CTO Corner

Time Management in CTO PCI

“Time management is the process of planning and exercising conscious control of time spent on specific activities, especially to increase effectiveness, efficiency or productivity,” according to Wikipedia. The key concept is that time is finite, hence using it in the best possible way can lead to the best outcomes.

Chronic total occlusion intervention can be challenging to perform and may take a long time. Not completing the procedure within 1 to 2 hours is a common cause of failure — due to reaching the radiation or contrast limit, patient and/or staff fatigue, or a complication — hence, time management techniques are of particular importance for CTO PCI.

Planning vs. Doing

Emmanouil S. Brilakis

Planning is deciding where we want to go, evaluating different routes to get there and selecting one of those routes to follow. Planning is key to success, since “failing to plan is planning to fail.” At the same time, only planning without doing will not get things accomplished. Achieving balance between planning and doing is at the core of time management, both in general and during CTO PCI and can be broken down into two key components:

  • creating an environment conducive to effectiveness; and
  • setting priorities and carrying out activities around prioritization.

Creating an Environment Conducive to Effectiveness

An ineffective and cluttered environment leads to wasting of time. This is true for day-to-day activities — for example, having a cluttered desk makes it hard to find things and creates mental fatigue — and for CTO interventions. The environment includes the cath table, the equipment, the staff and the interventionalist.

No. 1, Having a well-organized and clean procedure table is key. Some labs are using two tables to increase the available space, which is similar to using two screens when working on a computer. Several guidewires are often needed during CTO PCI, and having them neatly organized makes it easier to keep track of what is available and to use it again if needed, without opening new equipment. This can be achieved in various ways, for example by keeping the original hoop of the guidewire and writing on a label or on the sterile drape the name of the wire.

No. 2, Bringing new equipment to the table can waste time if it is not immediately available within the catheterization room. For example, if it takes 3 minutes for the techs to locate and bring in a guidewire into the room, about 30 minutes will be lost if 10 guidewires are required in a case. This is where the “CTO cart” is crucial. The CTO cart is stocked with the guidewires and other equipment likely to be used during CTO PCI, organized in an intuitive way. In our lab the top shelf has short guidewires, the second shelf has exchange-length guidewires, the third self has microcatheters and guide catheter extensions and the fourth shelf has coils and covered stents. Having the CTO cart inside the procedure room saves significant time when additional equipment is needed, improving the chances of being successful and minimizing the fatigue of the staff. However, the CTO cart should be well-stocked and checked after every case to replace the equipment utilized, otherwise it could become a source of frustration in itself.

No. 3, Training the cath lab personnel on the different equipment and techniques improves communication, minimizes errors and, hence, improves time efficiency. Well-trained staff members know the nuances and the names of the different equipment. For example, they know the difference between a Fielder XT and a Fielder XT-A guidewire (Asahi Intecc) and understand that the Suoh 03 wire (Asahi Intecc) has the softest tip of any guidewire and is mainly used for crossing collaterals during the retrograde attempt. They can often recommend alternative equipment, for example “a Trapliner (Teleflex) might work better during antegrade dissection and re-entry 6F guide catheter, as it allows trapping of the various microcatheters and other equipment used.” Insertion of a 4F venous sheath allows delegation of activated clotting time checking to the cath lab nurse, obviating operator interruptions.

No. 4, Continuous training of the interventionalist makes him or her more effective, efficient and safe. Having extra low radiation dose settings specific for CTO PCI minimizes patient and operator radiation dose, reducing potential adverse effects, but also contributing to the success of the case, as it makes it less likely for high radiation doses to be reached, requiring stopping the procedure. Continual learning and practice improve the efficiency of applying various techniques and being successful in their application.

Setting Priorities and Carrying Out Prioritizated Activities

According to the hybrid algorithm, the priority of CTO PCI is to achieve recanalization of the occlusion in the most safe, effective and efficient way, which is very similar to the definition of time management (planning and exercising conscious control of time spent on specific activities to increase effectiveness, efficiency or productivity). There are two key behaviors that are directly linked to time management during CTO PCI.

