15:20 Tsuchikane - Retrograde complication

CTO Toyohashi Heart Center
The Experts “Live” Workshop 2014
Dealing with Problems
in Retrograde PCI
Etsuo Tsuchikane, MD, PhD
Toyohashi Heart Center, Japan

 Systemic
 Procedure related
1. CIN
2. Radiation dermatitis
1. GC induced
2. Wire perforation
3. Vessel perforation
4. Retrograde approach related
5. Device entrapment in CTO
 from CTO site
 from small branch
 ballooning, stenting
 channel perforation by wiring - epicardial
 channel rupture due to catheter - septal, epicardial
 donor artery trouble - thrombus, dissection
Specific complications in CTO-PCI

Retrogarde approach
relevant complications

Primary Retrograde
Approach:
Retro Group (1287)
(including 399 re-attempt)
Immediately After Failed
Antegrade:
Combined Group (907)
(including 126 re-attempt)
2,194 cases
0
20
40
60
0
200
400
600
2009 2010 2011 2012 2013
N. of Participating Site
Total
Retro Group
Combined Group
5Yr Registry Data
from Retrograde Summit
(Sites)(Enrollment)

Complications (n=2194)
Channel injury: 9.6% (210)
Treatment Required 2.8% (61)
Cardiac Tamponade 0.4% (9)
Donor artery trouble: 0.50% (11)
Dissection Requiring Stent 0.4% (8)
Spasm 0.09% (2)
Ischemia due to Pre-existing Lesion 0.05% (1)
Thrombosis 0
Others: 0.9% (20)
Retrograde approach relevant 11.0% (241)
At CTO site 3.7% (82)
Other events during/after procedure 3.0% (65)

Epicardial channel for RCA Corsair with Fielder FC
Case: RCA-CTO

Type-I perforation

Ballooning for hemostasis Septal channel tracking

Successful revascularization Final LCA
It was controlled by neutralization of heparin.

LAD-CTO
Epicardial channel from LCx

SION wiring caused perforation through tiny branch

Successful rewiring with SION

Reverse CART

Small perforation after removal Corsair? Other injury??

Excelsior
Tip injection

Tip injection

Minor channel damage, but no major bleeding

No event after procedure

Retrogarde approach
• Prolonged balloon inflation
• Neutralization of heparin
• Embolization only when necessary

RCA CTO, 2nd Attempt

Fielder XTR

Channel rupture!?

Tip injection from 2 Transit MC

PD-LAD channel

XTR crossed successfully.

Successful recanalization was achieved, however…

Channel rupture was revealed after removal of Corsair.

2 coils was placed bilaterally.

Epicardial channel
RCA CTO, 2nd Attempt

Reverse CART
Ultimate 3XT-A
Corsair

Again! Rupture!!

Kissing Excelsior

A coil was released antegradely.

Successful hemostasis Final angiogram

Retrogarde approach
?

RCA-CTO

Corsair was stuck and bent
at the distal portion.
Channel rupture

Reverse CART
Tip of OTW
Retrograde wire
Tip of OTW
3m externalizationBalloon trapping

Nothing happened after procedure.

Q: How often we need embolization for
septal channel rupture?
A: 0.19%
(1 case / 533 successfully crossed septal channels)

LAD-CTO

Ipsilateral septal channel

Successful retrograde wire crossing

Septal hematoma after removal Corsair

Advanced MC 2 way coil embolizationNo major bleeding

LAD-CTO (courtesy of Dr. Yamane)

Septal channel
(courtesy of Dr. Yamane)

Septal channel injury after removal Corsair

Developing septal hematoma, chest pain, hypotention

Fenestration by wiring into ventricle

Reduced septal hematoma

 channel perforation by wiring – epicardial
Retrogarde approach
• In epicardial, hemostasis procedure must be done
immediately.
• In septal, carefully observe it. Fenestration or embolization
should be considered when it’s developing (chest pain).

Thrombus in Donor Artery
Epicardial channel tracking
Monitored BP down
Successful wiring
Final result Post LCA

Careful attention is mandatory to donor artery.
ACT > 300, occasional flushing are required.
Thrombus retrieved from GC for LCA

RCA-CTO
Mild lesion in LAD
Q: guilty or not guilty?

After IVUS examination DES implantation
A: guilty!

Septal Channel Selection
Failed Successful

Bilateral Wiring
Chest pain and BP down!

LAD occlusion

After removal of Corsair After stenting

Reverse CART Final angiogram

 channel perforation by wiring – epicardial
Retrogarde approach
• ACT > 300 sec.
• Occasional flushing in GC
• BP monitored from GC with side holes
• Prophylactic stenting of mild lesion
• Fix a vessel trauma immediately!
• Be cautious of vessel bend itself!

16th CTO Club
June 19-20, 2015, Nagoya, Japan
www.cct.gr.jp/ctoclub

15:20 Tsuchikane - Retrograde complication

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15:20 Tsuchikane - Retrograde complication