1. Prof. Leszek Bryniarski, MD, PhD, FESC
II Dept of Cardiology and Cardiovascular Interventions
Institute of Cardiology
Jagiellonian University Medical College
CTO at the crux cordis– which strategy ?

2. Proximal bifurcation
Bifurcation in CTO
Distal bifurcation
Classification of BFLs within CTO vessel
Bifurcation at the crux

3. The scale of the problem
922 CTOs – 244 BFLs (26.5%), RCA – 35,2%
Galassi A.R. et al. Coron Artery Dis. 2015;26:142-9.
391 CTOs – 130 BFLs (33%), distal cap – 52%, RCA – 31%
Ojeda S. et al. Intern J Cardio 2017;230:432-38.
335 CTOs – 182 BFLs (54.53%), RCA – 21,9%
Baystrukov V.I. et al. Coron Artery Dis. 2018;29:30-8.

4. Why important ?
Galassi A.R. et al. Coron Artery Dis. 2015;26(2):142-9.

5. Algorithms
Galassi A.R. et al. Eurointervention 2019;15:198-208.

6. > 20 possibilities
Retrograde Antegrade
- Double retrograde - Paralel wire
- One retrograde + dual
lumen microcatheter
- Dual lumen microcatheter
One retrograde + ADR - ADR

7. Case 1
Courtesy of Kambis Mashayekhi

8. Courtesy of Kambis Mashayekhi

9. Courtesy of Kambis Mashayekhi

10. Case 2

13. Case 3

16. Catheter Cardiovasc Interv 2018;91:1079-1083.

17. • Treating true-bifurcation CTO-PCI is common (near 1/3 of
CTO lesions have bifurcation at proximal or distal cap)
• Presence of bifurcation at the crux amplify complexity and
complication risk of the procedure
• A careful analysis of collateral support should be
performed before the procedure, to determine whether
both branches have independent collateral support
Conclusions

18. • The goal is to preserve both branches (PDA and PLA)
• Saving branches must be part of the initial plan
• Knowledge of specific materials (ex. ADR, IVUS / Double-
lumen catheter) and all technique is fundamental
• Tailored technique to anatomy and progress of the
procedure
Conclusions

19. Thank you for you attention
End of lockdown, but habits remained

20. Thank you for you attention
End of lockdown, but habits remained