How I Deal with … What to Avoid
How I Deal with ⦠What to Avoid
How I Deal with ⦠What to Avoid
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January 2009<br />
Hil<strong>to</strong>n Metropol<br />
<strong>How</strong> I <strong>Deal</strong> <strong>with</strong> <strong>…</strong> <strong>What</strong> <strong>to</strong> <strong>Avoid</strong><br />
Carlo Di Mario; Pawel Tziscinski; Neville Kukreja<br />
Royal Bromp<strong>to</strong>n Hospital & Imperial College, LONDON, UK
60 year old male<br />
Risk fac<strong>to</strong>rs: Hypertension, hypercholesterolaemia,<br />
ex-smoker<br />
Inferior MI in 1992; occluded LCx/RCA<br />
Persistent Class 2 CCS Angina <strong>with</strong> positive<br />
treadmill + reversible periinfarction ischaemia
Spider<br />
Right Caudal<br />
Best Projections Prox LCX occlusion
Right Cranial shows origin septal collaterals<br />
<strong>…</strong>. and distal LCx
AL 2.0 8 F GC<br />
Whisper +<br />
Finecross
Second channel did not work either
Third less promising channel
Pilot<br />
Asahi Miracle,<br />
later Confianza 8-12
Biplane is better
Anterograde/Retrograde Wires and<br />
Balloons Progressing
Anterograde Wire Distal PDA
Kissing Balloons<br />
2.5 & 2.0 mm<br />
Implantation of 2.5x24mm,<br />
3.0x24 mm, 3.5x14mm<br />
BioMatrix stents
46 Yr old man<br />
No his<strong>to</strong>ry of myocardial infarction<br />
3 attempts of PCI CTO dominant RCA<br />
since 2004 (first <strong>with</strong> opening acute<br />
marginal branch and stent proximal RCA,<br />
last <strong>with</strong> stent diagonal branch<br />
Persistent Class 2 CCS angina<br />
With thanks <strong>to</strong> Nikos Kakouros & Pitt Lim<br />
who greatly helped during this 6 hour long<br />
Procedure done at St George’s hospital
No septal collaterals from LAD
7 Fr Amplatz 2 GC
Confianza +<br />
Finecross <strong>to</strong><br />
penetrate<br />
cap; softer<br />
distal wires;<br />
parallel<br />
wire <strong>with</strong><br />
2 nd<br />
Finecross
Selective injection longest septal
Whisper through in few seconds!
1.25 mm Rujin balloon does not proceed<br />
further; new anterograde attempt
Aggressive<br />
dilatation<br />
septal 1.25<br />
+ new<br />
Rujin 2.0<br />
mm x 20<br />
mm
Implantation of 3 Xience stents
Final angiographic result
<strong>What</strong> did I learn?<br />
For impossible anterograde CTOs<br />
(ostial, multiple attempts, very long<br />
occlusions, poor distal target) think of<br />
retrograde approach first<br />
Angiographically invisible virtual<br />
collaterals are a viable option<br />
Check always position of your wire<br />
in contralateral views<br />
“Never give up”
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