Lots of interesting abstracts and cases were submitted for TCTAP 2022. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

TCTAP C-085

Primary V-A ECMO-Supported Retrograde CTO PCI via the Large, Last-Remaining and Indispensable Collateral

By Wei-Jhong Chen

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Presenter

Wei-Jhong Chen

Authors

Wei-Jhong Chen¹

Affiliation

Taichung Veterans General Hospital, Taiwan¹,

View Study Report

TCTAP C-085

CORONARY - Complex and Higher Risk Procedures for Indicated Patients (CHIP)

Primary V-A ECMO-Supported Retrograde CTO PCI via the Large, Last-Remaining and Indispensable Collateral

Wei-Jhong Chen¹

Taichung Veterans General Hospital, Taiwan¹,

Clinical Information

Patient initials or Identifier Number

Yang

Relevant Clinical History and Physical Exam

Sex:male

Age:66years old

Past history: Hypertension,for more than 10 years

Chief complaint:

Abruptonset of chest piercing pain with cold sweating in 2020/06

CAD, TVD, found at other hospital; CABGsuggested

Relevant Test Results Prior to Catheterization

Hemoglobin: 13.4 gm/dlPlatelet: 166X 10³/uLCrea: 1.14 mg/dlALT: 46 U/LPT(INR): 10.4(1.0)aPTT: 26.4 secCXR and ECG as uploaded image

Relevant Catheterization Findings

CAG finding:Bil. CAG : right dominant.LAD: severe AS changesLAD-M: segmental CTOLCX: mild AS changes, no significantlesion RCA : long dominant vessel, diffuse severeAS changesRCA-P; 90% stenosesRCA-M: segmental CTO with microchannelsRCA-PL: long CTO

Diagnostic angiogram-RCA.wmv

Diagnostic angiography-LCA-1.wmv

Diagnostic angiography-LCA-2.wmv

Interventional Management

Procedural Step

PCI on 2020/07/081. PCIfor RCA is to be done in this session followed by LAD CTO PCI in staged manner.-DES for RCA-PL and RCA-M CTO lesions-DES for RCA-os-P stenosis PCI on 2020/08/121. PCI for LAD-M wasapproached with XB 3.5x6F guide. 2. The distal CTO cap failed to be crossed with Conqquest Pro 9, 12or Conquest Pro 820. 3. Retrograde attempt then followed. The collaterals from PDA brancheswere tiny and difficult to be identified. 4. Due to prolonged procedureand radiation doses, further attempt was abandoned. Nextattempt will better support guide and probably ADR. Retrograde PCI via thefirst diagonal artery should be done under mechanical circulatory support dueto high risk of accordion effect and hemodynamic compromise. We finally choseretrograde PCI via first diagonal artery under primary VA-ECMO support. PCIon 2020/10/281. The ECMOV and A cannulation were done via right femoral vein and left femoral artery.2. The LAD CTO was approached with XB3.5x6F guidevia right femoral access.3. The diagonal collateral could be crossed by a Fielder XT-Rsupported by APT microcatheter.3. Tipinjection confirmed wire in LAD-D proper due to no flow to LAD-D.4. Antegrade wiring to septal branch wasdone by a Sion Blue through a second XB 3.5x6 F guide via right radial access.5. The retro UB crossed the lesion andentered the antegrade guide after reverse CART. Externalization was done by aRG3.6. The LAD-far distal to LAD-D and LAD-M-Dwere scaffolded 2 DES.

ECMO deploy.wmv

Third PCI-1.wmv

Third PCI-2.wmv

Case Summary

Patience and trust on both physicianand patient sides play important role in forging revascularization strategy.

Treatment planning tailored to asingle patient is an important key to successful CTO PCI.

Occluding a large last-remining andindispensable collaterals could result in severe hemodynamic compromise and chest pain during retrograde PCI and precludes further attempt.

ECMO, particularly primary, is an integral part of CHIP intervention and provides good temporary hemodynamic support, allowing retrograde PCI to continue in these cases.

Case

TCTAP C-085