CTO lesion PCI

Antegrade or retrograde Li Yue, M.D.

The First Affiliated Hospital of
Harbin Medical University

The distal side of the CTO brous cap is often less

resistant than the proximal cap, and once a wire is engaged

within the lesion, it is frequently easier to traverse than with a traditional antegrade approach.
Proximal

Distal

History of retrograde PCI

Cathet Cardiovasc Diagn. 1990 Jun;20(2):88-93

Kahn JK, Hartzler GO Cardiovascular Consultants, Inc., Mid America Heart Institute, St. Luke's Hospital, Kansas City, Missouri.

In 16 patients, coronary angioplasty in a retrograde direction through

degenerated saphenous vein grafts.

More than 10 years later, septal collaterals are considered to be

potential channels for retrograde approach.

What is the indication of retrograde approach

2008 TCT

the easiest is the best

Technical complexity
(Stump absentOcclusion at side-branch, Long occlusion segmentsmall distal vessel

Donor vessel is healthy and

collateral is good

Case 1
Clinical Data
58-years-old male Chest pain for 2 hours DM (12 y), OMI (inferior wall, 12y) CHOL 6.23mmol/L ; TNI 0.988 ng/ml (<0.02ng/ml) Echo: LVED: 55mm; EF 47%; Inferior wall hypokinesia

Which is the culprit artery

A. B.

LAD LCX

C.

RCA

Which is the culprit artery

A. B.

LAD LCX

C.

RCA

TRI

BL 3.0
Pilot 50

Pilot 50

Ryujin
1.25 x 15 mm

Parallel wire Voyager

2.0 x 15mm

Firebird 2.5 x 33mm

Partner 2.75 x 21mm

JR 4.0
Finecross

Pilot 50

Conquest pro 12

OMI (inferior wall, 12y)

Two weeks later

BL 3.0
JR 4.0

RAO + CRAN

AP + CRAN

Finecross

Fielder

Ryujin 2.0 x 15 mm

Excel 3.0 x 36mm

Which access is better for RCA PCI

A.
B.

Antegrade
Retrograde

OMI (inferior wall, 12y)

Finecross Superselective injection

1.0mm

Fielder
1.0mm

Fielder

Fielder FC

Fielder FC
0.3mm0.5mm

Fielder XT

Fielder XT

Fielder
Ryujin 2.0 x 15mm
(anchoring)

Back-end ballooning + MC reversal

CTO

MC

3m

Fielder 3 m
Ryujin 1.25 x 15 mm

Runthrough
Ryujin 2.0 x 15mm

Clinical Data
53-years-old male

Case 2

Chest pain on exertion 3 months Heavy smoking (30 yrs) Hypertension (10 yrs) CHOL 6.08mmol/L ,TG 2.99mmol/L ECG:V1-V3 Pathological Q wave Echo: EF 58%.

Transradial

LCA:
BL 3.0 RCA: AL 0.75 JR 4.0

Which is the best strategy

A.

Antegrade PCI

B.

Retrograde PCI

LCX:
Runthrough

LAD: Finecross Fielder

Miracle 6g

How to do next
A. Antegrade PCI

(parallel wire )

B. IVUS guide PCI

(entry search) C. Retrograde PCI

IVUS guide PCI

Entry search

Finecross

Fielder

Miracle 6g

Antegrade

Retrograde

Pilot 150

Ryujin 2.520mm

PT 3 m Ryujin 1.2515mm

Ryujin 2.015mm

LAD:
Runthrough

Ryujin 2.520mm

Case 3
Clinical Data
54-years-old male Paroxymal chest pain 1 month Heavy smoking (10y), Hypertension (10y) CHOL 6.81mmol/L

Which access should be the first choice for LAD PCI

A.

Antegrade

B.

Retrograde

Transradial

Which guide wire should be the first choice

A. Pilot 50

B.
C.

Pilot 200
Miracle 6

D.
E.

Miracle 12
Conquest Pro

Drilling strategy (Pilot 50, Miracle 6) Penetrating strategy

Which guide wire should be the first choice

A.
B. C. D. E.

Pilot 50
Pilot 200 Miracle 6 Miracle 12 Conquest Pro

Sprinter

1.56mm
Ryujin 1.2515mm

Can not cross

How to do next
A. Rota
B. Tornus catheter C. Cross over to TFI D. Change stronger

Multi-wire plaque crushing (pilot 150 can not cross) Anchoring balloon

back-up guiding catheter

E. Balloon crush and

pry technique

Tornus catheter

2.6F

2.1F

Guiding catheter selection (Transradial)

Comparing the backup force between TFI and TRI

it was found to be 60% greater in TFI with a JL catheter, and 8% greater in TFI with a backup (XB/EBU/BL) type catheter.
J Invasive Cardiol. 2005 Dec;17(12):636-41.

How to do next
A. Rota

B. Tornus catheter C. Cross over to TFI D. Change stronger

back-up guiding catheter E. Balloon crush and pry technique

AL-2
Sprinter 1.56mm

Case 4
Clinical Data
59-years-old male Paroxysmal chest pain 6 months Heavy smoking (40y) CHOL 6.30mmol/L Echo: LVED: 47mm; EF 53%

Which access is better for RCA PCI

A.
B.

Antegrade

Retrograde

Which collateral channel

?
A.
C

B. C. D.

Finecross

Finecross Fielder

Conquest pro

Case 5
Clinical Data
65-years-old female

Paroxymal chest pain 1 year, become worse for 3 weeks

Heavy smoking (40y) Echo: LVED: 47mm; EF 55%

Which access is better for RCA PCI

A. B.

Antegrade Retrograde

Which access is better for RCA PCI

A. B.

Antegrade

Retrograde

Pilot 50

Case 6
Clinical Data
67-year-old male Paroxysmal chest distress for 2 months OMI (anterior wall, 11Y), Heavy smoking (31Y) DM (10Y), Ischemic Stroke (hemiplegia 5Y) UCG: EF:44%; anterior wall aneurysm ECG: Pathologic Q wave ( V1 - V4 )

LADLCX CTO
RAO + CAU

LADLCX CTO
RAO + CRA

RCA CTO (ostial occlusion)

Which access is better for RCA PCI

A. Antegrade B.

?
Retrograde

CC 2 / Rentrop 2

Stump absent Occlusion at side-branch

Which access is better for RCA PCI

A. B. Antegrade

Retrograde

Retrograde proximal true lumen puncture

Fielder FC

Conquest Pro

False lumen

How to do next

Kissing wire technique

Conquest Pro

How to do next

A. Change ante/retro wire

B. STAR (subintimal tracking and reentry ) C. CART/Reverse CART D. Confluent balloon inflation

E. Knuckle wire technique

CART
Ryujin 1.515mm

6atm

Post-PCI

CART

Reverse CART

Tapered Soft Tip Provides

superior tip flexibility

SHINKA-Shaft

provides far superior pushability, trackability

Mircle 6g

Ryujin
1.25 15mm

Confluent balloon inflationing

Inflated simultaneously Slight withdrawal the retrograde balloon before passing the retrograde wire Not to use too large balloons

J INVASIVE CARDIOL 2009;21:539542

Reverse CART + Stenting

IVUS guide PCI

Check for true lumen position and guide wire peneration.

All roads lead to Rome!

Antegrade

Retrograde