No. 1 is planning. Detailed, in-depth planning is the best time-management tool, as it generates several potential approaches for getting across the occlusion and ranks them in priority. Once the case starts, the CTO is a less foreign and much more familiar territory in which to operate. The plan(s) can, and often should, change during the actual procedure, but spending enough time upfront to understand the coronary anatomy in depth will pay huge dividends.

No. 2 is not losing track of time during CTO PCI. A common mistake, especially during the earlier stages of learning CTO PCI, is to spend an inordinate amount of time on a strategy that is failing and has low likelihood of success. It has been said: “Insanity is doing the same thing over and over again and expecting different results.” Early change of strategy remains one of the two central concepts of the hybrid algorithm (together with careful and detailed planning), minimizes time wasting and improves the likelihood of success. Change does not have to be radical from step to step — even small changes can sometimes work.

The end result of the above strategies for time management is to minimize the time wasted during CTO PCI and, hence, increase the chances that the procedure will be completed successfully and within the least amount of time. Of course, nothing works 100% of the time, and occasionally there will be cases that will take several hours to complete. But even a small improvement in efficiency can increase the likelihood of success, increase patient and staff satisfaction and potentially reduce equipment utilization and the cost of the procedure. Effective time management can facilitate getting things done, both in life and in CTO PCI.

Disclosure: Brilakis reports he receives consultant/speaker honoraria from Abbott Vascular, ACIST, American Heart Association, Amgen, Asahi, Cardiovascular Innovations Foundation, Cardiovascular Systems Inc., Elsevier, GE Healthcare, Medicure, Medtronic and Nitiloop; he receives research support from Boston Scientific and Osprey; he holds equity in MHI Ventures; and he serves on the board of trustees of the Society for Cardiovascular Angiography and Interventions.

“Time management is the process of planning and exercising conscious control of time spent on specific activities, especially to increase effectiveness, efficiency or productivity,” according to Wikipedia. The key concept is that time is finite, hence using it in the best possible way can lead to the best outcomes.

Chronic total occlusion intervention can be challenging to perform and may take a long time. Not completing the procedure within 1 to 2 hours is a common cause of failure — due to reaching the radiation or contrast limit, patient and/or staff fatigue, or a complication — hence, time management techniques are of particular importance for CTO PCI.

Planning vs. Doing

Emmanouil S. Brilakis

Planning is deciding where we want to go, evaluating different routes to get there and selecting one of those routes to follow. Planning is key to success, since “failing to plan is planning to fail.” At the same time, only planning without doing will not get things accomplished. Achieving balance between planning and doing is at the core of time management, both in general and during CTO PCI and can be broken down into two key components:

  • creating an environment conducive to effectiveness; and
  • setting priorities and carrying out activities around prioritization.

Creating an Environment Conducive to Effectiveness

An ineffective and cluttered environment leads to wasting of time. This is true for day-to-day activities — for example, having a cluttered desk makes it hard to find things and creates mental fatigue — and for CTO interventions. The environment includes the cath table, the equipment, the staff and the interventionalist.

No. 1, Having a well-organized and clean procedure table is key. Some labs are using two tables to increase the available space, which is similar to using two screens when working on a computer. Several guidewires are often needed during CTO PCI, and having them neatly organized makes it easier to keep track of what is available and to use it again if needed, without opening new equipment. This can be achieved in various ways, for example by keeping the original hoop of the guidewire and writing on a label or on the sterile drape the name of the wire.

