Algorithm and Tools for the Uncrossable CTO
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1 Algorithm and Tools for the Uncrossable CTO David E. Kandzari, MD, FACC, FSCAI Chief Scientific Officer Director, Interventional Cardiology Piedmont Heart Institute Atlanta, Georgia
2 Disclosure Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company Abbott Vascular, Boston Scientific Corporation, Medtronic CardioVascular Boston Scientific Corporation, Medtronic CardioVascular, Micell Technologies None None None None None
3 Rare Sightings
4 Avoiding and Overcoming the Uncrossable CTO Guidecatheter Support 8 Fr guides: AL1, XB 35 cm arterial sheaths Deep engagement Hydrophilic embodiment of wires Anchor Balloon Guideliner Wedgies and Grenadoplasty X 80 Excimer Laser Ablative and acoustic energy Rotational Atherectomy Tornus/ Corsair Re crossing with second guidewire Retrograde approach Inpenetrable Uncrossable
5 Guidewire Support and Microcatheters Enhance Guidewire Stiffness and Support Product Guidewire Support Level Comments Finecross, Terumo Medical Low profile OTW PTCA Catheters Trackability, profile, kink resistant Expense Inexpensive, lesion treatment No distal tip marker, stiff bias Corsair, Abbott Vascular/Asahi Crossing ability, end hole Expense, Corsair fatigue Tornus, Abbott Vascular/Asahi Lesion crossing Expense, not end hole, braid unwind w/overtorque
6 Microcatheter Dimensions FineCross MG Excelsior (BSC) Transit (Cordis) Distal Proximal O.D. I.D. O.D. I.D 1.8Fr (0.60mm) 2.0Fr (0.67mm) 2.3Fr (0.76mm) 0.018'' (0.45mm) (0.48mm) 0.021'' (0.50mm) 2.6Fr (0.87mm) 2.6Fr (0.87mm) 2.8Fr (0.95mm) 0.021'' (0.55mm) 0.019'' (0.48mm) 0.021'' (0.50mm) FINECROSS MG Excelsior Transit Guidewire Control Crossing Profile Contrast Injection Coils
7 Tornus Penetration Catheter 135 cm Φ0.028 (2.1Fr)/0.018 Φ0.024 /0.016 Φ0.016 Φ0.018 Φ0.024 Φ0.028 Support Catheter Constructed with eight (8) individual wires stranded together to form the catheter Two sizes: 2.1Fr Diameter increases from to Fr Diameter increases from to 0.035
8 Corsair: Support and Penetration Tapered Soft Polyurethane Tip 20cm Screw Head Structure Hydrophilic Polymer Coating PTFE Inner Layer Marker coil 10.86mm (2.6Fr) 20.82mm (2.5Fr) 30.86mm (2.6Fr) 2 Thick Braids 8 Thin Braids Φ0.12mmx2pcs Φ0.07mmx8pcs Counterclockwise advancement Tschuchikane et al. JACC Intv 2010
9 73yo with >10y CTO, prior failed attempt
10 Algorithm: Proximal Cap Visibility, Good Landing Zone, Lesion Length <20 mm
11 Algorithm: Poor Interventional Collaterals
12 Antegrade Penetration with CP 12, Finecross
13 Antegrade Penetration with CP 12, Finecross
14 Microcatheter and Balloon Uncrossable Finecross Quickcross Sprinter, Apex (Wedge Technique)
15 Low Profile Angioplasty Catheters, Wedgies and Grenadoplasty Zero fold 1.25 mm balloon Crossing Profile Zero fold Balloon (no folding) Conventional Balloon (folding required) Kandzari et al. CCI 2010
16 Metrics for OTW PTCA Support Catheters Tip Crossing Profile Mid Balloon 1.2 Mini Trek Mini Trek Sprinter Sprinter Profile over Marker Band Crossing Profile Lesion Entry Profile
17 Inpenetrable CTO
18 Inpenetrable CTO Balloon serves as anchor and deflection point
19 Excimer X mj/mm fluence 0.9 mm tip, 50 μm fiber; 6 Fr guide compatible Enhanced ablative and acoustic effects Ablative effect vaporizes atherosclerotic tissue and thrombus Acoustic effect homogenizes calcium
20 Excimer X 80
21 Excimer X 80
22 Excimer X 80
23 Excimer X 80
24 Dual Access Catheters
25 Avoiding and Overcoming the Uncrossable CTO Guidecatheter Support 8 Fr guides: AL1, XB 35 cm arterial sheaths Deep engagement Hydrophilic embodiment of wires Anchor Balloon Guideliner Wedgies and Grenadoplasty X 80 Excimer Laser Ablative and acoustic energy Rotational Atherectomy Tornus/ Corsair Re crossing with second guidewire Retrograde approach Inpenetrable Uncrossable
Antegrade techniques for CTO recanalization. Dr. George Karavolias, MD, PhD, FESC, FACC Interventional Cardiologist
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