Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Complication Case

EuroCTO Club Meeting 2016

11.1

0.2

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Mark Rosenberg

University Medical Center Schleswig-Holstein

Campus Kiel, Germany

Dept. Cardiology, Angiology and Intensive Care Medicine

mark.rosenberg@uksh.de

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

55 y/o gentleman

Stable Angina, CCS 3

Risk Factors: Hypertension, Dyslipidemia, Smoker

Non-invasive Tests:

Bicycle ergometer: ST-Segment depression II, III and aVF

Echocardiography: Normal left ventricular function

Coronary Angiography

Case Presentation

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Coronary Angiography

LCARCA

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

• Coronary 2 Vessel Disease

– LAD stenosis in segment 7

– RCA occlusion in segment 2

• J-CTO Score 2 (blunt stump, occlusion length)

(Poor image quality)

• Interventional Plan

– Simultaneous contrast injection for clear visualization of the

CTO pathology

– Antegrade approach first with low threshold for switch to a

retrograde technique

Interpretation Coronary Angiography

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Coronary Angiography

Interventional setting:

Access: Bilateral femoral approach

Guiding Catheter: 90cm 7F AL 1.0 for RCA; 90 cm 7F EBU 4.0 for LCA

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

(1)Stop and referral to surgery

(2)Stop and retry in 6-8 weeks

(3)Try antegrade

(4)Try retrograde

(5)Stop and treat medically

What next ?????????

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Interventional Collaterals

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Successful Collateral Passage

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Successful Recanalization RCA/RIVP

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

(1)Stop and treat medically

(2)Stop and retry RPLA in 6-8 weeks

(3)Immediately try to reconstruct RPLA

What next ?????????

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Successful Rewiring of the RPLA

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Successful Reconstruction of the RPLA

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Final Result

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

6 Months Follow Up

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Always be careful with your guiding catheters

In case of a spiral dissection go retrograde

Avoid any contrast injection antegradely

Try to get the job done in one session

If necessary, it is also a good option to bring the patient back

to the cath lab after 6-8 weeks and retry the procedure

What have I learned from this case!

How will the vessel wall recover? Risk of negative

vessel remodelling with aneurysm formation?

How long should we keep the patient on DAPT?

Innere Medizin III, Campus Kiel

Schwerpunkt Kardiologie und Angiologie

Always be careful with your guiding catheters

In case of a spiral dissection go retrograde

Avoid any contrast injection antegradely

Try to get the job done in one session

If necessary, it is also a good option to bring the patient back

to the cath lab after 6-8 weeks and retry the procedure

What have I learned from this case!

How will the vessel wall recover? Risk of negative

vessel remodelling with aneurysm formation?

How long should we keep the patient on DAPT?