CTO Corner

Hiking and CTO PCI: Lessons Learned

Emmanouil S. Brilakis

One might not think there are many similarities between hiking and chronic total occlusion PCI, but a recent family trip led me to think there are many lessons about hiking that can also apply to CTO PCI.

To celebrate the new year, my family took a trip to Arizona to visit Phoenix, Sedona and the Grand Canyon. We arrived at the South Rim of the Grand Canyon during a blizzard, wondering to ourselves why we had traveled from Minneapolis to see more snow. We made the most of it, hiking 3 miles down the Bright Angel trial the first day and 3 miles down the South Kaibab trail the following day, which was no small task with a 6-year-old and an 8-year old. Thankfully, we were prepared with snow pants and boots and bought boot chains that helped prevent slipping on the trails. From there, we drove to Sedona, where we hiked several trails in Red Rock Country, many of which were also covered in snow and ice. Thankfully, we had a great time with no accidents.

This trip led me to make comparisons between hiking and CTO PCI in the lab.

1. Always Be Prepared

Our first day in the Grand Canyon, we brought two water bottles. We realized a couple hours into hiking that only one of them was in our backpack; we forgot the other one at the cabin. Similarly, planning is key for CTO PCI. For example, if you are planning to do a retrograde case, make sure you have an externalization guidewire before you start the case. When you anticipate difficulty with support, make sure you use an 8F guide upfront. You can never do enough planning. Be sure to write a procedural plan first. An equipment checklist can go a long way when doing a challenging case.

Understanding when the risks exceed the benefits is critical, whether it be an icy trail or a complex CTO PCI case.

Source: All images courtesy of Emmanouil S. Brilakis, MD, PhD

2. Don’t Complain and Don’t Blame

Trying to decide whose fault it was for forgetting the extra water bottle or the hats was not pleasant and made everyone grumpy. During CTO PCI, there will likely be opportunities to complain or blame yourself or others — when you accidentally pull the guidewire after crossing the CTO; when you lose guide and wire position while trying to deliver a stent; when contrast injection happens while trying to engage a coronary artery, causing a massive coronary or aortocoronary dissection. Don’t complain and don’t blame. Maintain positivity on the trail and on the case. Even with the best planning, unexpected things will occur. Accept the facts — fast — and work to find solutions.

3. Start Early

We were generally on the trails in Sedona by 8 a.m. At that time, the parking lot at the trailhead was empty, there were no crowds on the trail and the hike was enjoyable. Another day we started our hike in the afternoon. We eventually had to turn around before reaching the end of the hike. Similarly, you want to start your most complex CTO PCI early. You and your team will be well-rested, fresh and ready to work, making it more likely to reach the destination. And you will be less likely to run out of resources, such as team energy and focus, necessitating stopping.

4. Have a Hard-stop Rule

Temperatures in the Grand Canyon were in the 20s during the day. After dark, temperatures dropped much lower, making it extremely unpleasant and dangerous on the trail. Similarly, CTO PCI has some fairly hard-stopping rules: The procedure has to end after reaching the contrast or radiation limit, or when you are too tired to think clearly and execute the procedure steps. Changing the plan is at the heart of the hybrid algorithm for CTO PCI — not only for efficacy, but also for safety.

5. Going Down Is Optional; Coming Up Is Mandatory

A sign on the Grand Canyon trailheads warns people of the risks of hiking. People die every year in the Grand Canyon while attempting the 7 to 14 miles to the Colorado River. Similarly, patients die during CTO PCI. The operator must constantly evaluate whether to continue the procedure or stop. Deciding to take a specific approach might mean going too far down, to the point that you cannot return safely. Understanding when the risks exceed the benefits is critical and is learned with experience, especially, since the person whose life is at risk is not the operator, but the patient.

6. Train to Make the Next Case Easier

The day after hiking the Grand Canyon’s South Kaibab trail for 6 miles, we drove to Sedona and hiked the much easier, kid-friendly Boynton Canyon. It was amazing how easy the Boynton Canyon hike felt after having hiked the Grand Canyon. This brings up two analogies for CTO PCI: No. 1, after doing CTO PCI, regular PCI cases seem very easy; and, No. 2, training in hard CTO cases makes less complex cases much easier. You train and learn to make the next case easier.

This trail, like some CTO PCI cases, appears easy to navigate, but one must always be prepared for the unexpected.

7. Have a Clear Understanding of the Level of Difficulty

Many hikes have signs signaling the level of difficulty and how long it will take to cross it. In contrast, patients don’t have a sign that states, “Black diamond CTO.” You may start a case thinking that are going to hike the Boynton Canyon, when in reality it is the Grand Canyon you are trying to cross. This is a very common theme early in in learning curve of CTO PCI: The operator has lined up two to three J-CTO 5 cases (ie, extremely difficult) and expects to get through them successfully by 5 p.m. Learning to read the angiogram and calculate the J-CTO score, along with experience, will help correctly estimate the difficulty of the case. Even experienced operators, however, may only find during the case that it is the Grand Canyon they are trying to hike.

