LAD CTO: Retrograde Approach with IVUS Guidance

This didactic procedure concerns a 63 y.o male, with  medical history of CAD (Lcx already treated few months before, LAD CTO JCTO Score:4).

First attempt of LAD recanalization  has failed, the patient is still symptomatic  despite OMT.

The second attempt was a success with retrograde approach using IVUS guided retrograde puncture.

Educational objectives

• How to approach patients with Symptomatic coronary  chronic total occlusions.
• Optimal Application of the Hybrid algorithm in treatment of coronary CTO.
• Evaluation of the anatomical complexity of coronary CTO with combined angiography and IVUS.
• IVUS usefulness to decide strategy in coronary CTO procedures.
• Step by step retrograde approach in coronary CTO procedures.
• IVUS guidance for safe retrograde and antegrade punctures.
• How to optimize sizing and stent implantation in Coronary CTO procedures.

Step-by-Step procedure

• Double Femoral approach 7F introducers.
• EBU 3.5 7F to the Left system and AL0.75 7F to the right system with two Sion blue wires for stabilization.
• IVUS assessment of the LAD Poximal CAP.
• Retrograde approach with Corsair microcatheter and surfing technique via PDA-septal connections using a Sion black guidewire.
• IVUS evaluation of the  retrograde wire position.
• Retrograde puncture of the proximal CAP using a Confianza Pro 12 guidewire.
• IVUS evaluation of t the Confianza Pro12 wire confirming subintimal position in the Proximal LAD.
• Antegrade puncture using a Confianza Pro12 and Finecross microcatheter.
• Progession antergradelly using Finecross microcatheter and Sion black wire.
• Confirming the distal position with safe Tip injection.
• IVUS evaluation of the antegrade wire and LAD sizing.
• Retrograde material remove.
• Predilatation and stenting of Ostio-proximal LAD with Promus 3.0x32mm DES.
• Stenting of the Mid-LAD with Promus 2.5x24mm.
• Final angiographic and IVUS control and Optimization.

Biobliography

• A percutaneous treatment algorithm for crossing coronary chronic total occlusions. - Article
  Authors:Brilakis ES, Grantham JA, Rinfret S, Wyman RM, Burke MN, Karmpaliotis D, Lembo N, Pershad A, Kandzari DE, Buller CE, DeMartini T, Lombardi WL, Thompson CA.
  Publication:2012 Apr;5(4):367-79. doi: 10.1016/j.jcin.2012.02.006
   
• Optimal approach to percutaneous intervention for CTO in 2017: a hybrid strategy is now the preferred choice - Editorial
  Authors:Simon J. Walsh, MD, FRCP; Colm G. Hanratty, MD, FRCP; James C. Spratt, MD, FRCP
   
• Utility of Intravascular Ultrasound in Percutaneous Revascularization of Chronic Total Occlusions - Article
  Authors:Alfredo R. Galassi, Satoru Sumitsuji, Marouane Boukhris, Emmanouil S. Brilakis, Carlo Di Mario, Roberto Garbo, James C. Spratt, Evald H. Christiansen, Andrea Gagnor, Alexandre Avran, Georgios Sianos and Gerald S. Werner
  Publication:DOI: DOI: 10.1016/j.jcin.2016.06.057
   
• Chronic Total Occlusion Percutaneous Coronary Intervention: Evidence and Controversies - Contemporary reviews
  Authors:Peter Tajti, Emmanouil S. Brilakis
  Publication: doi.org/10.1161/JAHA.117.006732
   
• Retrograde Coronary Chronic Total Occlusion Intervention - Article
  Authors:Debabrata Dash
  Publication: doi:  10.2174/1573403X11666150909110300

• Intravascular Ultrasound Analysis of Intraplaque Versus Subintimal Tracking in Percutaneous Intervention for Coronary Chronic Total Occlusions and Association With Procedural Outcomes. - Article
  Authors:Song L, Maehara A, Finn MT, Kalra S, Moses JW, Parikh MA, Kirtane AJ, Collins MB, Nazif TM, Fall KN, Hatem R, Liao M, Kim T, Green P, Ali ZA, Batres C, Leon MB, Mintz GS, Karmpaliotis D.
  Publication:doi: 10.1016/j.jcin.2017.02.043.

• Use of Intravascular Imaging During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry - Article 
  Authors:Judit Karacsonyi, Emmanouil S. Brilakis,
  Publication:doi:  10.1161/JAHA.116.003890