Retrograde Cases with serious complications: Benign course, complicated course and fatal

Meruzhan Saghatelyan, MD

Head of Angiography Department, Erebouni Medical Center

Nork Marash Medical Center, Yerevan, Armenia

Georgios Sianos, CTO Summit 2015

EuroIntervention 2013;9:102-116Contemporary retrograde approach for the recanalisation of coronary chronic total occlusion: on behalf of the Japanese Retrograde Summit Group

Case 154 years old man with unstable angina

CABG procedure 6 years ago

LIMA to LAD, SVG to OM, SVG to PDA

Present Angiographic Data:

High grade stenosis of SVG – OM proximal part and at the distal anastomosis

Very long CTO of dominant RCA starting from proximal part and ending at distal bifurcation, diffuse long lesion of the big PL branch after the bifurcation: SVG functioning only for PDA

RCA CTO starting from proximal part CTO ending at the distal bifurcation, diffuse subtotal lesion of postero-lateral artery

Atrial channel to PL artery

CC tracking with SION Tip injection from Corsair

Puncture of distal cap with Conquest Pro

Retro wire passage and antegrade preparation Antegrade puncture with Conquest Pro

Allignment of bilateral gears for reverse CART procedure Corsair was stuck and impossible to control further retro wire

Perforation of proximal RCA Atrial channel rupture due to Corsair manipulation

4 days later

Retrograde procedure using SVG Retrograde knuckle wiring with Pilot 50 and OTW balloon

Reverse CART and externalization

Wiring of PL artery

Final result after stenting with 4 DES

Take home message

In long CTO lesions with unknown vessel course manipulation of penetrating stiff wire can automatically cause perforation

Rotational movement of Corsair can damage angulated epicardial channel, it might be better to use other type microcatheter in such channels

Coronary perforation and/or collateral channel rupture in a patient with a previous open heart surgery is benign in general and does not result in cardiac tamponade.

Anyway, local accumulation of blood is possible with a compression of specific heart chamber such as left or right atrium, right ventricle, but it is of a rare incidence.

Case 258 years old man with stable angina and dyspnea

Ex-smoker

Hypertension

Hyperlipidemia

Angiographic findings:

Flush occlusion of proximal RCA and a separate short calcified CTO of distal RCA ending just at the distal bifurcation; retrograde filling of the distal vessel by septal collaterals

Short CTO lesion of mid LCX

Antegrade GAIA II Tip injection in septal channel

Passage of SION into distal RCA Tip injection from Corsair

Distal cap puncture with Conquest Pro Subintimal course of retrograde Conquest Pro

Rewiring with Fielder FC

Reverse CART

Externalization and antegradewire passage into distal branches

Antegrade injection after predilatation Contrast is visible in pericardial space

Still some extravasation after stenting

Final result after prolonged balloon inflation with low pressure

2 hours later hypotension occurred with pallor and tachycardia

Same amount of pericardial effusion without signs of tamponade

Impairment of free RV wall motion

Pericardial tap with removal of about 100 ml of blood

No leakage form RCA on control angiogram

Delayed recovery during a week of hospital stay

Take home messageTo penetrate the distal cap at the distal bifurcation often very stiff wire is needed from retrograde side.

Advancement of the stiff retrograde wire through diffuse plaque can easily cause perforation that will become bigger with following advancement of the Corsair.

After successful penetration it is better to do step down for further tracking before advancement of the retrograde microcatheter.

Free RV wall motion impairment could be explained by possible extensive subintimal/intramural hematoma

Case 377 years old man presented with recurrent pulmonary edema

Moderate elevation of cardiac markers suggested a diagnosis of ACS

LAFB on ECG

Moderate –to severe LV systolic dysfunction with inferior and posterolateral hypokinesis

History of stroke 6 months ago

Total occlusion of the right and high grade stenosis of the left ICA by Dupplexscanning

Coronary angiographyDistal LM stenosis of 70 – 80%

Diffuse and calcified disease of mid – to – distal LAD with two steep angulations in its course

Diffusely diseased small circumflex artery

Heavily calcified mid RCA CTO with diffuse disease of distal vessel, filling of the distal RCA from septal and atrial epicardial channels

High take-off of both radial arteries with reverse angle loop join with axillary

Tortuous calcified deformation and extreme kinking of both iliac arteries and abdominal aorta

Planning the revascularization

The patient was considered inacceptable for open surgery

Anyway, he remained of very high risk also for PCI

PCI strategy:

Antegrade recanalization of RCA

Distal LM PCI probably with one stent strategy

Antegrade procedure using bifemoral approach GAIA II

Conquest Pro subintimal passage Unsuccessful parallel wiring

LM PCI procedure after septal channel wiring

DES in LM to proximal LAD

Result after LM stenting Corsair tip injection in distal RCA

Retrograde tracking with GAIA II Preparing for reverse CART, however…

Sudden onset of hemodynamic collapse.

Fast check of the left system showed abrupt occlusion of LAD just after take-off of the septal /not recorded/, although ACT had been kept about 350.

Ventricular fibrillation, cardiac arrest and unsuccessful CPR

No way to pass the wire into mid LAD

Gave up after prolonged resuscitation efforts

Calcified plaque and the loop of LAD did not allow distal wiring in the setting of acute injury and occlusion

Take home messagePlanning revascularization procedure in very high risk patient should be kept under the rule “as simple as possible”.

If both LM PCI and RCA CTO PCI procedures are planned in a clinically unstable high risk patient, it might be better to postpone RCA CTO PCI to a time when the patient had shown stability for a considerable period.

If distal artery access is complicated in donor vessel system and the artery has diffuse calcified disease it is better not to use collateral channels from that artery for retrograde procedure unless the operator can secure that artery for sure.

Corsair manipulation in diffusely diseased calcified vessel can cause donor vessel injury and occlusion even with ACT level above 350.

Thank you