TheRightDoctors Logo
Pre Alpha
Insights from the world's best medical minds
nine

Chronic Total Occlusion: Dr. Brian Pinto In Conversation With Dr. Samin Sharma

.
Pause
Love It
Embed

Dr. Samin Sharma

Interventional Cardiologist,

Mount Sinai Hospital, US

Dr. Brian Pinto

Chief of Cardiology

Holy Family Hospital, Mumbai


Dr. Brian Pinto in conversation with Dr. Samin Sharma


Mail us at editorial@therightdoctors.com. Stay updated on Facebook , Twitter , You Tube and LinkedIn.
Dr. Brian Pinto :
Q. Good afternoon. We are at the WCCICC at the Grand Hyatt in Mumbai and I must welcome my very close friend and superb interventional cardiologist, Dr. Samin Sharma who has been in the United States more precisely in New York City at Mt. Sinai and has been one of the pioneers both in interventions as well as in peripheral vascular disease and in TAVR. Welcome Dr. Samin Sharma. It is a great pleasure to have here.
Dr. Samin Sharma:
Same here.
Dr. Brian Pinto :
Q. You know, you just gave a wonderful-wonderful talk on CTOs, which is basically chronic total occlusions, I would like to ask you right up front is that a big part of your practice today in Mt. Sinai?
Dr. Samin Sharma:
Yes. CTO makes around 10% of our total intervention. The reason is the CTO, the justification, what we call appropriateness is very important. So patients with minimal symptoms not ischemia, even the CTO, the data support that should not be opened. Whether they are symptomatic or ischemia then only we go after. So overall the data have shown that while CTO incidents may be 20% when you do an angiogram, but CTO PCI makes only 8 or 10% of our PCI volume.
Dr. Brian Pinto :
Q. So you would say that every CTO you would not chase, you would try to look at whether there is an ischemia burden over there, whether it subtends to large territory of the myocardium, whether you are going to give him a benefit in LV function, is that all the kinds of areas that you look into before you attempt a CTO.
Dr. Samin Sharma:
Absolutely, and it also will be the same with ischemia, so many times the patient may be asymptomatic, but they have a big area of ischemia so as you said the large area LV function, the size of the vessel, and more we are kind of a lower threshold open that LAD because studies have shown that even once you open the LAD CTO you may improve survival. So those are the factors that do come in.
Dr. Brian Pinto :
Q. Dr. Sharma, I think you have been doing CTOs for may be more than 10 years, or may be 15 years, have you seen some change in the trend of how you are approaching these patients now. Have there been differences that have occurred over the past 5 or 10 years that have improved your results, can you throw some light on this shot?
Dr. Samin Sharma:
So, I would say the real breakthrough in my opinion on the CTO procedure PCI occurred about 7 to 8 years ago, when the specialty wires came out of Japan, all of them, Asahi and Miracle, now the Gaia family, which is there, that really improved our CTO success. That was about 7 or 8 years ago. Then about 4 or 5 years ago, addition of retrograde where you could not go antegrade so that added another 15 to 20% of success. So antegrade you try once or twice, your success rate is about 70 to 72%, you fail, but still then you bring back the patient for retrograde, you get another 20% success. So now we are reaching 90 to 92% success rate of the CTO at present, which is antegrade improved by the specialty wires and addition of retrograde has added to overall success, and this actually was published even about 9 months ago from European CTO club in Jack that how retrograde has aided to our improving antegrade success at present.
Dr. Brian Pinto :
Q. Dr. Sharma, is it such that you have certain parameters because when you go and approach a CTO, you know, do you set certain parameters to the amount of time that you would take to the amount of volume of contrast medium that you would use, is there some kind of parameters that you set before you start out on the CTO case. How you plan your CTO case. Give us an idea about that.
Dr. Samin Sharma:
That is very important. Reason is the a CTO case is very unpredictable compared to our 90% to 95% lesion, you know will be done in 30 minutes. Here it could be 3 hours or 4 hours or so. So clearly these are elective cases. So we do not schedule more than two CTOs in a day; one, second we actually have a limit. If your fluoro time is more than 100 minutes you stop. Because the studies have shown that excessive flow of radiation exposure, the patient may develop dermatitis and of course the physician has fatigue and many other factors, and the same also the contrast dye, the mL, so basically studies have shown that you have 5 to 7 mL/Kg is reasonable so usually about 500 mL of dye will be a cut off. So it is not to say that you fail there, yes you fail temporarily, but when you come back for the settlement.
Dr. Brian Pinto :
Q. I want to ask you that when you are using contrast because I was talking to some Japanese operators and watching them also they tend to use contrast through the micro catheter, you know small amounts of dye, which sometimes I am a little worried about. Do you tend to do that as a technique, you know, inject dye through the micro catheter to look at where you are, besides of course having the contralateral approach, you have a contralateral injection as well, so can you give us some idea about the contralateral as well as injection through the micro catheter.
Dr. Samin Sharma:
