15:05 Sianos - Optimizing
- 1. Optimizing Collateral Crossing The Experts „Live“ Workshop 2014 Session 3 AN INITIATION TO RETROGRADE TECHNIQUES 25 Sept 2014, 15:05 - 15:20 Prof Georgios Sianos, MD, PhD, FESC Department of Interventional Cardiology, AHEPA University Hospital, Thessaloniki , Greece
- 2. Collaterals in RCA occlusion Pathways and Functional Significance of the Coronary Collateral Circulation David C Levin, Circ 1974;50:831-837 Collaterals in LAD occlusion Pathways and Functional Significance of the Coronary Collateral Circulation David C Levin, Circ 1974;50:831-837
- 3. Collateral Connections RAO Caudal Projection Septal Septal-Septal Epicardial- Dg Epicardial-Apical Conus-Septal Epi (OM to Dg or Dg to Dg) Yamane TCT 2014
- 4. Collateral Connection Grades in Septal Channels CC 0 : no visible connection CC 1: thread-like, but visible connection, mild torturosity and mild cork-screw morphology CC 2: clearly defined visible channel, mild torturosity and mild cork-screw morphology (Werner G. Circ 2003)
- 5. ”Collateral Connection Size“ (CC) Septal pathways in 44%, epicardial in 32% CC0 14% CC1 51% CC2 35% B D E A C F AB C Werner et al. Circulation 2003;107:1972-7
- 6. Corkscrew-like Inextensible/ Stenosis Length Applicability Distensibility Epicardial Significant Potential Long Modest(>35%) Undilatable Atrial Moderate Occasional Long Low(<10%) Undilatable Septal Moderate∽Mild Rare Short High(>60%) Dilatable Modified from O. Katoh: CCT 2008: Retrograde for CTO Course Characteristics of specific channels-not all the same
- 7. Predictors of Retrograde failure Rathore S, Katoh O, et al, Circ Cardiovasc Intervent. 2009;2:124-132
- 8. View angle in Septal Channels RAO cranial view: good for checking the origin of the septal channel Pitfalls continuing channel crossing with this view Notice non-orthogonal view for the junction point RA0 caudal view: mandatory to check the anatomy of the body and the junction point Single view is inadequate to check the anatomy Rotational angiography
- 9. View Angle and Issues in Other Channels optimal view angles issues epicardial (RV channel) •RAO (cranial) •APcranial for connection to LAD •most tortuous channel •many side branches •invisibility of channel during wiring •shape-changeable channel by heart beating •step by step approach PL channel • RAO/ AP cranial (LCx-RCA, Dx-DX/LCx) • LAO(cranial/ caudal) for PL channels located in anterolateral wall tortuous feeding artery atrial •LAD (cranial) •RAO cranial •RAO/AP caudal for checking origin of feeding artery •difficult to access feeding artery •most fragile channel
- 11. Tip injection – Epicardial Collateral
- 12. Tip injection – Epicardial Collateral
- 14. Septal Surfing
- 16. Septal Surfing • Septal surfing is useful for saving time • Try to slide the wire through gently, avoid buckling, avoid loops, follow with the micro-catheter • Do not persist on a specific pathway • The wire must move quickly with changing directions towards the orientation of the target vessel • The wire tip shaping is less acute bending compared to the targeted collateral crossing after tip injection • Tapered wires should not be used for SS • Invisible channels are sometimes crossed with septal surfing.
- 17. Tip Injection Tip injection (with rotational angiogram) is useful to maximize chance of channel crossing. isolating channel revealing channel anatomy estimating possibility of crossing Check of blood back-flow is mandatory to avoid channel injury and confirm connection with recipient artery prior to tip injection. As long as channel anatomy is revealed with tip injection, double/triple wire technique is helpful.
