15:20 Tsuchikane - Retrograde complication

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Dealing with Problemsin Retrograde PCIEtsuo Tsuchikane, MD, PhD

Toyohashi Heart Center, Japan

CTO Toyohashi Heart Center

The Experts Live Workshop 2014 Systemic Procedure relatedCINRadiation dermatitisGC induced Wire perforation

Vessel perforation

Retrograde approach related

Device entrapment in CTO from CTO sitefrom small branch

ballooning, stenting

channel perforation by wiring - epicardialchannel rupture due to catheter - septal, epicardialdonor artery trouble - thrombus, dissection Specific complications in CTO-PCI


The Experts Live Workshop 2014

channel perforation by wiring - epicardial

channel rupture due to catheter - septal, epicardial

donor artery trouble - thrombus, dissection 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 cases5Yr Registry Datafrom Retrograde Summit(Sites)(Enrollment)

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Complications (n=2194)Channel injury: 9.6% (210)Treatment Required2.8% (61) Cardiac Tamponade0.4% (9)

Donor artery trouble: 0.50% (11)Dissection Requiring Stent0.4% (8)Spasm0.09% (2)Ischemia due to Pre-existing Lesion0.05% (1)Thrombosis0

Others: 0.9% (20)

Retrograde approach relevant11.0% (241)At CTO site3.7% (82) Other events during/after procedure3.0% (65)

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Epicardial channel for RCACorsair with Fielder FCCase: RCA-CTO



Type-I perforation



Ballooning for hemostasis

Septal channel tracking



Successful revascularizationFinal LCA

It was controlled by neutralization of heparin.



LAD-CTOEpicardial channel from LCx



SION wiring caused perforation through tiny branch



Successful rewiring with SION



Reverse CART



Small perforation after removal Corsair? Other injury??



ExcelsiorTip injection



Tip injection



Minor channel damage, but no major bleeding



No event after procedure






Prolonged balloon inflation Neutralization of heparin Embolization only when necessary



RCA CTO, 2nd Attempt



Fielder XTR



Fielder XTR



Channel rupture!?



Tip injection from 2 Transit MC



PD-LAD channel



Tip injection



XTR crossed successfully.



Successful recanalization was achieved, however



Channel rupture was revealed after removal of Corsair.



2 coils was placed bilaterally.


The Experts Live Workshop 2014Epicardial channel

RCA CTO, 2nd Attempt





Reverse CARTUltimate 3XT-A

Corsair



Again! Rupture!!



Kissing Excelsior



A coil was released antegradely.


The Experts Live Workshop 2014Successful hemostasisFinal angiogram






?



RCA-CTO



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



Reverse CARTTip of OTW

Retrograde wire

Tip of OTW3m externalizationBalloon trapping



Nothing happened after procedure.


The Experts Live Workshop 2014 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 MC2 way coil embolizationNo major bleeding



LAD-CTO (courtesy of Dr. Yamane)



Septal channel (courtesy of Dr. Yamane)



Septal channel injury after removal Corsair (courtesy of Dr. Yamane)



Developing septal hematoma, chest pain, hypotention (courtesy of Dr. Yamane)



Fenestration by wiring into ventricle (courtesy of Dr. Yamane)



Reduced septal hematoma (courtesy of Dr. Yamane)



channel perforation by wiring epicardial



In epicardial, hemostasis procedure must be done immediately.

In septal, carefully observe it. Fenestration or embolization should be considered when its developing (chest pain).


The Experts Live Workshop 2014Thrombus 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 examinationDES implantationA: guilty!



RCA-CTO



Septal Channel Selection

FailedSuccessful



Bilateral WiringChest pain and BP down!



LAD occlusion



After removal of CorsairAfter stenting



Reverse CARTFinal angiogram



channel perforation by wiring epicardial



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!


The Experts Live Workshop 201416th CTO Club June 19-20, 2015, Nagoya, Japan

www.cct.gr.jp/ctoclub



15:20 Tsuchikane - Retrograde complication

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