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RETROGRADE APPROACH SEPTAL COLLATERAL CHANNELS Paul Hsien-Li Kao, MD Associate Professor National Taiwan University Hospital Paul Kao CCT 2013.

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Presentation on theme: "RETROGRADE APPROACH SEPTAL COLLATERAL CHANNELS Paul Hsien-Li Kao, MD Associate Professor National Taiwan University Hospital Paul Kao CCT 2013."— Presentation transcript:

1 RETROGRADE APPROACH SEPTAL COLLATERAL CHANNELS Paul Hsien-Li Kao, MD Associate Professor National Taiwan University Hospital Paul Kao CCT 2013

2 CCT2013 COI Disclosure Paul Hsien-Li Kao The authors have no financial conflicts of interest to disclose concerning the presentation.

3 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 Kao CCT 2013

4 Devices used to track septals  Microcatheter  Corsair  Finecross  Sortana, etc  Guidewire  Sion  Sion Blue, Suoh, XTR, etc  OTW BC Paul Kao CCT 2013

5 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 Kao CCT 2013

6 Cranial vs. caudal Paul Kao CCT 2013

7 Tip injection for details Paul Kao CCT 2013

8 RCA CTO via septal from LAD Paul Kao CCT 2013

9 Tip injection isolating track Paul Kao CCT 2013

10 Tracking with Sion Paul Kao CCT 2013

11 LAD CTO via septal from RCA Paul Kao CCT 2013

12 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 Kao CCT 2013

13 Ipsi. septal for LAD CTO Paul Kao CCT 2013

14 Sion and Corsair Paul Kao CCT 2013

15 Reverse CART and final Paul Kao CCT 2013

16 Ipsi. septal for RCA CTO Paul Kao CCT 2013

17 Ipsi. septal for RCA CTO Paul Kao CCT 2013

18 Sion in Corsair, exchanged to M6 Paul Kao CCT 2013

19 Retro wiring and reverse CART Paul Kao CCT 2013

20 Rendezvous in proximal RCA Paul Kao CCT 2013

21 Tip shaping of Sion Paul Kao CCT 2013

22 Short tip fracture/bend Paul Kao CCT 2013

23 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 Kao CCT 2013

24 Attack angle (AA) & length from emerge point (LEP) Paul Kao CCT 2013 large AA small AA short LEP long LEP

25 Distal is the better one in this case Paul Kao CCT 2013

26 Consequence of rupture  Hematoma – mostly benign, but may develop into abscess/VSD  AV fistula - benign  Dry tamponade/acute HOCM – extremely fatal! Paul Kao CCT 2013

27 LAD CTO using septal Paul Kao CCT 2013

28 Corsair jump causing hematoma Paul Kao CCT 2013

29 RCA CTO using septal Paul Kao CCT 2013

30 Fistula into middle cardiac vein Paul Kao CCT 2013

31 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 Kao CCT 2013

32 CART via septal for RCA CTO Paul Kao CCT 2013

33 OMG! fortunately, lucky patient!! Paul Kao CCT 2013

34 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 Kao CCT 2013

35 Thank You For the Attention Paul Kao CCT 2013

36 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 Kao CCT 2013

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