- 18. Epicardial vs Septal Crossing Epicardial Directed Higher need for MC support to negotiate tortuosity Higher need for “tip injections” Septal Often more random (septal surfing) Tortuosity responds less well to MC support Tip injection if failure of septal surfing
- 19. Collateral Connection size and continuity (CC class) Tortuosity/branching of the channel Angle of take-off from the donor artery Collateral take-on from the distal cup Donor artery proximal from the take-off of the CC Diseased/Tortous Relation of the CC insertion site to the distal cup Parameters to be considered for CC selection
- 20. Collateral Connection size and continuity (CC class) Tortuosity/branching of the channel Angle of take-off from the donor artery Collateral take-on from the distal cup Donor artery proximal from the take-off of the CC Diseased/Tortous Relation of the CC insertion site to the distal cup Parameters to be considered for CC selection
- 21. Corkscrew appearance: scientific approach O. Katoh: CCT 2008: Retrograde for CTO Course
- 22. CC Tortuosity/branching What is visible is not necessary crossable and visa versa Failure to cross this branch
- 23. CC Tortuosity Septal surfing crossing of a more proximal septal channel
- 24. CC tortuosity-ischemia at the territory of the occluded artery
- 25. Collateral Connection size and continuity (CC class) Tortuosity/branching of the channel Angle of take-off from the donor artery Collateral take-on from the distal cup Donor artery proximal from the take-off of the CC Diseased/Tortous Relation of the CC insertion site to the distal cup Parameters to be considered for CC selection
- 26. CC take-off
- 27. Acute angle at origin/destination Acute angle (>90°) at A or B is a negative factor for channel crossing. Dissection/ rupture is rarely caused by wire/ catheter. For negotiating acute curve at origin (A/B), double lumen microcatheres (Twinpass, Crusade are useful. A B
- 28. Collateral Connection size and continuity (CC class) Tortuosity/branching of the channel Angle of take-off from the donor artery Collateral take-on from the distal cup Donor artery proximal from the take-off of the CC Diseased/Tortous Relation of the CC insertion site to the distal cup Parameters to be considered for CC selection
- 29. Donor artery and CC selection
- 30. Donor artery and CC selection
- 31. Collateral Connection size and continuity (CC class) Tortuosity/branching of the channel Angle of take-off from the donor artery Collateral take-on from the distal cup Donor artery proximal from the take-off of the CC Diseased/Tortous Relation of the CC insertion site to the distal cup Parameters to be considered for CC selection
- 32. Relation of the CC insertion site to the distal cup
- 33. Relation of the CC insertion site to the distal cup Wire entrapment
- 34. Channel crossing wire selection Polymer wires (Fielder FC / Whisper) were the first to be used for channel crossing but were related with high incidence of collateral injuries. Metal ball tip hydrophilic wires are more effective and safer. Sion is first choice wire for channel crossing instead of polymer jacket wire (Fielder FC, Whisper, etc). Tapered polymer jacket wires (XTR) became the choice for very thin and very tourtous collaterals during targeted channel crossing
- 35. Composite core technology Addressing the channel tortousity
- 36. Collateral Crossing Wires + Tortuosity/Size - Modified J. Spratt
- 37. Potential Sequence for Collateral Crossing SION SION Black / FFC XRT Hydrophilic ball tip Polymeric Tapered
- 38. Bend used for septal access Bend used to facilitate septal crossing Tip shaping for Collateral Crossing In targeted crossing of very tortuous and thing channels a very sharp and short tip bending might be necessary
- 39. Retrograde: Collateral approach 48.6% 18.6% 9.9% 9.9% 13.0% SION XT-R Fielder FC SION blue other Attempt 94.2% 9.6% 1.5% 0% 50% 100% Corsair OTW Catheter Other microcatheter Catheter used for GW support (multiple selection) 92.2% 7.2% 0.6% 0% 50% 100% Successfully crossed catheter Corsair OTW Catheter Other microcatheter No. of GW: 1.8 60.1%25.1% 7.1% 3.3% 4.4% Succesful collateral route Septal Epicardial AC Ipsilateral Bypass graft Collateral cross by GW, 77.1% (370/480) Multicenter Japanese Registry (2012)
- 40. Japanese Multicenter Registry Evaluating the Retrograde Approach for Chronic Coronary Total Occlusion (801 patients treated in 28 Japanese centers between January 2009 and December 2010, Corsair use increased from 36% to 95.3% from 2009 to 2010) Tsuchikane et al, Catheterization and Cardiovascular Interventions 82:E654–E661 (2013) Procedural success rate 84.8 % (retrograde success 71.2%) Clinical success rate 83.8% (retrograde success70.3%) All (n:801) 2009 (n:378) 2010 (n:423) Collateral channel cross by guidewire 82.3% (659) 80.4% (304) 83.9% (355) Successfully crossed collateral channel Septal 63.0% (415/659) 68.4% (208/304) 58.3% (207/355) Epicardial 32.6% (215/659) 27.6% (84/304) 36.9% (131/355) Bypass graft 4.4% (29/659) 3.9% (12/304) 4.8% (17/355) Procedure time (min) 195.1±84.5 203.3±84.4 187.9±84.1 (p:0.024) Multivariate analysis identified age 65 years or more and lesion calcification as unfavorable factors and the use of a channel dilator as a favorable factor for retrograde procedural success.
- 41. MALE, 63 Y, SA CLASS III Radial AL 1.5 6Fr Femoral EBU 3.5 7 Fr Gaia First
- 43. Corsair/ Finecross failed to cross despite anchoring in D1
- 44. Different S crossing with surfing also failed to cross Return to first S and balloon dilatation Mini Trek 1.25
- 45. Prox LAD spasm MC crossing
- 46. LAD compromised
- 47. Balloon predilatation and stent implantation in prox LAD
- 48. MC advancement underneath the stent struts
- 49. Final result
- 50. Solving MC crossing problems Choose Guiding catheters with good backup support Change the failing MC (Corsair/Finecross) Ballooning by small balloon with low pressure Balloon anchoring Others (another retro channel, ante approach)
- 51. Summary Good guiding catheter support Careful evaluation of the angiogram in multiple projections or rotational angiography Donor artery CC for angle of take-off, size, tortouosity, branching, angle of insertion at the distal vessel, its relation with the distal cup In septal channels try surfing first Slide the wire through gently, avoid buckling, avoid loops, follow with the microcatheter In case of failure continue with tip injections In epicardial channels tip injection is mandatory Use composite core SION wire as first choice followed by polymeric/tapered wires according to the anatomy of the channel Reshape the wire tip once you are in the channel if necessary Optimize parameters for micro-cather crossing Most injuries are un-harmful but be prepared for coil embolization if nessecary Remember what is visible is not necessary crossable and visa versa
Editor's Notes
- #5: 4