CTO Corner

Cross-Pollination: The Catalytic Impact of CTO Interventions

Cross-pollination is the process by which pollen is transferred from the anther, or male part, of one plant to the stigma, or female part, of another plant, thereby enabling fertilization and reproduction. The past 2 years have witnessed a revolution in chronic total occlusion PCI teaching through a proliferation of didactic and live courses, proctoring and participation in online communities. This remarkable process has fostered transfer of techniques, ideas and culture from operator to operator and from laboratory to laboratory, giving birth to new and improved ways of doing things.

Technical Tips and Tricks

The best way to learn and implement a new technique, tip or trick is by observing it being performed by another operator or, even better, by having an experienced proctor walk you through the steps. Several tips and tricks, both CTO specific and non-CTO related, have been and are being transferred, such as:

  1. Administration of nitroglycerin through the hemostatic valve using the introducer needle, obviating the need for disconnection and reconnection of the Tuohy.
  2. Routine use of 7.5 frames per second fluoroscopy for all cases, significantly reducing patient and operator radiation exposure.
  3. Use of radiation shields, such as the RadPad, and radiation protection hats (such as the “no-brainer”) in all complex interventions.
  4. Use of dual injection in any case with poor distal vessel visualization, regardless of whether it is a CTO.
  5. Use of the trapping technique for exchanging over-the-wire equipment over short guidewires.
  6. Writing the name of each guidewire on the tablecloth next to the wire for keeping the table organized (optimal table management).
  7. Use of CTO PCI techniques for bailout if a complication (such as acute vessel dissection) occurs.
  8. Appropriate and early use of advanced guide catheter support techniques such as “side branch anchor,” “distal anchor” and use of guide catheter extensions in both CTO and non-CTO interventions.
  9. Use of long (45-cm) femoral sheaths to facilitate guide manipulation, minimize the risk for guide catheter kinking and increase guide catheter support.
  10. Use of the 0.9-mm laser for “balloon-uncrossable” lesions.
  11. Effective use of snares for capturing and externalizing guidewires (in both coronary and peripheral interventions).
  12. Careful and detailed review of the angiograms to devise a detailed procedural plan.
  13. Understanding which equipment combinations can and cannot pass through a guide catheter (Figure 1).
  14. Not being afraid to proactively use large (8F) guide catheters for performing complex coronary interventions.

Cath-Lab Culture

Two Corsair catheters and a 3x20 mm Rx balloon inserted through an 8F catheter.

Figure 1. Two Corsair catheters and a 3x20 mm Rx balloon inserted through an 8F catheter.

Image: Emmanouil S. Brilakis; printed with permission.

Besides technical improvements, the CTO-initiated cross-pollination extends to cath lab culture and attitudes in multiple ways:

  • Developing skills in CTO PCI has become a source of pride and accomplishment for the entire cath team. It provides a new “challenge and opportunity” and creates an initiative for everyone to improve, from interventionalists to cath lab technicians and nurses. This can be a tremendous motivator for cath lab team members who may have been feeling stagnant, without outlets for learning and improving.
  • The comradery and support across the CTO community is unparalleled. It creates access to a highly committed and readily available group with tremendous experience and expertise in complex PCI. As a result, when you are not sure about a case or complication, being part of the CTO community enables you to call someone you trust. For instance, I recently had an epicardial collateral perforation that appeared to continue despite protamine administration, although no pericardial effusion could be seen by echo. After talking to my friend and colleague Stéphane Rinfret, MD, SM, I felt much more comfortable observing the patient rather than continuing rescue attempts. The patient did great, and so did the operator.
  • CTO PCI forces you to always think one step ahead. What is the next strategy to try if the present strategy fails? What is the best next action? Besides optimizing success and quality, CTO PCI cultivates the need for optimizing efficiency.
  • CTO PCI effectively teaches us how to handle failure constructively; failure is actually considered a “prelude to success,” as discussed in the CTO Corner column from January/February 2014.
  • No one knows everything and everyone can teach you something.
  • Big egos can get in the way of growth and success.

Conclusion

by Emmanouil S. Brilakis, MD, PhD

Emmanouil S.
Brilakis

The explosion of CTO-related education has brought the interventional community closer and has enhanced learning opportunities for everyone — with both patients and providers benefiting.

Of course, all of the above presuppose a willingness to try new ways of planning and performing cardiac catheterization, a humble and receptive approach, and openness in conjunction with critical thinking. Not everyone may be ready for cross-pollination, but those who are stand to derive magnificent benefits.

References:
Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. Elsevier; 2013.
Mahmood A. J Invasive Cardiol. 2011;23:291-294.
Martinez-Rumayor AA. J Am Coll Cardiol Intv. 2012;5:e31-32.
Patel VG. J Invasive Cardiol. 2013;25:483-484.
Emmanouil S. Brilakis, MD, PhD, is the director of the cardiac catheterization laboratory at the VA North Texas Health Care System, Dallas, and is associate professor of medicine at the University of Texas Southwestern Medical Center, Dallas. He is the author of the Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach, and is a Cardiology Today’s Intervention Editorial Board member. He can be reached at Dallas VA Medical Center (111A), 4500 S. Lancaster Road, Dallas, TX 75216; email: esbrilakis@gmail.com.
Disclosures: Brilakis reports receiving speaker honoraria/consulting fees from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Janssen Pharmaceuticals, Sanofi Aventis, St. Jude Medical and Terumo; research support from Guerbet; and his spouse is an employee of Medtronic.