Very-very important. So I actually personally had never done the injection through the micro catheter. I know people do it, but at the same time, I have seen so many bad cases where the micro catheter wire is little underneath the plaque and they give the dye and the whole thing is dissected. Second, what I would do is the contralateral when you use, use a smaller catheter so you would get less dye, 4-French, my usual contralateral unless we are thinking about retrograde, which you can always upgrade, it is a 4-French contralateral.
Dr. Brian Pinto :
Q. So you do not give too much dye over there.
Dr. Samin Sharma:
That’s how we save the dye.
Dr. Brian Pinto :
Q. So you save the dye. Do you tend to dilute the dye when you think of that sort, do you have some kind of technique that, because we do that sometimes in our lab. We have been doing that not for contralateral but for the antegrade kind of approach. So we dilute the dye because you do not need the full contrast of the dye all the time so that may be we save some of the dye in this kind of situation
Dr. Samin Sharma:
That is a very good point. That was one of the point I made that to decrease the overall contrast volume, I would say use it in small percentage, where the creatinine is the major issue. The patient’s serum creatinine is 1.8 or 2.2, in that situation. But yes that is another good tool, very useful tool to decrease the overall contrast volume.
Dr. Brian Pinto :
Q. Dr. Sharma, I want to know from you is that when you start off do you think right in the beginning that a certain group of patients may after you try for may be a short time, you directly cross over to the retrograde approach, which would be this group of patients where you would think that after trying for a short time, you would go to the retrograde approach.
Dr. Samin Sharma:
I would say the most important in that group where you say, “let me look into it if can go and antegrade, if not I am going to go retrograde, so one would be ostial lesion. So it will be kind of area because of you are given contralateral injection you know that that may be the area where it was occluded. Blood stump of the non-aorta ostial, so lets say ostial LAD is closed, but you do not have anything when you inject from the left side, but you have some idea because of the contralateral injection, so you do try once or twice for lets say for 5 to 10 minutes. Second will be the case of the bridge collaterals. You try to go antegrade and every time your wire is going into the small capillaries and sometime may _, so that is the case you quickly stop and go through the retrograde.
Dr. Brian Pinto :
Q. More about the length of the lesion, if you have a very long kind of a lesion, with the calcified plaque in the proximal segment, would that be one of the areas also where you would go, you would tend to go quickly through the retrograde, would that make a sense to you?
Dr. Samin Sharma:
Let me clear your point of the calcium of course that is one of the big bad factor for us for CTO recanalization. The length I would say what we learnt now from the length point of view actually we have a better catheter like CrossBoss. It may not be only sting ray that you have to go and re-puncture it. CrossBoss will help you to go through the length of occlusion. So my first approach in a long lesion of 20, 30, 40 mm we still go antegrade and use the CrossBoss catheter.
Dr. Brian Pinto :
Q. That is a very good point that you have given us. The CrossBoss is a very nice catheter. It is like, you know, it is almost like you are causing blunt dissection. When you see a surgeon and he is doing blunt dissection, that is how the CrossBoss works, so that is a very good point that you have given us. Now tell me amongst your cases of success in how many percentage of cases are you successful by the antegrade approach?
Dr. Samin Sharma:
Approximately about 70%
Dr. Brian Pinto :
Q. So that you know is a good idea for us also to understand that the antegrade approach can be successful and up to may be in our hand 60 to 70% of cases and we could you use that. What would you say is the biggest thing that has helped you in terms of the wires? Which are the wires, how do you escalate, tell us?
Dr. Samin Sharma:
Clearly, what I also say, that the whole battery of wires are available, but you make two or three your CTO wires, so that you get experience, you get a good control, you know the wires dynamics. The first wire of course, once you bring your micro catheter, which we usually bring it.
Dr. Brian Pinto :
Q. You have to bring them. In a CTO you will always use the micro catheter?
Dr. Samin Sharma:
So bring it there on the field of wire and then my first wire now is Gaia 2, straight go to the wire
Dr. Brian Pinto :
Q. Would you start anytime with an XT or something of that sort with a Fielder XT, is that your starting wire?
Dr. Samin Sharma:
Yes. Fielder XT would be the rare case where you think that there is a working channel
Dr. Brian Pinto :
Q. This is not a powerful wire. It is only got 9000s at the tip, it is not powerful enough actually.
Dr. Samin Sharma:
That is why to me more often we fail rather succeeded, so therefore threshold of using Fielder XT will be when you say very micro channel then you will try. Even in that case, we will be successful only 50% of the time. The big advantage of Gaia is the way the wire has been made, it rarely is subintimal, it rarely perforates, and it is just to go through at one time when you reaching the distal part, it suddenly goes in.
