RETROGRADE APPROACHSEPTAL COLLATERAL CHANNELSPaul Hsien-Li Kao, MD

Associate Professor

National Taiwan University Hospital

Paul K

ao C

CT

2013

CCT2013COI Disclosure Paul Hsien-Li Kao

The authors have no financial conflicts of interest to disclose concerning the presentation.

Septals in retrograde PCI

Connects LAD and RCA(PDA)

Most frequently used in retrograde PCI for CTO’s of LAD or RCA

In theory, more straight forward course than epicardial channels

Variable channel size/diameter

Can be very tortuous too

Paul K

ao C

CT

2013

Devices used to track septals

Microcatheter Corsair Finecross Sortana, etc

Guidewire Sion Sion Blue, Suoh, XTR, etc

OTW BC

Paul K

ao C

CT

2013

Viewing the septal course

Take-off from LAD RAO cranial

Take-off from PDA RAO caudal

Septal track RAO

Tip injection from micro-catheter to isolate the track is important to isolate the desired track

Paul K

ao C

CT

2013

Cranial vs. caudal

Paul K

ao C

CT

2013

Tip injection for details

Paul K

ao C

CT

2013

RCA CTO via septal from LAD

Paul K

ao C

CT

2013

Tip injection isolating track

Paul K

ao C

CT

2013

Tracking with Sion

Paul K

ao C

CT

2013

LAD CTO via septal from RCA

Paul K

ao C

CT

2013

Unusual conditions

Ipsi-lateral connection for m-LAD CTO p-LAD septal d-LAD

Ipsi-lateral connection for m-RCA CTO p-RCA conus branch septal PDA

Part of collateral loop involving other epicardial channel, connecting not only between LAD and RCA

Paul K

ao C

CT

2013

Ipsi. septal for LAD CTO

Paul K

ao C

CT

2013

Sion and Corsair

Paul K

ao C

CT

2013

Reverse CART and final

Paul K

ao C

CT

2013

Ipsi. septal for RCA CTO

Paul K

ao C

CT

2013

Ipsi. septal for RCA CTO

Paul K

ao C

CT

2013

Sion in Corsair, exchanged to M6

Paul K

ao C

CT

2013

Retro wiring and reverse CART

Paul K

ao C

CT

2013

Rendezvous in proximal RCA

Paul K

ao C

CT

2013

Tip shaping of Sion

Paul K

ao C

CT

2013

Short tip fracture/bend

Paul K

ao C

CT

2013

Which septal to choose?

Multiple septal connections may be present, can we select one logically or just by chance?

AA and LEP Rhythm issues Total loop length Cardiac cycle motion

“Septal surfing”

Paul K

ao C

CT

2013

Attack angle (AA) & length from emerge point (LEP)

Paul K

ao C

CT

2013

large AA

small AA

short LEP

long LEP

Distal is the better one in this case

Paul K

ao C

CT

2013

Consequence of rupture

Hematoma – mostly benign, but may develop into abscess/VSD

AV fistula - benign

Dry tamponade/acute HOCM – extremely fatal!

Paul K

ao C

CT

2013

LAD CTO using septal

Paul K

ao C

CT

2013

Corsair jump causing hematoma

Paul K

ao C

CT

2013

RCA CTO using septal

Paul K

ao C

CT

2013

Fistula into middle cardiac vein

Paul K

ao C

CT

2013

What is dry tamponade?

Rare, but has been reported as a consequence of dissecting septal hematoma after surgical VSD repair

Septum bulging into ventricles reducing the end-diastolic volume, with hemodynamic effects similar to pericardial tamponade

If positioned at LVOT level, will also create HOCM-like hemodymanics

High mortality (~90%) if managed conservatively Surgical evacuation and un-roofing Hemostasis is not effective!!

Vargus-Barron J, et al.Echocardiography 2009; 26:254

Paul K

ao C

CT

2013

CART via septal for RCA CTO

Paul K

ao C

CT

2013

OMG! fortunately, lucky patient!!

Paul K

ao C

CT

2013

Conclusions

With current devices and treatment strategies, CTO PCI produces acceptable and consistent results

The choice of collaterals should be liberal, and pre-PCI planning is important

Septals are useful and important, but as delicate and dangerous as other collaterals

We still need improved wire design for better and safer tracking

Paul K

ao C

CT

2013

Thank You For the Attention

Paul K

ao C

CT

2013

Personal breakdown

300 consecutive unselected CTO attempts from 2012-Jan to 2013-Sep

10 failures, without emergent surgery nor mortality Success rate 96.7%

155 retrograde (51.7% of all CTO procedures) with 96.1% success

72 using septal, 46.5% of all retrograde cases, with 98.6% success

Paul K

ao C

CT

2013