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Retrograde Approach Septal Collateral Channels

Retrograde Approach Septal Collateral Channels. Paul Hsien -Li Kao, MD Associate Professor National Taiwan University Hospital. Paul Kao CCT. 2013. CCT2013 COI Disclosure Paul Hsien-Li Kao. The authors have no fi nancial conflicts of interest to disclose concerning the presentation.

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Retrograde Approach Septal Collateral Channels

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  1. Retrograde ApproachSeptal Collateral Channels Paul Hsien-Li Kao, MD Associate Professor National Taiwan University Hospital Paul Kao CCT 2013

  2. CCT2013COI DisclosurePaul Hsien-Li Kao The authors have no financial conflicts of interest to disclose concerningthe 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) short LEP long LEP large AA small AA Paul Kao CCT 2013

  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!! Paul Kao CCT 2013 Vargus-Barron J, et al.Echocardiography 2009; 26:254

  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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