I was just going to present a case, and we'll make up some time here, since many of the prior speakers have talked about many of the concepts that are relevant to this space, too. So in the next five minutes, I'm going to talk to you about using CTO techniques in complex PCI. Here are my disclosures. So I'm not going to teach you how to do this in seven minutes or five minutes, whatever time is left. Reverse cart. That's not relevant to take care of a shock patient, especially if CTO PCI is not part of your daily practice or regular practice. My objectives are to help everyone understand the utility of using microcatheters, understand the characteristics of the wires on your cath lab shelf. And the one technique I might show you that's not necessarily commonly known is the hairpin technique. Just so I understand who we're talking to, how many people are CTO operators? Is CTO PCI part of your regular practice? So a fair number. So all of you can have more breakfast, and I'll carry on. So the case is a 58-year-old man with known CAD. He had a Lima to the LED in 2018 at an outside hospital and presented to where I work, to one of my colleagues in January of this year with exertional angina. That colleague is a nuclear cardiologist, so of course he got a PET stress test that showed the findings on the screen here. And due to those findings, he underwent a cath, which showed that his Lima to LED was patent, but his left main disease had progressed, which is why the CERC territory was ischemic. So you can see there's a complex calcified lesion in the left main. So I won't perseverate too much on that just yet. Because, and his right has a mild to moderate disease in it, but importantly, there are no significant collaterals to the CERC. So he was placed on guideline-directed medical therapy for stable ischemic heart disease, as shown on the screen here. And due to the ischemia trial, was left on that. So that was in February of this year. In July, he was admitted with recurrent polymorphic VT. Loaded with the Amio, he had more VT. Started on Amio, a lidocaine, and the electrophysiology consultant recommended revascularization. At this point, his EF was found to have decreased to 30%. His lactate was going up. We didn't place a SWAN in the cardiac ICU because of the VT, but we did place a central line in the IJ, and his CVP was 14. His FIC output was 3, and his CPO was 0.6. So the plan was revascularization of the left main and CERC. So an impeller was placed, and then we did the compulsory SWAN, confirming our human dynamics. Six French guide engaging the left main here. As you look at this plaque, you can see that the plaque is obviously eccentric, and it points upward. And wires tend to go towards the convex side. So the plaque's pointing up. The wire's going to keep going into the LED. I couldn't initially cross this with a workhorse wire, so I used a micro catheter. Initially, a whisper wire, which is a tapered wire. Then a Fielder XT, which is a tapered hydrophilic wire. That couldn't cross. And that wire, you don't want to push incredibly hard, because then you're going to go sub-internal and cause a dissection, which is often the goal when you have a CTO vessel, but not when you have a patent vessel with a hybrid stenosis that is not collateralized. Then I tried a Pilot 200, which is a stiffer wire, but not tapered, and it could not cross. So I switched to a Shion Black, which is typically a wire that we use in the CTO space, and I'll get back to that shortly. The Shion Black kept going into the LED. I could not redirect it into the CERC. So I switched the Mamba micro catheter to a Suzuki, which I'll show you in a moment. It's a dual lumen catheter, but it's slightly larger. It would not cross the lesion. So I was kind of stuck there. So this is the Shion Black. This is from the Asahi website. It's a hydrophilic wire with a floppy tip, but it's got a steel core, so it's got a little bit of body. And so micro catheters aren't something that we use routinely outside of the CTO space, but they can be useful. In the CTO space, we use them to increase wire penetration. So the shorter the distance between the wire tip and the micro catheter tip, the more force you have on the wire. What's useful in non-CTO PCI is exchanging and redirecting wires. And they're often more useful than using an over-the-wire balloon because the tip of a micro catheter is radiopaque. The tip of an over-the-wire balloon is not radiopaque. You just can tell where the balloon is sort of based on where the two dots are, but the tip of the balloon is often more distal than the most distal dot. So this is why micro catheters can be useful in this space. There are dual lumen micro catheters, which allow you to add a second wire once you've placed the initial wire. So the one I tried was a Suzuki, but the crossing profile of these dual lumen catheters is slightly larger. Most of the micro catheters that are single lumen are 2.4 French or smaller, which in this case made a difference because that Mamba micro catheter could cross, but the Suzuki couldn't. There's also the twin