1. 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

2. 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.

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

4. 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

5. 2/10/16 51-Year-Old Female CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy

6. 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

7. 2/11/16 51-Year-Old Female CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy

8. 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

9. 2/14/16 51-Year-Old Female CTO of RCA Factor V Leiden Deficiency on Long-term Coumadin Therapy

10. 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

11. Radiation Dermatitis

12. 16-21 weeks depigmentation and atrophy
30 days
16-21 weeks depigmentation and atrophy
3-6 months
ulceration

13. 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

14. 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 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).

15. 78-year-old Male CTO of RCA

16. 78-year-old Male CTO of RCA

17. 78-year-old Male, CTO of RCA Post procedural Echocardiogram
Large hematoma in Rt AV groove with RV compression

18. 63-yo Male CTO of RCA

19. 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

20. 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
Length 12-26

21. 63-yo Male CTO of RCA

22. 63-yo Male, CTO of RCA: Follow up

23. 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

25. Stent perforation

26. 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

27. 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