient

2) By which strategy i will begin

3) in case of antegrade by which wire

beginning

4) in case of retrograde by which collaterals

5) In case of failure is there a switch strategy