pass, which is slightly larger. And if you ever need a second wire in the lesion, it's not quite as tight as the one I showed you. And you don't have one of these dual lumen catheters. You can also use the old aspiration catheters like a Pronto. You can use the aspiration lumen to get a second wire down. Anyway, so what I had to do to get the wire into the CERC is use something called the hairpin technique. This is described in Manos Perlakis' textbook on CTO PCI. Basically, if your wire's going down the sidearm, in this case, the sidearm was the occluded LED, because the Shion black has a floppy tip, I was able to gently prolapse it against the cap of the LED CTO and make this hairpin shape, then pull it back, which allows the wire to prolapse into the CERC complex, and then advance the Mamba micro catheter. So the wire went down the CERC, advanced the micro catheter, and switched out the Shion black for rotowire. And then it's standard bread-and-butter PCI, used a 1-5 burr, drove to the left main into the CERC, dilated the proximal CERC lesion with a 2-5 balloon, and then 3-0 balloon, and the left main initially with a 3-0 balloon. And as my colleagues have shown, Ives showed that the appropriate size for the more distal lesion was a 3-0 stent, so I placed a 3-0 stent from the left main into the CERC, did a proximal optimization based on the Ives with a 4-0 NC at about 20 atmospheres in the left main. Ives again showed us we needed more work to do in the CERC, so dilated the proximal CERC with a 3-mm NC at high pressure, and got a result that looks like that. Then we were able to wean the impello the next 24 hours, and the patient was discharged 48 hours later. So in summary, I hope I've shown you that microcatheters can be useful for navigating complex anatomy, even when the lesion is not a CTO. Understanding the characteristics of all the wires on your cath lab shelf can lead to wiring solutions, even if CTO-PCI is not something you routinely do. And the hairpin technique is useful in standard PCI as well as CTO-PCI. And so with that, we have a few minutes left. We're happy to take questions or contact us on email or social media. Thanks. A great, great point. The problem with that case was that despite the impella, the patient was requiring escalating doses of pressors. We did not have perfect flow in the distal LAD, so the idea of potentially struggling to get back into the CERC after stenting across the CERC was, we didn't think that he could tolerate that. So we were sort of in a bond, and we had to come up with some reperfusion strategy that wouldn't take more than a couple of minutes, because he wasn't stable despite the impella placement. I think your point is an excellent one, Dr. Opp, and it goes towards making the argument that if we practice these techniques in stable patients and do them routinely, then when we have an emergency patient, it's not as much of a fire drill to do these more complex procedures. Dr. Rajan, nice case. Why did you decide to leave the impella in your case? Because it was a routine case, you know, because we always come across this decision, right, whether to leave the impella in after a routine case or not, or to wean it off, so do you use certain protocols, you always leave it in, you're worried about the anti-coagulation? Yeah, so great question. Why leave the impella in after a complex PCI? This patient actually was in shock based on the elevated lactate and cardiac power output at the time because of the recurrent VT that he'd been having. It probably caused some degree of myocardial stunning. But it's become my routine, and I think most of the operators in the PROTECT for randomized trial, which is for relatively stable patients, non-shock patients, to wean the impella based on a protocol. And so that's where the SWAN comes in, becomes particularly useful at the end of the case, checking the filling pressures and the cardiac power output, and making sure they're compatible with life without the impella or with the impella being weaned down. One of the ways that I think many of us have been fooled in the past doing protective PCI with impellas is at the end of the case, the mean arterial pressure looks okay, but sometimes the myocardium can be stunned, and the only reason that the MAP is high or in the normal range is because the SVR is 3,000, the SVR is very high. And so having the FICC cardiac output helps us figure out, is the MAP okay because the cardiac output's good, or is it because the SVR is very high and the cardiac output's actually quite low? Because in that latter situation, when the SVR is quite high in the cath lab, you take the patient back to the, you remove the impella, take the patient back to the ICU, and then a couple hours later, you get a call from the cardiac ICU nurse saying the patient's not looking so good, they're hypotensive, they're clamped down, and then you're starting all over again. We are at the hour. Thank you very much for participating in this session.

chronic total occlusion

percutaneous coronary intervention

calcified lesions

microcatheters

impella