Transcription
Uh, hello. Welcome all uh to the session three of the anti-r C2 Academy. In this lecture, I would be summarizing about the various techniques and the various wires that were used uh that I discussed in the uh last two sessions about the various technique and characteristic about the various wires.
So this is how uh we should approach our uh this CTO cases. We should take the bilateral injections and we should carefully analyze the proximal stump of the CTO. And this is how the anr wire escalation should go from the proximal CTO cap to the uh this CTO body and should go into the uh distal uh Lumen. So these are the three various ties: trainging, penetration, and sliding. Sliding should be the first thing that should be tried. We should look for the the micr channels and depending upon the CTO body we can escalate or deescalate the wire. If the CTO body is hard then we can go with the escalation of the wire with the high 23. And if it is having a calcium and we need to penetration then of course the quas pro wires can be escalated. And if once uh we are through the distal cap into the trium we can deescalate the wire to complete the procedure.
The most important thing needs discussion is the JCT score. In this JCT score we can see if the end is tapered and uh if it is blunt then we are going to differentiate into uh like two thingss: that if it is uh tapered then entry with any taper tap or dimple indicates the direction of the true Lum and it is categorize a taper. So tapered is a good sign and it a bit easier as compared to the blunt because blunt will have a lesser success because we don't get a chance we don't get a place where the tip of the wire to be negotiated or where we can escalate The Wire. So for blunt we give a score of one. For calcium regardless of severity one point is a signed. If there is any evidence of calcium in the cdio segment and we give a score presence will give a score of one. And if there is a Bend present between the proximal cdio segment and the distal vessel more than 45 degree then of course it is again a difficult one and it its presence of Bend more than 45 gives a score of one. If the occlusion length is more than 20 mm then of course it is a tougher and a score of one is given. And if it is a retry or second attempt after the first fail attempt then again it will again qualify uh in a score of fun. And depending upon the score we can see the jc2 with zero are usually having a success rate of more than 95%. And if the score is more than three than three or above then this a very difficult CD and the score in between are considered intermediate to difficult.
Coming on to the case one we can see uh this is uh of a patient who uh has this this angina for two to three years and uh uh in March 2021 it CTU was shown in this both LED and RCA and RC was filling retrogradely from the sapal collaterals. So it was a double CTO situation but in LED we can see there is a bit of a stum we can see appreciate in the AR cordal View. And in this routine sliding method was used. We took a routine uh Workhorse uh this uh routine wire for the sliding technique uh that is Fielder XTR was taken over the micro catheter fine cross micro catheter was taken and over this we took a Fielder XT wire and it considering it to be a tap tip hydrophilic polymer jacked wire it went through the micr channels and after this the wire was de-escalated to the routine run through wire and the routine PCI was done and this was the good result obtained. So just we can see with the uh recapitulating our knowledge that the first approach we see if a taper tip wire uh this polymer jacketed wire can be taken to open the CTU with the sliding technique because many times it will just Coss a micr channel and we can deescalate the wire and complete the procedure. So this was the out of DPS drilling penetration sliding that was the case that was done with the sliding technique.
Now comes the second case. This particular 60-year-old gentleman had an inal MI for that a primary PCI was done. At that time it was seen that the patient had a CTO of the LED. So this was RC that was open and we can see from this uh LED CTU segment is seen. So next time when we took uh this RC was open at the time of primary PC and now we have got a good collateral filling the LED with grade 2 CC collateral and good vessel distal vessel can be seen. So analyzing the CD segment is most important. We could see there is a taper tip there is no calcification no pens occlusion length is around 20 mm. So we are dealing with the DCd score of around one. So uh first thing that we did just took a micro cetor fine cross and over this fill XD wire was tried to negotiate across if there are any micr channels. So that is the first step we often do. Out of DPS s was done but we could see it was not going to the proximal capab a bit of calcium can be seen in the El qued View. Then we thought we as we can see the T tip is buckling and it is not going it's not making any Hardway inside that means we need to take a uh we need to escalate the wire and this is how we took a Gaia one followed by the Gaia 2 and with the help of the micro catheter support and we could see this Gia wire is making some way ahead guia 2 and with the help of retrograde injection that should always be done we should uh see the wire in various views whether it's going into the distal Trin or not uh so in this particular case the wire got into the distal T Lumin and that was confirmed by the retrograde injection and after that after taking the guia two wire micro CER was crossed through the cdio segment and after that the routine Workhorse run through wire was taken. That means uh downgrading or down escalation of the wire should always be done because these wire are having high tip load and the tip can be injurious to the distal vessel and any distal wire perforation is very dangerous and unpredictable course and it very difficult to manage. So we have to be very very cautious and very meticulous in taking out the hard wires which have a higher tip load which uh have a longer uh this radio lens because the vessel architecture cannot be seen uh in a good manner. So it is a very good practice to take out this type of wire and down escalate and complete the procedure over work cost wire like run through or sh blue. So this was after putting a death this was the end result and we could see a good timy thr flow was achieved.
So many times what to do if the CTO is having a breaching cor. So this was a CTO of RCA we can see and it was again as a part of the strategy of a sliding Technique we took a Fielder XTR wire but this XTR despite having a tip load of 6 and this tapering it it could not go into the tree Lumen and we can say probably it is going into the some small bridging collateral. So at this moment the best strategy is to take a wire with a high tip load like Gaia 2 or Gaia three. So U this is what was done in this keeping that wire in that place we took a Gaia 3 wire and we can see uh this was going into the distal to lumen and this is how uh this such cases we can escalate the tip load High tip load wires and this make uh its way made its way into the distal RCA and after this we can see in various views it was in dist Lumen and over this uh we just downgraded the wire did the ballooning and after that uh this desk was implanted and we could see a good result in the RCA.
So just uh starting from the sliding techn we went to the drilling technique with the higher tip load wire and coming on to the uh this case uh of a stenina in which the conquest Pro wire helped. So this is a particular case of LED osal CTU we could see there is a stump and we tried first with as usual by sliding where the FI XTR wire but it was not making a Headway because there was a lot of calcium we can appreciate in the alal view. So it's a calcified CTU and as usual we took the RCA and the right coronary collateral shows the uh this distal course of the vessel. It was a longer C with a lot of calcium and we can see the wire the tip of the wire is buckling back and uh this guide is coming back though there is no adequate support there is lot of calcium and this this tip load of 6 G will not help. So in this particular setting we need to we can see it's a short segment and we can make use of the highlo wire. So in this particular case we took the help of the conest pro wire and with the help of the contralateral injection from the RCA we confirm the position of this wire whether it was in Lumen or not into orthogonal views and it was in Lumen. It was predilated with very small balloons and after that uh we just completed we downgraded this and we completed the procedure.
So in this presentation we discussed all three technique of drilling penetration and sliding and in the next session I would be discussing uh about the micro catheters. So uh thank you all for patient listening and we'll be meeting in the next session. Thank you.