8. Don’t Miss a Step

Missing a step in the Grand Canyon can mean death; missing a step in Boynton Canyon usually means getting dirty or running into a bush. The consequences of missing a step are different on different trails. Missing a step, such as losing an acute marginal during PCI of a right coronary artery CTO, may mean nothing in a patient with single-vessel disease and normal ejection fraction. However, the same event in a patient with an ejection fraction of 20% and triple-vessel disease may mean death or need for veno-arterial extracorporeal membrane oxygenation.

9. Have an Experienced Colleague to Help, if Needed

A lesson my children learned: When on a challenging trail, make sure your dad is there to carry you when you can no longer walk. Similarly, when you are attempting a highly complex CTO PCI, make sure you have an experienced colleague or proctor there to help if things go south.

10. Communicate and Share Experiences

Most hikers were happy to see us and greet us on the trail. They were also eager to provide advice. When climbing Cathedral Rock in Sedona, another family coming down told us to go the left instead of following the standard path, which was icy and slippery. Remember, you are not alone on the trail or in CTO PCI. Say hello to others and ask for advice. Most CTO PCI operators are happy to share what they know.

In hiking as in CTO PCI, while the destination is very important, the journey is, too.

11. Enjoy the Journey

Except for a few times when the cold got the best of them, my kids were extremely happy on the trail — splashing in every mud puddle, going up interesting cliffs, breaking the ice, picking up sticks and piling up stones — much to the chagrin of their father, who kept on screaming about the importance of safety, staying on the trail and picking up the pace when it got too slow. Fortunately, I was reminded by their mother that the kids need to play. This is something adults may forget too easily: In the process of planning, thinking about the next step and thinking about potential problems, you may forget to enjoy the hike — or CTO PCI case. Of course, planning and constant monitoring are needed during CTO PCI; however, the procedure can and should be a joyful experience. It is not only about the destination: The journey is important too.

Disclosure: Brilakis reports he receives consultant/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Boston Scientific, Cardiovascular Innovations Foundation (board of directors), Cardiovascular Systems Inc., Elsevier, GE Healthcare, InfraRedx, and Medtronic; research support from Regeneron and Siemens; is a shareholder in MHI Ventures; and is on the board of trustees for the Society for Cardiovascular Angiography and Interventions.

Emmanouil S. Brilakis

One might not think there are many similarities between hiking and chronic total occlusion PCI, but a recent family trip led me to think there are many lessons about hiking that can also apply to CTO PCI.

To celebrate the new year, my family took a trip to Arizona to visit Phoenix, Sedona and the Grand Canyon. We arrived at the South Rim of the Grand Canyon during a blizzard, wondering to ourselves why we had traveled from Minneapolis to see more snow. We made the most of it, hiking 3 miles down the Bright Angel trial the first day and 3 miles down the South Kaibab trail the following day, which was no small task with a 6-year-old and an 8-year old. Thankfully, we were prepared with snow pants and boots and bought boot chains that helped prevent slipping on the trails. From there, we drove to Sedona, where we hiked several trails in Red Rock Country, many of which were also covered in snow and ice. Thankfully, we had a great time with no accidents.

This trip led me to make comparisons between hiking and CTO PCI in the lab.

1. Always Be Prepared

Our first day in the Grand Canyon, we brought two water bottles. We realized a couple hours into hiking that only one of them was in our backpack; we forgot the other one at the cabin. Similarly, planning is key for CTO PCI. For example, if you are planning to do a retrograde case, make sure you have an externalization guidewire before you start the case. When you anticipate difficulty with support, make sure you use an 8F guide upfront. You can never do enough planning. Be sure to write a procedural plan first. An equipment checklist can go a long way when doing a challenging case.

Understanding when the risks exceed the benefits is critical, whether it be an icy trail or a complex CTO PCI case.

Source: All images courtesy of Emmanouil S. Brilakis, MD, PhD

2. Don’t Complain and Don’t Blame

Trying to decide whose fault it was for forgetting the extra water bottle or the hats was not pleasant and made everyone grumpy. During CTO PCI, there will likely be opportunities to complain or blame yourself or others — when you accidentally pull the guidewire after crossing the CTO; when you lose guide and wire position while trying to deliver a stent; when contrast injection happens while trying to engage a coronary artery, causing a massive coronary or aortocoronary dissection. Don’t complain and don’t blame. Maintain positivity on the trail and on the case. Even with the best planning, unexpected things will occur. Accept the facts — fast — and work to find solutions.