No. 2, Bringing new equipment to the table can waste time if it is not immediately available within the catheterization room. For example, if it takes 3 minutes for the techs to locate and bring in a guidewire into the room, about 30 minutes will be lost if 10 guidewires are required in a case. This is where the “CTO cart” is crucial. The CTO cart is stocked with the guidewires and other equipment likely to be used during CTO PCI, organized in an intuitive way. In our lab the top shelf has short guidewires, the second shelf has exchange-length guidewires, the third self has microcatheters and guide catheter extensions and the fourth shelf has coils and covered stents. Having the CTO cart inside the procedure room saves significant time when additional equipment is needed, improving the chances of being successful and minimizing the fatigue of the staff. However, the CTO cart should be well-stocked and checked after every case to replace the equipment utilized, otherwise it could become a source of frustration in itself.

PAGE BREAK

No. 3, Training the cath lab personnel on the different equipment and techniques improves communication, minimizes errors and, hence, improves time efficiency. Well-trained staff members know the nuances and the names of the different equipment. For example, they know the difference between a Fielder XT and a Fielder XT-A guidewire (Asahi Intecc) and understand that the Suoh 03 wire (Asahi Intecc) has the softest tip of any guidewire and is mainly used for crossing collaterals during the retrograde attempt. They can often recommend alternative equipment, for example “a Trapliner (Teleflex) might work better during antegrade dissection and re-entry 6F guide catheter, as it allows trapping of the various microcatheters and other equipment used.” Insertion of a 4F venous sheath allows delegation of activated clotting time checking to the cath lab nurse, obviating operator interruptions.

No. 4, Continuous training of the interventionalist makes him or her more effective, efficient and safe. Having extra low radiation dose settings specific for CTO PCI minimizes patient and operator radiation dose, reducing potential adverse effects, but also contributing to the success of the case, as it makes it less likely for high radiation doses to be reached, requiring stopping the procedure. Continual learning and practice improve the efficiency of applying various techniques and being successful in their application.

Setting Priorities and Carrying Out Prioritizated Activities

According to the hybrid algorithm, the priority of CTO PCI is to achieve recanalization of the occlusion in the most safe, effective and efficient way, which is very similar to the definition of time management (planning and exercising conscious control of time spent on specific activities to increase effectiveness, efficiency or productivity). There are two key behaviors that are directly linked to time management during CTO PCI.

No. 1 is planning. Detailed, in-depth planning is the best time-management tool, as it generates several potential approaches for getting across the occlusion and ranks them in priority. Once the case starts, the CTO is a less foreign and much more familiar territory in which to operate. The plan(s) can, and often should, change during the actual procedure, but spending enough time upfront to understand the coronary anatomy in depth will pay huge dividends.

No. 2 is not losing track of time during CTO PCI. A common mistake, especially during the earlier stages of learning CTO PCI, is to spend an inordinate amount of time on a strategy that is failing and has low likelihood of success. It has been said: “Insanity is doing the same thing over and over again and expecting different results.” Early change of strategy remains one of the two central concepts of the hybrid algorithm (together with careful and detailed planning), minimizes time wasting and improves the likelihood of success. Change does not have to be radical from step to step — even small changes can sometimes work.

PAGE BREAK

The end result of the above strategies for time management is to minimize the time wasted during CTO PCI and, hence, increase the chances that the procedure will be completed successfully and within the least amount of time. Of course, nothing works 100% of the time, and occasionally there will be cases that will take several hours to complete. But even a small improvement in efficiency can increase the likelihood of success, increase patient and staff satisfaction and potentially reduce equipment utilization and the cost of the procedure. Effective time management can facilitate getting things done, both in life and in CTO PCI.

Disclosure: Brilakis reports he receives consultant/speaker honoraria from Abbott Vascular, ACIST, American Heart Association, Amgen, Asahi, Cardiovascular Innovations Foundation, Cardiovascular Systems Inc., Elsevier, GE Healthcare, Medicure, Medtronic and Nitiloop; he receives research support from Boston Scientific and Osprey; he holds equity in MHI Ventures; and he serves on the board of trustees of the Society for Cardiovascular Angiography and Interventions.