Kỹ thuật để mở các tổn thương tắc nghẽn mạn tính mẹo để tối ưu kết quả và giảm thiểu biến chứng

VNCC 2016, Hanoi “Tips & Tricks to Open CTO” Wasan Udayachalerm, MD, FAPSIC Cardiac center King Chulalongkorn Memorial Hospital 10 Tips for CTO intervention Good preparation for CTO Guiding techniques to have good back up support Contra-lateral injection (Mandatory for accurate identification of the lesion) Using Microcatherter(s) Guide wire(s) selection & shaping Good techniques : Antegrade & retrograde Passing the lesion after the wire pass !! Others techniques prevent & prepare to solve complication(s) 10 Thinking & mentality!! Tip : The Good Preparation • Sufficient baseline angiographic images of the entire coronary artery anatomy • Deliberate planning of the primary technical approach – Anatomic considerations – Non-coronary variables • renal function • prior attempts • overall health of the patient • Biplane system if possible • Review of Cath Lab inventory - you have everything you need on the shelf and in the room? • Stopping rules - x-ray dose and contrast volume VNCC 2016, Hanoi Tip : Guiding Techniques • • • • XB for LCA and AL1/XB RCA for RCA or Fr guiding may be better Use both passive & active back up Deep seated techniques with careful manipulation • Mother & child/ guiding extension techniques • Sheathless guiding for bigger lumen (TRI) or new virtual sheath Tip : Contra-Lateral Injection Contra-Lateral Injection Case Presentation A 48 y/o woman, having atypical anginal chest pain with positive EST at low work load ( with chest pain ) Case Presentation Double injection technique Case Presentation Double injection technique Case Presentation Double injection technique Retrograde wire into antegrade guiding Kissing microcathers A 65 Y/O male with angina on Exerton After stenting After stent graft Complications During PCI for CTO Lesions • QMI (~1%) – Due to reocclusion or damage to the collateral feeding, or due to extensive dissection • Urgent CABG (rare) • Death (~0.2%) • Coronary perforation/rupture (~2%) – The incidence depends on which guidewires are used and exiting with large devices • Cardiac tamponade • Dissection of coronary arteries (esp with aggressive guides) • Slow or no reflow • Radiation dermatitis • Contrast nephropathy SIAM Technique SIAM = SImultaneous Antegrade & retrograde Microcatheter (kissing) technique Advantages of the technique  Usually success after failed regular antegrade and retrograde appoach  Less contrast used  Need only extra microcatheter and guide wire  Less injury to distal vessel by the guide wire  No major dissection before stenting  Usually in the true lumen (side branch always preserve after the procedure)  Easily changing guide wire Limitations  May be difficult to manipulate guide wire into contralateral microcatheter  In some cases, microcatheter may not be able to pass the lesion  Needs skilled operator (esp for retrograde approach) Tip 10 : Good Mentality & Thinking Conclusions • In an environment of increased scrutiny of all PCI procedures, CTO treatment will be under the microscope and compelling clinical rationales are necessary • Meticulous attention to the angiogram in planning and during the procedure is mandatory • Comfort with a variety of wire and “bailout” techniques are vital Patience Patience Patience Conclusions • • • • It’s all about decision making PCI of CTO: indication, risk benefit ratio Antegrade vs retrograde When to abandon the planned procedure? Misuse version • • • • • • • Low volume operator No special expertise No special equipment “Have a poke” Unilateral only Don’t know where you are Give up Misuse version • • • • • hour procedures All about the operator and not the patient Huge radiation doses to patient Inability to give up Risks increase late into a procedure