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Alexander Ghanem & David Leistner
Antegrade Approach – How to start?
Minimalists‘ versus Maximalists‘ Approaches
17. September 2017
Our aim and its Paradigmata
Minimalists‘ view Maximalists‘ view
“The patient is treated in one attempt by the mostexperienced operator fitted to his lesion complexity.“
Patient
Patient
ProcedureProcedure
Outcome
G. Werner
Minimalists‘ Appropriateness List
adopted from Prof. G. Werner, Darmstadt
• Selection of the patient with normal LV-EF
– Symptoms, but „asymptomatic“ patients may beadapted to their limitations by a CTO...
– Ischemic territory should be > 10%
Relationship between mortality and extentof myocardial ischaemia, depending on therapy
Montalescot / Sechtem et al., Eur Heart J 2013;34:2949–3003. Hachamovitch et al., Circulation 2003;107:2900–2907.
OMT / Revascularisation
adopted from Prof. G. Werner, Darmstadt
• Selection of the patient with normal LVF
– Symptoms, but „asymptomatic“ patients may beadapted to their limitations by a CTO...
– Ischemic territory should be > 10%
• In patients with akinesia and ischemic CMP
– Presence of viability tested by MRI
– A grey zone of scar tissue extension remains
Minimalists‘ Appropriateness List
Baks T et al. JACC 2006;47:721-5
Improvement of LV-Function dependson viability of revascularized myocardium
Garcia S et al, JACC 2013;62(16):1421 –31
Outcome after incomplete versus complete revascularisation in MVD
Farooq et al., Circulation. 2013; 128: 141-151
Prognosis is significantly related toresidual SYNTAX-Score
SYNTAX Revascularisation Index
Genereux et al., Am J Cardiology, 2015, DOI: 10.1016/j.amjcard.2015.03.056
Symptoms
ObjectifiedIschemia
Procedure: Wires
Procedure: Guiding
Outcomes: Angiography
1:0
Min vs. Max
Srivatsa et al. JACC 1997;29:955-63
Necrotic Core, Cholesterol, inflammated Tissue
Fibrous-calcific Tissue
Micro Channels
Histological CTO Correlates
CTO Toyohashi Heart Center
Complex PCI, NYC
Development of CTO-PCI procedure
Miracle
Conquest
Parallel wiring
IVUS guidance
Retrograde approach
1995 2000 2005 2010
Fielder XT
Pilot
Fielder FC
SION
MDCT
Corsair
wire, device
imaging modality
wiring technique
CTO Toyohashi Heart Center
Complex PCI, NYC
Development of CTO-PCI procedure
Miracle
Conquest
Parallel wiring
IVUS guidance
Retrograde approach
1995 2000 2005 2010
Fielder XT
Pilot
Fielder FC
SION
MDCT
Corsair
wire, device
imaging modality
wiring technique
ACS standard
Cross-ItProgress family
RG3
Ultimate
Gaia family
Fielder XT A/R
Wire evolution
CTO Toyohashi Heart Center
Complex PCI, NYC
Development of CTO-PCI procedure
Miracle
Conquest
Parallel wiring
IVUS guidance
Retrograde approach
1995 2000 2005 2010
Fielder XT
Pilot
Fielder FC
SION
MDCT
Corsair
wire, device
imaging modality
wiring technique
Wire evolution
Improve wire pushabilityConcentrate rotating forcefor better wire control
Superior device passage for the next option
1. 2.
3.
Microcatheter
Symptoms
ObjectifiedIschemia
Procedure: Wires
Procedure: Guiding
Outcomes: Angiography
Min vs. Max
1:1
1:0
Guiding Backup
BEST OPTION FOR STRENGTHENING A GUIDE:
1. FIRST best maneuver- put the guide in power position or deepseat the guide.
2. SECOND best maneuver – Add a second stiffer wire
3. THIRD best maneuver – change to a stronger guide
4. use the balloon anchoring technique
5. insert a smaller straight inside the current guide (mother &child)
6. remove everything- change the short sheath to a longer one
Symptoms
ObjectifiedIschemia
Procedure: Wires
Procedure: Guiding
Outcomes: Angiography
1:1
1:0
1:2
Min vs. Max
Symptoms
ObjectifiedIschemia
Procedure: Wires
Procedure: Guiding
Outcomes: Angiography
1:1
1:0
1:2
1:3
Min vs. Max
Symptoms
ObjectifiedIschemia
Procedure: Wires
Procedure: Guiding
Outcomes: Angiography
Strategy
Patient Selection
StandardizedProtocols
Min vs. Max
Strategic Options
adopted from Prof. G. Werner, Darmstadt
The apparent length of theocclusion is often shorter
than you think !
Bilateral Injection
Maximum Guide Backup
AntegradeFielder XT/A/R orGaia 1 Gaia 2,
Confienza, Progress
Penetration, thenstep down
AntegradeNo stump
IVUS for guidedpenetration?
Reentry-System
Crossboss / Stingray
Distal good target
Parallel with stiffwire
Retrograde
Feasible collateralpathways