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How to Perform and Interpret Coronary Angiography for CTO RecanalisationThierry lefvreICPS, Massy, France

Angiography / imagingFefer P et al. J Am Coll Cardiol. 2012;59:991-997

20-25%

Lesion morphologyPatient characteristicsLearning curve The Success Rate of CTO Carefull reading of diagnostic angiography !Take extra time to evaluate both the collateral donor vessel and the occluded vessel even if the initial intervention is done on an other lesion

Guidewire Crossing < 30 min.

Morino et al. JACC Interv 2011; 4: 213-221

Guidewire Crossing < 30 min.Morino et al. JACC Interv 2011; 4: 213-221

Calcium, tortuosity (including donor)Previous stentEvaluate graft for possible retrograde accessLeft ventriculographyChronic kidney disease Coronary Angiogramm

CTO Success

No ad Hoc PCI !

Good AngiogramPowerfull and selective injectionLong injectionLarge fieldNo paning

Good CTO AngiographyOptimal view of the distal run offOptimal view of the donor vesselGood views of the collateralsSeveral views of the occluded vesselAt least 1 same view for both vesselsEducate the referring physicians

What are the Questions ?Is it really a CTO ?Proximal and distal ambiguity ?Lesion length ?Vessel course, Island ?Lesion calcification and tortuosity ?Distal run off ?Collaterals ?Good and safe support ?

Is it a CTO ?Clinical historyVigorous and selective injectionCarefull frame-by frame analysisDifferent views

What about the support ?

What about the support ?

What about the support ?

What about the support ?

What about the support ?

What about the support ?

What about the support ?

Fielder XT + Finecross

What about the support ?

3D right

Miracle 12 + Finecross

What about the support ?

Anchoring balloon

What about the support ?

What about the support ?

Antegrade or Retrograde ?

Ostial and calcified lesionGC Support, Stability ?Risk of ostial dissection ?

Antegrade or Retrograde ?

Antegrade or Retrograde ?

What about the support ?

Antegrade or Retrograde ?

Antegrade or Retrograde ?

Antegrade or Retrograde ?

Antegrade or Retrograde ?

Mother and Child TechniqueAntegrade or Retrograde ?

Antegrade or Retrograde ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Vessel Course ?

Proximal Ambiguity ?

No CalcificationLesion length < 20 mmProximal ambiguity ?

Proximal Ambiguity

Proximal ambiguity ?Proximal Ambiguity ?

Proximal Ambiguity ?

What about the support ?

Proximal Ambiguity ?

Proximal Ambiguity ?

Proximal Ambiguity ?

Finecross + Fielder XT

Proximal Ambiguity ?

Proximal Ambiguity ?

Distal Run-off

Distal Run-off

Proximal ambiguity

Distal ambiguitySpace for good supportGood distal Run-offTortuosity

Distal Run-off

Distal Run-off

Distal Run-off

Good candidate for Crossboss-Stingray

Distal Run-off

Distal Run-off

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

Collaterals

LAD Occlusion

Cranial for entryCaudal for Exit

Cranial for entryLao or lateral for ExitCranial view

RCA Occlusion

Caudal view

LCx Occlusion

Caudal view

Collaterals

ConclusionTake extra time during the diagnostic angiogram to obtain specific anatomic information that will guide strategy (ies) for the subsequent CTO PCI.

Study the film in detail during coronary angiography in order to check that you have all the informations needed.

Educate refering physicians