Review of Common & Uncommon CTO Complications CRT 2017 Review of Common & Uncommon CTO Complications Barry D. Rutherford, MD Saint Luke’s Mid America Heart Institute Kansas City, Missouri, USA

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have not had a financial interest/arrangement or affiliation with the organization(s) listed below.

Antonio Colombo Hawaii, 1997 “Sometimes I feel if I don’t get complications, then I am not trying hard enough” Antonio Colombo Hawaii, 1997

Review of Common & Uncommon CTO Complications General Guidelines Never undertake “drive-by” CTO PCI Careful evaluation of the angio (30-40 min) Always use double guide injections One-dimensional operator not acceptable Skills in antegrade, dissection/re-entry, retrograde Discuss with colleagues

2/10/16 51-Year-Old Female CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy

51-Year-Old Female – CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy Critique Set up initial freeze frame as road map No repeat injections IVUS guidance is mandatory With aortic root dissection, always stent across the ostium Consider visualizing the LMCA Surgical intervention almost never necessary

2/11/16 51-Year-Old Female CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy

51-Year-Old Female – CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy Post intervention: Large, retroperitoneal bleed ASA, Plavix and Coumadin withheld Developed severe retrosternal chest pain Taken back to cath lab at outside facility for repeat angiography

2/14/16 51-Year-Old Female CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy

51-Year-Old Female – CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy Careful consideration of the timing for staged procedures Avoid staged procedures from the same entry site If possible, avoid triple therapy

Radiation Dermatitis

16-21 weeks depigmentation and atrophy 30 days 16-21 weeks depigmentation and atrophy 3-6 months ulceration

Prevention of Radiation Dermatitis Alert to staged procedures Knowledge of previous fluoro times Physician alerts at 2 Gy intervals >5 Gy skin dose Patient education regarding radiation exposure Skin monitoring and skin care Documentation of patient Notification to PCP > 10 Gy or > 50 min fluoro time Consider aborting the procedure >15 Gy is “Sentinel Event” reported to Dept of Health

OPEN CTO Trial Overall Complications (N=1000 patients) MACCE 70 (7.0%) Death 9 (0.9%) MI 26 (2.6%) Stroke 0 (0.0%) Emergent surgery 7 (0.7%) Clinical perforation (Treated) 48 (4.8%) Perforations (all) 88 (8.8%) Ellis grade 1 11 (12.5%)  Ellis grade 2  44 (50.0%) Ellis grade 3  28 (31.8%) Ellis grade 3 cavity spilling  5 (5.7%) Perforation Location  CTO Vessel 75 (85%)  Non CTO vessel 3 (3.4%)  Collateral 8 (9.1%)          Septal 3 (37.5%)          Epicardial 5 (62.5%) Barry this is the complications table from the OPEN CTO paper currently in review.  Use whatever you need, just site as unpublished data from OPEN CTO.  These numbers are different than earlier reported numbers.  These are from the core lab and after events adjudication.  We saw a significant number of perforations that were clinically insignificant and not reported by the investigators.  (save that information for Q/A if it comes up).

78-year-old Male CTO of RCA

78-year-old Male CTO of RCA

78-year-old Male, CTO of RCA Post procedural Echocardiogram Large hematoma in Rt AV groove with RV compression

63-yo Male CTO of RCA

Management of Coronary Perforation DO NOT PANIC! Prolonged balloon inflation (do not remove balloon) Reverse heparin: DC Angiomax (do not use in CTO’s) Echocardiogram – pericardiocentesis (remember echo later if suspicion of perforation) Access other femoral artery (ping-pong guides) Alert cardiac surgery team Punishment should fit the crime – most guidewire perforations are minor events, but this is a MAJOR event

Management of Coronary Perforation Thrombus injection Adipose tissue injection Gel foam Polyvinyl alcohol (PVA) AngioDynamics™ Thrombin injection Coils: Cook: Hilal-Embolization MicroCoil™ (2mm); Boston Scientific: VortX™ Diamond-18 (3x3.3mm) Boston Scientific: Renegade™ Delivery Catheter (Tip 2.5 Fr) Covered Stent (JoStent) Diameter 3.0-5.0 Length 12-26

63-yo Male CTO of RCA

63-yo Male, CTO of RCA: Follow up

58-Year-Old Male 12/21/16 Presented with NSTEMI; troponin level 4.2; EF 20% Tobacco and drug abuse; dyslipidemia; hypertension 12/23/16 Coronary angiogram: severe TVD, prox LAD, prox LCX and CTO of RCA Referred for surgery, however surgeons felt he was very high risk and therefore was a surgical turndown 12/28/16 Stenting of LAD, LMCA and LCX with good results. 2/2/17 CTO of RCA stenting

Stent perforation

58-Year-Old Male Treatment Options Prolonged balloon inflation Antegrade delivery of balloon Retrograde delivery of balloon Ping pong guides Antegrade delivery of JoStent Echo evaluation Pericardiocentesis if indicated

Retrograde Delivery of Balloon ASAHI RG3 wire; 330 cm Vascular Solutions R350 wire Balloon Shaft Length MAVERICK™ XL 153 cm APEX™ 145 cm SPRINTER Legend 142 cm