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Questions / Answers from February 16, 2010 Case

Questions / Answers

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What is the percentage of CTO cases in your practice?
The incidence of CTO lesions detected during coronary angiography in CAD patients has been around 15-18%. Of these about 15-25% are selected for CTO PCI based on the clinical indications (moderate-to-large ischemic area on perfusion imaging) and expected procedural success rate of over 70%. CTO PCI makes about 3-4% of total PCI done every year at Sinai (about 160-200 CTO PCIs every year).
Is this number increasing?
YES. With introduction of newer guide-wires (from Ashai family marketed by Abbott Vasc Inc) in 2005, the % of CTO cases becoming attempted has increased from 15% to 25% now. This is largely due to higher, procedural success (from 65-68% to 88-90% now) of CTO to really make the difference in ischemia and also, that patients (& family) are not disappointed and frustrated. With our established reputation of CTO success, many of these CTO cases are selectively referred to us from the surrounding locality. This is little different than data from ACC-NCDR registry, which shows that for last 4-5 years CTO PCI is, being done in 10-12% of CTO cases encounterd and that number has not increased until 2008 data.
What percentage of these are done via the ante grade approach?
Over 99%. Rare cases we try retrograde approach. If we fail antegrade, we bring the ptt back for 2nd attempt after 4-6 weeks with cumulative success of approximately 90%.
How has this affected your surgical program - are several patients with successful CTO intervention not going to surgery now?
YES. More than one CTO is the common indication for CABG. But pts want us to try to open them and we do, if expected success rate over 70%. Some of these multiple CTOs pts would have gone to CABG in the past, but now, getting successful percutaneous revascularization.
When you will absolutely not do a CTO?
If CTO recanalization is clinically indicated but is not tried routinely percutaneously, in following situations; Heavy calcification, High SCr >2.0 mg/dL (eGFR <30), severe diffuse distal disease seen via collaterals, absence, of proximal stump in ostial RCA or ostial LAD.
What is your preferred starting wire for a CTO?
Fielder XT or MiracleBro 3 is the starting guide wire for CTO.
French or 8 French?
We use 6Fr long sheath (45 cm) sheath. Many interventionalists (especially Japanese...)sgpref
Preferred support catheter?
We have tried numerous support catheters and found Fine-cross (Terumo medical) as the best. 1.5mm 6 or 9mm over-the-wire balloon can also be used.
Preferred stent for successful cases?
If DES is indicated (as in over 90% of cases) Xience V (Abbott Vascular Inc or Promus by BSC Inc) is the preferred DES. Although we have only good randomized data for Cypher (Passion trial) DES, and because of longer DAPT of 3 yrs, we reserve Cypher to only few selected cases (usually long CTOs where 2 Cyphers 33mm will do the job vs 3 Xience V 28mm)
Of all the new devices coming to the market for CTO, which ones do you find most promising?
Unfortunately NONE. We have found that these devices are cumbersome, expensive and do not add to already reached 90% procedural success rates with CTO wires and various advanced techniques.
How often are you using the Tornus device?
In about 1-2% of PCI where 2.0/20mm Maverick balloon (BSC Inc) will not go. When used success rate of Tornus to cross the lesion is about 70%.
What practical steps do you take to minimize radiation exposure while doing these long CTO cases?
It's most important to being close to the shutter of exposure and use the vessel landmarks. Frequent cines are 3x more harmful than just Fluoro.
How long should a CTO take?
In my opinion maximum limit of the (delete "the") 3 hrs of procedural cath lab time, which includes maximum total 99 minutes of Fluoro time.
In busy practices, and keeping in mind the training involved, should there be a dedicated person in the lab who does CTO?
My answer to this will be both NO and YES. All practicing Interventionalists should learn to do regular CTOs. Yes, a complex
CTO or a failed CTO should be done by the dedicated expert Interventionalist. Dr Kini is serving that purpose in the
Mount Sinai Cath Lab.
What is your anti-coagulant strategy for CTO?
We have just published the use of Bivalrudin during CTOs, and is the preferred agent as it causes less complications with wire perforations because of its short duration of action. Kini et al, Cathet Cardiovasc Intervent 74:700, 2009.
What criteria do you use to decide between the ante grade and retro grade approach?
We routinely start with antegrade approach irrespective of the CTO anatomy. We use retrograde only if antegrade approach has failed twice. I know few Interventionalists will start the retrograde approach at the outset if there is no CTO stump or heavy calcification.
Should bilateral groin cannulation be a mandatory step for performing CTO?
YES, except if vascular access is a major issue and there are left to left collaterals such as mid LAD filling via a circumflex branch.
When do you absolutely give up in a CTO?
Fluoro time has reached 3 digits (>100 min) and there is extensive dissection or perforation causing cardiac tamponade.
Is Japan the only place to train for CTO?
ABSOLUTELY NOT. Many US centers like ours have really mastered the technique of CTO recanalizations and we organize
monthly CTO sessions where other visiting Interventionalists from the country come to our cath lab to learn the techniques.
Therefore, I would advise young/emerging Interventionalists to visit a high volume center and spend a day or two learning the tips and tricks to advanced CTO techniques and the accompanying equipment for these procedures.
 

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