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The Hybrid approach to CTO PCI
Bill Lombardi MD University of Washington Seattle WA
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Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial Interest /arrangement or affiliation with the organization(s) listed below Affiliation/Financial Relationship Company Grant/ Research Support: Consulting Fees/Honoraria: Abbott Vascular, Boston Scientific, Asahi Intec, Trireme Medical, Roxwood Medcial Major Stock Shareholder/Equity Interest: Bridgepoint medical systems Royalty Income: Ownership/Founder: Salary: Intellectual Property Rights: Other Financial Benefit: Spectranetics (wife is an employee)
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What would you attempt to do if you knew you could not fail?
Disclosure number 2 What would you attempt to do if you knew you could not fail?
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Disclosure number 3 Myocardial cells become ischemic when myocardial oxygen demand outstrips myocardial oxygen deliver The myocardial cell has no idea why that is happening or what is going on to cause that The myocardial cell has no idea what is going on with the artery that supplies it only you do. So why did you cath the patient? Because the patient had myocardial cells that were ischemic causing symptoms.
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What is limiting the adoption of CTO PCI
Excuses Lack of support from partners, hospitals, governing bodies Understanding that what I did no longer works Am I truly better at PCI now than I was last year? Fear
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Bellingham CTO Workshop Jan 2011
17 patients from 6 states (9 previous failures) 13 physicians 5 CTO operators working in pairs C Thompson, B Lombardi, A Grantham, T DeMartini, M Wyman Strategy determined by group blinded to operator assignment Hybrid approach Initial strategy/device Time and progress parameters to switch strategies Operator unblinding immediately prior to case Primary and secondary operator Execute assigned strategy
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Baseline Demographics Bellingham CTO Workshop Jan 2011
17 Mean age (yrs) 63.7 Gender (M) 94% Prior CABG 35% CTO location LAD 47% RCA 29% LCx 24% Reattempt 53% ISR 6% Lesion Length (bilateral injection) 23.5mm Proximal Reference Diameter 2.89mm Distal Reference Diameter 2.60mm
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Procedure Outcomes Bellingham CTO Workshop Jan 2011
Efficiency Case time (mean) 89.9 min Cases < 2hrs 82% Contrast 273.5 cc Fluoro Time 39.6 min Effectiveness Technical Success 100% Safety MACE 5.8% (perforation) Death/MI 0%
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The Continuum of CTO PCI: Hybrid
Dissection Reentry Antegrade Retrograde Adoption of only 1 or 2 of these limbs will limit the patients that can be treated on the basis of coronary anatomy
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Adequate distal target Interventional collateral
Hybrid Strategies Dissection Reentry Lesion >20 mm Antegrade Defined cap Adequate distal target Retrograde Interventional collateral After analysis of the angiogram, antegrade or retrograde is selected on the basis of our confidence in defining the proximal cap, quality of the distal target and suitability of interventional collaterals. An initial attempt at wire escalation is undertaken for lesions < 20 mm in length, for long lesions dissection and re-entry is the primary strategy.
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Hybrid CTO PCI Strategy
Hybrid Strategy Simple retrograde Complex Antegrade Complex Retrograde Simple Antegrade
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Hybrid CTO PCI basic principles
Procedural efficiency, contrast, radiation with greater priority Maintain safety, improve efficacy Always make progress…don’t let case stall Preplanned multistep procedural strategy Setup for seamless transition between antegrade wire escalation, dissection reentry, and retrograde Quick transition to alternate plans when failure mode occurs Opportunity for contingency plan success Can return to more focused attempt to earlier strategies if needed
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The “base of operations”
Antegrade Goal Move gear safely and quickly to distal cap to focus on true lumen entry or… Move gear beyond distal cap to focus on reentry Retrograde Goal Move gear safely and quickly to proximal cap for true lumen entry or reverse CART (dissection connection)
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Equipement Externalization Wire Snare Guide Extension Catheters Laser
Crossing and reentry devices Crossboss Stingray balloon Stingray guidewire Microcatheters Finecross Corsair Tornus Externalization Wire Snare Guide Extension Catheters Laser Rotoblator Perforation management kit Wire Platforms Tapered soft (~1gram) hydrophilic guidewire Fielder XT an example Antegrade microchannel/soft plaque probing Knuckle wire technique Non tapered, plastic jacketed low gram force wire Fileder FC, Sion Retrograde collateral workhorse wire Non tapered, high gram force plastic jacketed wire Pilot 200 Lesion crossing Knuckle wire Facilitation of wiring in complex dissection and re-entry High gram force (12g+), tapered penetration wire Confienza pro 12 Penetration of cap
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Anatomy Dictates Strategy
Direction Antegrade vs Retrograde determined by: Proximal cap Ambiguous: yes or no Distal vessel poorly visualized or at a bifurcation: yes or no Collateral channel morphology Operator skillset Initial technique wires vs dissection re-entry determined by: - Lesion Length greater or less than 20mm
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Hybrid Approach Anatomy Dictates Strategy
The Four Questions Is the Proximal cap clear by angio +/- IVUS or ambiguous? Quality of the distal target Suitability of “interventional” collaterals Lesion length < or > 20mm The Hybrid algorithm was developed by a group of expert CTO operators in an attempt to utilize antegrade, retrograde, and dissection and re entry with the express purpose to target procedural efficiency and success. Lesion characteristics that lend themselves to one approach or another are first ascertained by reviewing the diagnostic angiogram.
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The Hybrid Algorithm for CTO PCI provisional approaches
Dual Catheter Angiography yes no Clear proximal cap Good Distal Target Antegrade Retrograde yes no no Length < 20mm yes Wire escalation fail Dissection Reentry (crossboss-stingray) Wire escalation fail Dissection Reentry (reverse CART) fail fail Dissection Reentry (reverse CART) Dissection Reentry (crossboss-stingray))
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Facilitated Antegrade dissection and re-entry
BridgePoint Medical
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Conclusion You must unlearn to learn new things
New concepts and rules for performing “complex” PCI Dedicated Program, education and system to improve success Patients not procedures are what matter. What needs to be done outweighs, what I can do.
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