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Questions / Answers from July 20, 2010 Case

Questions / Answers

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Normally, it is a good practice for multi-vessel disease to do the technically difficult lesion first, which is this case was the LAD? Can you explain your rationale from departing from this strategy?
YES. That is correct if the plan is to refer for CABG if PCI fails and complex vessel is collateralized by the PCI vessel. In this case CABG was declined and LAD fills via bridge collaterals. Hence we felt it was appropriate to initially open 2 stenosed vessels and leave well antegrade collateralized CTO LAD for last.
Would you consider surgery if the patient fails treatment this time?
This pt was first referred to CABG but declined and hence if we would have failed the CTO LAD, pt would have been managed medically and no CABG.

Or bring him back for a second CTO attempt?
Certainly if would have failed, then pt would have been scheduled for 2nd try in 4-8 weeks.

Your follow up on the previous failed CTO was remarkable. Thank you for the follow up. Is this your routing practice?
YES It was important to show the F/U of the 2nd attempt which is an usual practice and this strategy has further improved the CTO success.
Are patients comfortable with this strategy?
YES As long as you explain to them well. In some of these cases such as present case, there was no other choice.
How do you deal with the insurance issues?
YES Sometimes it requires making call to the insurance carriers for justifications. In all cases we were able to convince them.
It can be very difficult for a patient to have failed with 2 CTO attempts and then to be recommended surgery? How do you feel about this?
YES I feel bad about it but that is the usual strategy in the majority. This strategy will avoid CABG in almost 95% of cases.
What is your recommended anti platelet strategy for the patients awaiting a second CTO attempt?
If pt does not have any stent at the time or before, then only aspirin is ok. Otherwise pts are on DAPT anyway for the stents.
How do you approach the second CTO attempt differently? Is reviewing of the previous attempt an important part of your strategy?
Clearly close analysis of previous procedure's attempt is the key before proceeding for 2nd try. Also be more aggressive 2nd time compared to the first time in terms of stiff wire selection.
How much importance do you pay to the micro channels? When does that become your first approach?
In majority of cases we start with Fielder XT which should find these micro channels. But it is successful only 25% of the times. In majority, it's the penetration technique with wire escalation which makes the CTO recanalization successful.
Tell us about the first support catheter you use for CTO?
Finecross by Terumo Inc is the support catheter of choice in our lab. Sometimes we require Corsair of Abbott vascular to push thru the CTO lesion after wires has crossed the lesion.
And the first guide wire?
Usually Fielder or Fielder XT wire of Abbott Vascular Inc is the first wire & in some cases Cross-it 100.
Which would be your next 3 guide wires?
Miracle 3 or 6 and then Confianza 9 or 12 with escalation approach.
When do you decide to stop?
Total 100 minutes of Fluro time, 3hrs of procedure time, >5cc/Kg contrast use or any major complication of extensive dissection or perforation.
When do you decide to move to a retrograde approach?
After 2nd antegrade attempts fails. Some Interventionalists start retrograde approach sooner and we are in process of refining our retrograde techniques.
What percentage is your retrograde use?
Only 1-2% of CTO procedures at Sinai are retrograde attempts.
How much should it be?
I would say good number should be 10%. Still will do only after antegrade approach failed (at least once).
Has more CTO use impacted your CTS volume?
Yes many of these cases otherwise would have gone to CT surgery and now are being successfully recanalized obviating the need for CABG.
How helpful are you finding CT angio before a CTO attempt?
Presently we are still in process of getting experience on this front. I am aware of publications emphasizing it's importance and utility in CTO recanalization.
How do you presently rate the Angiosculpt? Do you see its use increasing? What are its favorable characteristics?
Angiosculpt is a simple Atherotomy device for ostial, inelastic and mildly calcified lesions. We find it very useful in cases of ISR. Also it is quite trackable and can be inflated to high pressures in un-dilatable lesions.
 
 

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