RETROGRADE APPROACH SEPTAL COLLATERAL CHANNELS Paul Hsien-Li Kao, MD Associate Professor National Taiwan University Hospital Paul Kao CCT 2013

CCT2013 COI Disclosure Paul Hsien-Li Kao The authors have no financial conflicts of interest to disclose concerning the presentation.

Septals in retrograde PCI  Connects LAD and RCA(PDA)  Most frequently used in retrograde PCI for CTO’s of LAD or RCA  In theory, more straight forward course than epicardial channels  Variable channel size/diameter  Can be very tortuous too Paul Kao CCT 2013

Devices used to track septals  Microcatheter  Corsair  Finecross  Sortana, etc  Guidewire  Sion  Sion Blue, Suoh, XTR, etc  OTW BC Paul Kao CCT 2013

Viewing the septal course  Take-off from LAD  RAO cranial  Take-off from PDA  RAO caudal  Septal track  RAO  Tip injection from micro-catheter to isolate the track is important to isolate the desired track Paul Kao CCT 2013

Cranial vs. caudal Paul Kao CCT 2013

Tip injection for details Paul Kao CCT 2013

RCA CTO via septal from LAD Paul Kao CCT 2013

Tip injection isolating track Paul Kao CCT 2013

Tracking with Sion Paul Kao CCT 2013

LAD CTO via septal from RCA Paul Kao CCT 2013

Unusual conditions  Ipsi-lateral connection for m-LAD CTO  p-LAD  septal  d-LAD  Ipsi-lateral connection for m-RCA CTO  p-RCA  conus branch  septal  PDA  Part of collateral loop involving other epicardial channel, connecting not only between LAD and RCA Paul Kao CCT 2013

Ipsi. septal for LAD CTO Paul Kao CCT 2013

Sion and Corsair Paul Kao CCT 2013

Reverse CART and final Paul Kao CCT 2013

Ipsi. septal for RCA CTO Paul Kao CCT 2013

Ipsi. septal for RCA CTO Paul Kao CCT 2013

Sion in Corsair, exchanged to M6 Paul Kao CCT 2013

Retro wiring and reverse CART Paul Kao CCT 2013

Rendezvous in proximal RCA Paul Kao CCT 2013

Tip shaping of Sion Paul Kao CCT 2013

Short tip fracture/bend Paul Kao CCT 2013

Which septal to choose?  Multiple septal connections may be present, can we select one logically or just by chance?  AA and LEP  Rhythm issues  Total loop length  Cardiac cycle motion  “Septal surfing” Paul Kao CCT 2013

Attack angle (AA) & length from emerge point (LEP) Paul Kao CCT 2013 large AA small AA short LEP long LEP

Distal is the better one in this case Paul Kao CCT 2013

Consequence of rupture  Hematoma – mostly benign, but may develop into abscess/VSD  AV fistula - benign  Dry tamponade/acute HOCM – extremely fatal! Paul Kao CCT 2013

LAD CTO using septal Paul Kao CCT 2013

Corsair jump causing hematoma Paul Kao CCT 2013

RCA CTO using septal Paul Kao CCT 2013

Fistula into middle cardiac vein Paul Kao CCT 2013

What is dry tamponade?  Rare, but has been reported as a consequence of dissecting septal hematoma after surgical VSD repair  Septum bulging into ventricles reducing the end-diastolic volume, with hemodynamic effects similar to pericardial tamponade  If positioned at LVOT level, will also create HOCM-like hemodymanics  High mortality (~90%) if managed conservatively  Surgical evacuation and un-roofing  Hemostasis is not effective!! Vargus-Barron J, et al.Echocardiography 2009; 26:254 Paul Kao CCT 2013

CART via septal for RCA CTO Paul Kao CCT 2013

OMG! fortunately, lucky patient!! Paul Kao CCT 2013

Conclusions  With current devices and treatment strategies, CTO PCI produces acceptable and consistent results  The choice of collaterals should be liberal, and pre-PCI planning is important  Septals are useful and important, but as delicate and dangerous as other collaterals  We still need improved wire design for better and safer tracking Paul Kao CCT 2013

Thank You For the Attention Paul Kao CCT 2013

Personal breakdown  300 consecutive unselected CTO attempts from 2012-Jan to Sep  10 failures, without emergent surgery nor mortality  Success rate 96.7%  155 retrograde (51.7% of all CTO procedures) with 96.1% success  72 using septal, 46.5% of all retrograde cases, with 98.6% success Paul Kao CCT 2013