PAGE BREAK

3. Start Early

We were generally on the trails in Sedona by 8 a.m. At that time, the parking lot at the trailhead was empty, there were no crowds on the trail and the hike was enjoyable. Another day we started our hike in the afternoon. We eventually had to turn around before reaching the end of the hike. Similarly, you want to start your most complex CTO PCI early. You and your team will be well-rested, fresh and ready to work, making it more likely to reach the destination. And you will be less likely to run out of resources, such as team energy and focus, necessitating stopping.

4. Have a Hard-stop Rule

Temperatures in the Grand Canyon were in the 20s during the day. After dark, temperatures dropped much lower, making it extremely unpleasant and dangerous on the trail. Similarly, CTO PCI has some fairly hard-stopping rules: The procedure has to end after reaching the contrast or radiation limit, or when you are too tired to think clearly and execute the procedure steps. Changing the plan is at the heart of the hybrid algorithm for CTO PCI — not only for efficacy, but also for safety.

5. Going Down Is Optional; Coming Up Is Mandatory

A sign on the Grand Canyon trailheads warns people of the risks of hiking. People die every year in the Grand Canyon while attempting the 7 to 14 miles to the Colorado River. Similarly, patients die during CTO PCI. The operator must constantly evaluate whether to continue the procedure or stop. Deciding to take a specific approach might mean going too far down, to the point that you cannot return safely. Understanding when the risks exceed the benefits is critical and is learned with experience, especially, since the person whose life is at risk is not the operator, but the patient.

6. Train to Make the Next Case Easier

The day after hiking the Grand Canyon’s South Kaibab trail for 6 miles, we drove to Sedona and hiked the much easier, kid-friendly Boynton Canyon. It was amazing how easy the Boynton Canyon hike felt after having hiked the Grand Canyon. This brings up two analogies for CTO PCI: No. 1, after doing CTO PCI, regular PCI cases seem very easy; and, No. 2, training in hard CTO cases makes less complex cases much easier. You train and learn to make the next case easier.

PAGE BREAK
This trail, like some CTO PCI cases, appears easy to navigate, but one must always be prepared for the unexpected.

7. Have a Clear Understanding of the Level of Difficulty

Many hikes have signs signaling the level of difficulty and how long it will take to cross it. In contrast, patients don’t have a sign that states, “Black diamond CTO.” You may start a case thinking that are going to hike the Boynton Canyon, when in reality it is the Grand Canyon you are trying to cross. This is a very common theme early in in learning curve of CTO PCI: The operator has lined up two to three J-CTO 5 cases (ie, extremely difficult) and expects to get through them successfully by 5 p.m. Learning to read the angiogram and calculate the J-CTO score, along with experience, will help correctly estimate the difficulty of the case. Even experienced operators, however, may only find during the case that it is the Grand Canyon they are trying to hike.

8. Don’t Miss a Step

Missing a step in the Grand Canyon can mean death; missing a step in Boynton Canyon usually means getting dirty or running into a bush. The consequences of missing a step are different on different trails. Missing a step, such as losing an acute marginal during PCI of a right coronary artery CTO, may mean nothing in a patient with single-vessel disease and normal ejection fraction. However, the same event in a patient with an ejection fraction of 20% and triple-vessel disease may mean death or need for veno-arterial extracorporeal membrane oxygenation.

9. Have an Experienced Colleague to Help, if Needed

A lesson my children learned: When on a challenging trail, make sure your dad is there to carry you when you can no longer walk. Similarly, when you are attempting a highly complex CTO PCI, make sure you have an experienced colleague or proctor there to help if things go south.

10. Communicate and Share Experiences

Most hikers were happy to see us and greet us on the trail. They were also eager to provide advice. When climbing Cathedral Rock in Sedona, another family coming down told us to go the left instead of following the standard path, which was icy and slippery. Remember, you are not alone on the trail or in CTO PCI. Say hello to others and ask for advice. Most CTO PCI operators are happy to share what they know.

PAGE BREAK
In hiking as in CTO PCI, while the destination is very important, the journey is, too.

11. Enjoy the Journey

Except for a few times when the cold got the best of them, my kids were extremely happy on the trail — splashing in every mud puddle, going up interesting cliffs, breaking the ice, picking up sticks and piling up stones — much to the chagrin of their father, who kept on screaming about the importance of safety, staying on the trail and picking up the pace when it got too slow. Fortunately, I was reminded by their mother that the kids need to play. This is something adults may forget too easily: In the process of planning, thinking about the next step and thinking about potential problems, you may forget to enjoy the hike — or CTO PCI case. Of course, planning and constant monitoring are needed during CTO PCI; however, the procedure can and should be a joyful experience. It is not only about the destination: The journey is important too.

Disclosure: Brilakis reports he receives consultant/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Boston Scientific, Cardiovascular Innovations Foundation (board of directors), Cardiovascular Systems Inc., Elsevier, GE Healthcare, InfraRedx, and Medtronic; research support from Regeneron and Siemens; is a shareholder in MHI Ventures; and is on the board of trustees for the Society for Cardiovascular Angiography and Interventions.