tim schäufele - successfultransradialretrogradecto revascularisation via an...
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RBK – Coronary Interventions
Successful transradial retrograde CTO
revascularisation via an epicardial collateral
using a single 6F guideTim Schäufele
Robert-Bosch-Krankenhaus Stuttgart
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Potential conflicts of interest
Speaker's name: Tim Schäufele
I do not have any potential conflict of interest
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Case summary
Demographics: Age: 76 yrs old Gender: female
cvRisk Factors: Hypercholosterolemia Ex smoker Arterial hypertension
Demographics: Age: 76 yrs old Gender: female
cvRisk Factors: Hypercholosterolemia Ex smoker Arterial hypertension
Clinical Presentation and Indication: Stable but recurrent angina despite OMT Significant risk profile
Clinical Presentation and Indication: Stable but recurrent angina despite OMT Significant risk profile
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Medical History 5/2015: de novo angina 9/2015: stable angina on OMT Unknown coronary status No known history of MI
Peripheral vascular disease IIa
Coronary angio
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Baseline angiography
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RCA- LAO LCA- RAO/CRAN
Diagnostic Catheter: TIGER II 3.5 5F via right TRA
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Baseline angiography
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RCA- LAO LCA- RAO/CRAN
Diagnostic Catheter: TIGER II 3.5 5F via right TRA
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Baseline angiography
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RCA- LAO LCA- RAO/CAUD
Diagnostic Catheter: TIGER II 3.5 5F via right TRA
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Baseline cMRI
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Normal wallmotion lateral
Severe inducible ischemia Lateral (RCX) Inferolateral (RCA/PLD) NB: not anterior!
<50% myocardial scar
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Anatomically 3 VD with functional stenosis in 2 vascular territorries (RCA/RCX)
SYNTAX score 21.3
STS score mortality 1.1%
Anatomically 3 VD with functional stenosis in 2 vascular territorries (RCA/RCX)
SYNTAX score 21.3
STS score mortality 1.1%
Baseline summary and MDT recco
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x
x
x
xx
3MDT Recco: PCI
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Strategy
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TRA because of PVD no palpable puls left radial Ipsilateral collaterals only
Brilakis et al JACC 2012
Plan A
Wire escalation Paralell Wire-
Technique
Plan B
Retrograde via epicardial collateral
Externalisation
Plan C
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CTO Procedure Step 1 Antegrade/Single Wire
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RAO/CAUD
Guide: EBU 3.5/ 6F via right TRA; FINECROSS; FIELDER XTA;Step-Up: Gaia 2nd
LAO/CAUD
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CTO Procedure Step 2 Antegrade/Parallell Wire
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Guide: EBU 3.5/ 6F via right TRA; FINECROSS; FIELDER XTA;Gaia 2nd as parallell wire
LAO/CAUD
RAO/CAUD
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CTO Procedure Step 2 Antegrade/Parallell Wire
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Guide: EBU 3.5/ 6F via right TRA; FINECROSS; FIELDER XTA;Gaia 2nd as parallell Wire
LAO/CAUD
RAO/CAUD
Gaia 2nd
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CTO Procedure Step 3 Retrograde-search the collateral
14Guide: EBU 3.5/ 6F via right TRA; CORSAIR 150mm; SION black
LAO/CRAN
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CTO Procedure Step 4 Retrograde-collateral crossing
15Guide: EBU 3.5/ 6F via right TRA; CORSAIR 150mm; GAIA 2nd (a)
LAO/CRAN
a
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CTO Procedure Step 5 Retrograde-Externalisation
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Guide: EBU 3.5/ 6F; CORSAIR 150mm; CONFIANZA pro 9 retro-GAIA 2nd antegrade
RAO/CAUD
Unsuccsessfulattempt to „tip-in“ due to heavylymovingmicrocatheter
Unsuccsessfulattempt to „tip-in“ due to heavylymovingmicrocatheter
Confianza pro 9
Gaia 2nd
Confianza pro 9
Finecross
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CTO Procedure Step 5 Retrograde-Externalisation
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Left: Guide: EBU 3.5/ 6F; CORSAIR 150mm; RG3 (left)Right: Guide: EBU 3.5/ 6F; BHW (right)
RAO/CAUD RAO/CAUD
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Was that all?
RCA:SYNERGY 3.0x38 mm; SYNERGY 3.5x20 ml; SYNERGY2.75x12 mm;SYNERGY
4.0x12 mm (left) LAD: SYNERGY 3.5x16 (right) 4 wks later
LAO/CRAN
RAO/CRAN
Procedural Time: 140 minutesCummulative Air Kerma: 3865 mGyDose Area product: 9874 cGycm²
Procedural Time: 140 minutesCummulative Air Kerma: 3865 mGyDose Area product: 9874 cGycm²
@ Follow up 9 months: patient does well, no anginaMed Tx reduced to Statin, ACEI, ASS, CLOPIDOGREL @ Follow up 9 months: patient does well, no anginaMed Tx reduced to Statin, ACEI, ASS, CLOPIDOGREL
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CTO Procedure Final Result (FUP 4 Wks)
19RCX: SYNERGY 2.5x28mm; SYNERGY 3.0x8mm ; SYNERGY 2.5x8 mm
RAO/CAUD
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Case summary Final/Discussion
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TRA is a valuable option for CTO procedures Ipsilateral collaterals are an elegant way to go Use of single Guiding catheters for externalisation as
a „bail-out“ warrants special attention
TRA is a valuable option for CTO procedures Ipsilateral collaterals are an elegant way to go Use of single Guiding catheters for externalisation as
a „bail-out“ warrants special attention
apropriate patient selection is mandatory MDT provide best patient specific results cMRI is a usefull add- on but cann miss anterior
ischemia
apropriate patient selection is mandatory MDT provide best patient specific results cMRI is a usefull add- on but cann miss anterior
ischemia
My personal take home message: Give 7F TRA at least a try!
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Thank you for your attention!
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