Complex CTO: Ostial LAD CTO with ambiguous Proximal CAP

Educational objectives

• How to manage diabetic patients with one vessel disease (Proximal LAD CTO): CABG vs PCI.
• Step-by-Step setup & Access-guiding catheters choice.
• Application of the Hybrid algorithm in CTO PCI procedures.
• IVUS guided proximal  CAP puncture technique.
• Tips & Tricks to gain support and safely advance microcatheters, balloons...in uncrossable lesions.
• How to Stent bifurcations in CTO lesions.
• How to perform double Stent Technique: DK-Crush.
• How to prevent complications during every Step CTO PCI procedure.

Step-by-Step procedure

• Dual Femoral Access : 8F introducer in Right CFA & 7F introducer in Left CFA.
• JR 7F  guiding catheter for the RCA & 8F EBU3.0 for the Left main.
• Proximal CAP engagment using Workhorse guidewire Sionblue (Asahi) then Fielder XT-A (Asahi) & Low profile microcatheter Caravel (Asahi).
• Advancement of the Filder XT-R into the first diagonal.
• Trapping the microcather with Trapping dedicated Device: Trapper (Boston Scientific).
• Predilation toward the Diagonal with small balloon 1.5x20mm.
• Exchange of the Fielder XT-A (Asahi) with a workhorse guidewire Sionblue (Asahi).
• IVUS evaluation of the proximal CAP.
• Echo-guided puncture using a Fielder XT-A Guidewire & Caravel microcatheter (Asahi).
• Exchange Fielder XT-A guidewire to Gaia Second (Asahi) to cross the occlusion & angiographic control in two orthogonal views.
• Anchoring balloon technique in the diagonal to advance the Caravel into the LAD.
• After failing the Anchoring balloon technique, a dilatation of the proximal Cap using a small balloon 1.5x20mm was performed.
• Exchange  to the microcatheter & Crossing into the true lumen using a workhorse guidewire Runthrough guidewire (Terumo).
• Predilatation of the Diagonal & the LAD with  2.5x15mm.
• Angiographic control.
• Bifurcation two stents technique: LAD-1st Diagonal with DK-Crush Technique.

Biobliography

• A percutaneous treatment algorithm for crossing coronary chronic total occlusions.ink title - Article
  Authors:Brilakis ES, Grantham JA, Rinfret S, Wyman RM, Burke MN, Karmpaliotis D, Lembo N, Pershad A, Kandzari DE, Buller CE, DeMartini T, Lombardi WL, Thompson CA.
  Publication: 2012 Apr;5(4):367-79. doi: 10.1016/j.jcin.2012.02.006.
   
• Intravascular Ultrasound Guided Percutaneous Coronary Intervention for Chronic Total Occlusionink title - Abstact
  Authors:Dash D, Li L.
  Publication:2015 Nov 6;11(4):323-317. doi: 10.2174/1573403X11666150909105827.
   
• Utility of Intravascular Ultrasound in Percutaneous Revascularization of Chronic Total Occlusions: An Overview.ink title - Article
  Authors:Galassi AR, Sumitsuji S, Boukhris M, Brilakis ES, Di Mario C, Garbo R, Spratt JC, Christiansen EH, Gagnor A, Avran A, Sianos G, Werner GS.
  Publication: 2016 Oct 10;9(19):1979-1991. doi: 10.1016/j.jcin.2016.06.057.
   
• Chronic Total Occlusion Interventions: Update on Current Tips and Tricks.ink title - Article
  Authors:Tajti P, Xenogiannis I, Karmpaliotis D, Alaswad K, Jaffer FA, Nicholas Burke M, Ungi I, Brilakis ES.
  Publication: 2018 Oct 22;20(12):141. doi: 10.1007/s11886-018-1083-7.
   
• Intravascular ultrasound guidance of percutaneous coronary intervention in ostial chronic total occlusions: a description of the technique and procedural results.ink title - Article
  Authors:Ryan N, Gonzalo N, Dingli P, Cruz OV, Jiménez-Quevedo P, Nombela-Franco L, Nuñez-Gil I, Trigo MD, Salinas P, Macaya C, Fernandez-Ortiz A, Escaned J.
  Publication:2017 Jun;33(6):807-813. doi: 10.1007/s10554-017-1086-2. Epub 2017 Feb 14
   

CTO technics