antegrade recanalization of cto using star … recanalization of...1 wmv1.wmv the difficulty: artery...
TRANSCRIPT
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Dr SundeepMishraDr SundeepMishraChairman National Intervention Council of India
Department of CardiologyDepartment of CardiologyAIIMS, Delhi, India
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Clinical Historyy56 year old male, Di b i I li R HTDiabetic on Insulin Rx, HTCAD Past H/O MI 4 months back,Now chronic stable anginah/o Failed attempt to reanalyze CTO 6 weeks backAfter failed CTO attempt, progression of symptoms
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Cine Angiogram : Short Segment g g gCTO
1 wmv1.wmv
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The Difficulty: artery is tortuousThe Difficulty: artery is tortuous at the occluded partp
2.wmv
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Plus: Stumpless CTO with SidePlus: Stumpless CTO with Side Branch
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Important to Recapitulate theImportant to Recapitulate the previous attemptp p
Wire was repeatedly going to SB, therefore IVUS Guidance was taken to identify true lumenGuidance was taken to identify true lumenUsed Fielder FC to enter the true lumen but couldn’t make much progressmake much progressTried parallel wire technique, used Miracle wire but failedfailedThen did something which shouldn’t have been done,
d C t P i hi h l d t i used Conquest Pro 12 wire which led to minor perforation and therefore the procedure had been abandonedabandoned
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Options AvailablepRetrograde technique: Collateral connection present but not good distal artery seemed diffusely diseasedbut not good, distal artery seemed diffusely diseasedAntegrade approch : Star Technique – generally avoided for non RCA vessels (because of risk of avoided for non‐RCA vessels (because of risk of compromising side‐branch), but here there was only short segment occlusionshort segment occlusion.Star technique with micro‐catheter contrast injection is another option but we feel it is too invasive (? is another option but we feel it is too invasive (? Responsible for high ISR seen in Colombo’s technique)
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Initially tried with Whisper wireInitially tried with Whisper wire but Failed
Whisper is not a very persuasive wire with a tip load of 1 and lateral support of only 81 and lateral support of only 8.An option was to take Fielder XT wire, however again tip load is only slightly more (1 2) and lateral support tip load is only slightly more (1.2) and lateral support only 9, but very poor tactile feel, the only advantage is a tapered tip (009) and long polymer coated distal tip a tapered tip (009) and long polymer coated distal tip (160 mm), which will glide easily through a micro‐channel. channel.
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Crosswire TM from Terumo wasCrosswire from Terumo was used
Crosswire is a unique non‐penetrating wire:non penetrating wire:It is completely made of nitinol (unlike Asahi (which are stainless steel)But tip load is 6Lateral support is also moreIts distal tip is non tapering and tactile feel is more than Fielder XTis more than Fielder XT
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An angle of >45⁰ was made and crosswire was used to create a false lumenfalse lumen
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Wire was re‐crossed into true lumenWire was re‐crossed into true lumen and a dissection flap was raisedp
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Wire must have entered from true lumen to falselumen to false lumen, raised ,dissection flap d hand then re‐
entered trueentered true lumen
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Therefore decided to Balloon Dilate
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With balloon dilatation dissectionWith balloon dilatation, dissection in false lumen increased
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But landing zone could now beBut landing zone could now be identified
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The stent was positioned to entirely cover th di ti fl i f t lthe dissection flap i.e. from true lumen via false lumen into true lumenvia false lumen into true lumen
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Check angio showed that false lumen d b t di t l t th t twas covered but distal to the stent
some disease was still persistingsome disease was still persisting
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Decided to position another stentp
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Finally, good end resulty, g
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DiscussionDiscussionStar technique should be the last resortq
In our case it was a short segment, with no branch g ,arisingNo Compromise of side‐branch – short segment No Compromise of side branch short segment occlusion in our caseNo perforationNo perforationAfter procedure patient beacme asymptomatic and remains so at 9 months follow‐up remains so at 9 months follow up ‐ no stent thrombosis ‐ no in stent restenosis