Dr. Brian Pinto :
Q. Is there a particular technique that you use with the Gaia wire. Is it different from the other wires?
Dr. Samin Sharma:
So I think what basically is that knowing that it restores the energy, so while you are doing, you just do, you do not keep spinning all the time.
Dr. Brian Pinto :
Q. Absolutely
Dr. Samin Sharma:
So do you spin, you pullback and then go and with gradual advancement.
Dr. Brian Pinto :
Q. So there is a gradual kind of advancement that is done rather than just talking the wire all the time like you do with the other wires. So, that I think is a very important point that you have given us. Are there any kind of, you know, tips or tricks that you would like to tell us which I have not brought up to the fore. Is there something that you want to say?
Dr. Samin Sharma:
Yeah. Few of them. One actually is not uncommon in long calcific lesion your wire is on and nothing goes further, your micro catheter may have gone little bit. Your balloon can go about 1.25 or 1.5 balloon, your wire has gone, but you are stuck now. So there, there are only few techniques left. One would be that use a laser which is not available everywhere. Second, will be that you change that wire to the RotaWire and then use a 1.25 balloon.
Dr. Brian Pinto :
Q. You change it to a RotaWire by passing the wire alongside or what?
Dr. Samin Sharma:
Basically what will you do, you will bring your micro catheter up to the site of the occlusion so it is not crossing, only the nose is there, take the CT wire out and put a RotaWire. It would go. With the small percentage, it will not happen. No matter what you do would not happen so then in that situation what you do is you leave your CTO wire directly and you try to create an additional channel again by bringing a separate micro catheter and try to make another subintimal passage. So that is one thing that is very important that many times our wire goes, but we are not able to advance our devices so this is one of the biggest issue.
Dr. Brian Pinto :
Q. Does the toners or anything of that sort help in these kinds of cases? Have you used the toners in these cases? Have you found any benefit with that?
Dr. Samin Sharma:
So once your micro catheter does not go, our second step is to use the corsair It is a like a toner. So it is a little more tip by tip.
Dr. Brian Pinto :
Q. It is a good micro catheter also.
Dr. Samin Sharma:
Actually many people they start with the corsair
Dr. Brian Pinto :
Q. Because if you need to rotate it and take it down, the corsair is better than any other micro catheter. And so I think that is another point. Something about guide catheter support, which I would like to get from you in these CTO cases. Would you like to tell us something about the guide catheter support that you need?
Dr. Samin Sharma:
Actually I would say that our own practice or I would say majority of the United States practice is a little different than Japanese. Japanese recommend using a large guide catheter like 8-French to give the support. We on the contrary say use the long sheath, but use a 6-French guide because the 6-French guide will cause less trauma
Dr. Brian Pinto :
Q. You said the sheath, means the sheath that is 45 cm
Dr. Samin Sharma:
Yeah 45 cm sheath. In that way I would say our 6-French guide almost add 1 to 1.5 French because of the state there and then the key is that if necessary then you use the mother-child catheter with it and therefore retrieval is helpful rather going to the 8-French because 8-French, more dye, many times dampening of the pressure and the third potential for causing injury to the ostium.
Dr. Brian Pinto :
Q. Are you one of those people who use this anchoring balloon technique and the anchoring, do you subscribe to that quite often for your guide catheter support, do you kind of anchor your wire, or anchor your balloon into a side branch to get better guide support.
Dr. Samin Sharma:
So particularly for the proximal right coronary artery, we used to use quite a bit of anchor technique. You put a small balloon, but then you usually go with a 7-French guide, you put a small balloon into the clonus branch and it keeps anchors your guide. Now there is a new device called Center-Cross, actually just approved by FDA about 8 to 9 months ago. I am sure it will be coming to India also soon. So it is fixed at the ostium of the RCA, at your guide catheter. So it now has engaged just after the guide in the proximal RCA, so any wire you will go since it is stuck between the vessel and the guide catheter, so your guide is not moving. Because there is a balloon so you go in the center. So it is called Center-Cross.
Dr. Brian Pinto :
Q. That is a wonderful new aspect that you have given us. I think you know we have covered up most of the issues regarding CTO over her and I really thank you for giving us this insight, Dr. Samin Sharma, that it was wonderful to speak to you and I am sure all our viewers will have enjoyed this interview with you. Thank you very much.
:

Join TheRightDoctors on WhatsApp. Type "JOIN" and send to 9676401536

Multi-Modality Imaging

Dr.HK Chopra Panel: Dr Amal Banerjee, Dr.Satyendra Tewari, Dr. Jagat Narula and Dr.RR Kasliwal

Pause
Love It
Embed

Dr.HK Chopra

Best Selling Author - STEMI,Chairman, CSI National Affairs,Past President (2015)

Dr. Amal Banerjee

Chairman

CSI International Affairs

Dr. Satyendra Tewari

Sr. Prof. Dept. of Cardiology

SGPGI, Lucknow



Join TheRightDoctors on WhatsApp. Type "JOIN" and send to 9676401536