Cross-pollination is the process by which pollen is transferred from the anther, or male part, of one plant to the stigma, or female part, of another plant, thereby enabling fertilization and reproduction. The past 2 years have witnessed a revolution in chronic total occlusion PCI teaching through a proliferation of didactic and live courses, proctoring and participation in online communities. This remarkable process has fostered transfer of techniques, ideas and culture from operator to operator and from laboratory to laboratory, giving birth to new and improved ways of doing things.

Technical Tips and Tricks

The best way to learn and implement a new technique, tip or trick is by observing it being performed by another operator or, even better, by having an experienced proctor walk you through the steps. Several tips and tricks, both CTO specific and non-CTO related, have been and are being transferred, such as:

  1. Administration of nitroglycerin through the hemostatic valve using the introducer needle, obviating the need for disconnection and reconnection of the Tuohy.
  2. Routine use of 7.5 frames per second fluoroscopy for all cases, significantly reducing patient and operator radiation exposure.
  3. Use of radiation shields, such as the RadPad, and radiation protection hats (such as the “no-brainer”) in all complex interventions.
  4. Use of dual injection in any case with poor distal vessel visualization, regardless of whether it is a CTO.
  5. Use of the trapping technique for exchanging over-the-wire equipment over short guidewires.
  6. Writing the name of each guidewire on the tablecloth next to the wire for keeping the table organized (optimal table management).
  7. Use of CTO PCI techniques for bailout if a complication (such as acute vessel dissection) occurs.
  8. Appropriate and early use of advanced guide catheter support techniques such as “side branch anchor,” “distal anchor” and use of guide catheter extensions in both CTO and non-CTO interventions.
  9. Use of long (45-cm) femoral sheaths to facilitate guide manipulation, minimize the risk for guide catheter kinking and increase guide catheter support.
  10. Use of the 0.9-mm laser for “balloon-uncrossable” lesions.
  11. Effective use of snares for capturing and externalizing guidewires (in both coronary and peripheral interventions).
  12. Careful and detailed review of the angiograms to devise a detailed procedural plan.
  13. Understanding which equipment combinations can and cannot pass through a guide catheter (Figure 1).
  14. Not being afraid to proactively use large (8F) guide catheters for performing complex coronary interventions.

Cath-Lab Culture

Two Corsair catheters and a 3x20 mm Rx balloon inserted through an 8F catheter.

Figure 1. Two Corsair catheters and a 3x20 mm Rx balloon inserted through an 8F catheter.

Image: Emmanouil S. Brilakis; printed with permission.

Besides technical improvements, the CTO-initiated cross-pollination extends to cath lab culture and attitudes in multiple ways:

  • Developing skills in CTO PCI has become a source of pride and accomplishment for the entire cath team. It provides a new “challenge and opportunity” and creates an initiative for everyone to improve, from interventionalists to cath lab technicians and nurses. This can be a tremendous motivator for cath lab team members who may have been feeling stagnant, without outlets for learning and improving.
  • The comradery and support across the CTO community is unparalleled. It creates access to a highly committed and readily available group with tremendous experience and expertise in complex PCI. As a result, when you are not sure about a case or complication, being part of the CTO community enables you to call someone you trust. For instance, I recently had an epicardial collateral perforation that appeared to continue despite protamine administration, although no pericardial effusion could be seen by echo. After talking to my friend and colleague Stéphane Rinfret, MD, SM, I felt much more comfortable observing the patient rather than continuing rescue attempts. The patient did great, and so did the operator.
  • CTO PCI forces you to always think one step ahead. What is the next strategy to try if the present strategy fails? What is the best next action? Besides optimizing success and quality, CTO PCI cultivates the need for optimizing efficiency.
  • CTO PCI effectively teaches us how to handle failure constructively; failure is actually considered a “prelude to success,” as discussed in the CTO Corner column from January/February 2014.
  • No one knows everything and everyone can teach you something.
  • Big egos can get in the way of growth and success.

Conclusion

by Emmanouil S. Brilakis, MD, PhD

Emmanouil S.
Brilakis

The explosion of CTO-related education has brought the interventional community closer and has enhanced learning opportunities for everyone — with both patients and providers benefiting.

Of course, all of the above presuppose a willingness to try new ways of planning and performing cardiac catheterization, a humble and receptive approach, and openness in conjunction with critical thinking. Not everyone may be ready for cross-pollination, but those who are stand to derive magnificent benefits.

References:
Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. Elsevier; 2013.
Mahmood A. J Invasive Cardiol. 2011;23:291-294.
Martinez-Rumayor AA. J Am Coll Cardiol Intv. 2012;5:e31-32.
Patel VG. J Invasive Cardiol. 2013;25:483-484.
Emmanouil S. Brilakis, MD, PhD, is the director of the cardiac catheterization laboratory at the VA North Texas Health Care System, Dallas, and is associate professor of medicine at the University of Texas Southwestern Medical Center, Dallas. He is the author of the Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach, and is a Cardiology Today’s Intervention Editorial Board member. He can be reached at Dallas VA Medical Center (111A), 4500 S. Lancaster Road, Dallas, TX 75216; email: esbrilakis@gmail.com.
Disclosures: Brilakis reports receiving speaker honoraria/consulting fees from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Janssen Pharmaceuticals, Sanofi Aventis, St. Jude Medical and Terumo; research support from Guerbet; and his spouse is an employee of Medtronic.