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Dealing with Problemsin Retrograde PCIEtsuo Tsuchikane, MD, PhD
Toyohashi Heart Center, Japan
CTO Toyohashi Heart Center
The Experts Live Workshop 2014 Systemic Procedure relatedCINRadiation dermatitisGC induced Wire perforation
Vessel perforation
Retrograde approach related
Device entrapment in CTO from CTO sitefrom small branch
ballooning, stenting
channel perforation by wiring - epicardialchannel rupture due to catheter - septal, epicardialdonor artery trouble - thrombus, dissection Specific complications in CTO-PCI
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
channel perforation by wiring - epicardial
channel rupture due to catheter - septal, epicardial
donor artery trouble - thrombus, dissection Retrogarde approach relevant complications
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Primary Retrograde Approach: Retro Group (1287) (including 399 re-attempt)Immediately After Failed Antegrade: Combined Group (907) (including 126 re-attempt)
2,194 cases5Yr Registry Datafrom Retrograde Summit(Sites)(Enrollment)
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Complications (n=2194)Channel injury: 9.6% (210)Treatment Required2.8% (61) Cardiac Tamponade0.4% (9)
Donor artery trouble: 0.50% (11)Dissection Requiring Stent0.4% (8)Spasm0.09% (2)Ischemia due to Pre-existing Lesion0.05% (1)Thrombosis0
Others: 0.9% (20)
Retrograde approach relevant11.0% (241)At CTO site3.7% (82) Other events during/after procedure3.0% (65)
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channel perforation by wiring - epicardial
channel rupture due to catheter - septal, epicardial
donor artery trouble - thrombus, dissection Retrogarde approach relevant complications
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Epicardial channel for RCACorsair with Fielder FCCase: RCA-CTO
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Type-I perforation
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Ballooning for hemostasis
Septal channel tracking
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Successful revascularizationFinal LCA
It was controlled by neutralization of heparin.
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
LAD-CTOEpicardial channel from LCx
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
SION wiring caused perforation through tiny branch
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Successful rewiring with SION
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Reverse CART
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Small perforation after removal Corsair? Other injury??
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
ExcelsiorTip injection
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Tip injection
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Minor channel damage, but no major bleeding
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
No event after procedure
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
channel perforation by wiring - epicardial
channel rupture due to catheter - septal, epicardial
donor artery trouble - thrombus, dissection Retrogarde approach relevant complications
Prolonged balloon inflation Neutralization of heparin Embolization only when necessary
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
RCA CTO, 2nd Attempt
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Fielder XTR
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Fielder XTR
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Channel rupture!?
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Tip injection from 2 Transit MC
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
PD-LAD channel
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Tip injection
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
XTR crossed successfully.
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Successful recanalization was achieved, however
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Channel rupture was revealed after removal of Corsair.
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
2 coils was placed bilaterally.
CTO Toyohashi Heart Center
The Experts Live Workshop 2014Epicardial channel
RCA CTO, 2nd Attempt
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Reverse CARTUltimate 3XT-A
Corsair
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Again! Rupture!!
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Kissing Excelsior
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
A coil was released antegradely.
CTO Toyohashi Heart Center
The Experts Live Workshop 2014Successful hemostasisFinal angiogram
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
channel perforation by wiring - epicardial
channel rupture due to catheter - septal, epicardial
donor artery trouble - thrombus, dissection Retrogarde approach relevant complications
?
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
RCA-CTO
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Corsair was stuck and bent at the distal portion.Channel rupture
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Reverse CARTTip of OTW
Retrograde wire
Tip of OTW3m externalizationBalloon trapping
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Nothing happened after procedure.
CTO Toyohashi Heart Center
The Experts Live Workshop 2014 Q: How often we need embolization for septal channel rupture?A: 0.19%(1 case / 533 successfully crossed septal channels)
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
LAD-CTO
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Ipsilateral septal channel
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Successful retrograde wire crossing
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Septal hematoma after removal Corsair
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Advanced MC2 way coil embolizationNo major bleeding
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
LAD-CTO (courtesy of Dr. Yamane)
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Septal channel (courtesy of Dr. Yamane)
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Septal channel injury after removal Corsair (courtesy of Dr. Yamane)
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Developing septal hematoma, chest pain, hypotention (courtesy of Dr. Yamane)
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Fenestration by wiring into ventricle (courtesy of Dr. Yamane)
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Reduced septal hematoma (courtesy of Dr. Yamane)
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
channel perforation by wiring epicardial
channel rupture due to catheter - septal, epicardial
donor artery trouble - thrombus, dissection Retrogarde approach relevant complications
In epicardial, hemostasis procedure must be done immediately.
In septal, carefully observe it. Fenestration or embolization should be considered when its developing (chest pain).
CTO Toyohashi Heart Center
The Experts Live Workshop 2014Thrombus in Donor Artery
Epicardial channel tracking
Monitored BP down
Successful wiring
Final result
Post LCA
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Careful attention is mandatory to donor artery.ACT > 300, occasional flushing are required.Thrombus retrieved from GC for LCA
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
RCA-CTO
Mild lesion in LAD Q: guilty or not guilty?
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
After IVUS examinationDES implantationA: guilty!
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
RCA-CTO
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Septal Channel Selection
FailedSuccessful
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Bilateral WiringChest pain and BP down!
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
LAD occlusion
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
After removal of CorsairAfter stenting
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
Reverse CARTFinal angiogram
CTO Toyohashi Heart Center
The Experts Live Workshop 2014
channel perforation by wiring epicardial
channel rupture due to catheter - septal, epicardial
donor artery trouble - thrombus, dissection Retrogarde approach relevant complications
ACT > 300 sec. Occasional flushing in GC BP monitored from GC with side holes
Prophylactic stenting of mild lesion Fix a vessel trauma immediately! Be cautious of vessel bend itself!
CTO Toyohashi Heart Center
The Experts Live Workshop 201416th CTO Club June 19-20, 2015, Nagoya, Japan
www.cct.gr.jp/ctoclub
CTO Toyohashi Heart Center
The Experts Live Workshop 2014