Antegrade techniques for CTO recanalization. Dr. George Karavolias, MD, PhD, FESC, FACC Interventional Cardiologist
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1 Antegrade techniques for CTO recanalization Dr. George Karavolias, MD, PhD, FESC, FACC Interventional Cardiologist
2 can CTOs be reliably opened by PCI? Meta-Analysis of 18,061 Patients Patel V, J Am Coll Cardiol Intv. 2013;6(2):
3 CTO PCI Techniques Used Successful technique PROspective Global REgiStry for the Study of CTO interventions Christopoulos G, Int J Cardiology 2015;198:
4 Crossing strategy selection Christopoulos G., Int J Cardiology 2015;198:
5 Keys to successful antegrade CTO PCI IMAGING Angiography Coronary CT EQUIPMENT Guidewires Support TECHNIQUE Good procedure planning Not ad-hoc Single Wire Dual Wire Complex Antegrade CTO Techniques
6 Keys to successful antegrade CTO PCI IMAGING Angiography Coronary CT EQUIPMENT Guidewires Support TECHNIQUE Single Wire Dual Wire Complex Antegrade CTO Techniques
7 Predictors of anterograde procedural failure ERCTO, EuroIntervention 2011;7:
8 Angiographic assessment for CTO-PCI! Procedure Planning Brilakis ES et al.. JACC Cardiovasc Interv. 2012;5(4):
9 Angiographic review for CTO-PCI 1. Proximal cap ambiguity 2. Lesion length 3. Quality of distal target vessel 4. Collateral circulation Dual Injections
10 Angiography for CTO-PCI: Dual Injections Single Dual
11 Angiography for CTO-PCI: dual injections Alfredo R. Galassi, Euro CTO Insights, TCT 2015
12 Coronary computed tomography Information on the occluded segment: course length tortuosity calcification resolve issues of anatomic ambiguity Identification of the best angiographic projection for CTO crossing. Co-registration of the CCTA image with angiographic images Wilson W, Current Cardiology Reviews, 2014, 10,
13 Keys to successful antegrade CTO PCI IMAGING Angiography Coronary CT EQUIPMENT Guidewires Support guiding catheters guide catheter extension Guideliner Guidezilla anchoring techniques wire balloon micro-catheters TECHNIQUE Support Support Support Single Wire Dual Wire Complex Antegrade CTO Techniques
14 Support: guide catheters Guide catheters size (7F-8F): enhanced passive support better visualization accommodation for: micro-catheters IVUS anchoring balloon CrossBoss catheter, the Stingray balloon Access: bilateral femoral femoral + radial bilateral radial? Guide catheters shape: Left coronary artery: XB, EBU, and AL, for the left coronary right coronary artery: AL, JR
15 Guiding catheter size selection in the ERCTO Alfredo R. Galassi, Euro CTO Insights, TCT 2015
16 Radial access in the ERCTO Alfredo R. Galassi, Euro CTO Insights, TCT 2015
17 Support: guide catheter extension Guideliner (Vascular Solutions) Guidezilla (Boston Scientific) Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
18 Support: anchoring techniques wire anchoring balloon anchoring Wilson W, Current Cardiology Reviews, 2014, 10,
19 Support: anchor balloon Side branch anchor Coaxial anchor Distal anchor Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
20 Support: micro-catheter & Over-the-Wire balloon micro-catheters & OTW balloons: enhance the wire-penetrating capacity improve wire torque response allow wire tip reshaping without losing wire position facilitate wire exchanges. micro-catheter vs OTW balloon: more flexible and track better less kinking upon wire removal less likely to cause proximal vessel injury better assessment of the tip location better penetration of the CTO once a wire is through cost a micro-catheter or OTW balloon should be used for antegrade crossing in all CTOs
21 Support: micro-catheters Change in GW tip stiffness with various GW lengths extending past a microcatheter tip Waksman, Chronic total occlusions: a guide to revascularization. Wiley-Blackwell; 2013.
22 Support: micro-catheters Finecross (Terumo) Corsair (Asahi)
23 Keys to successful antegrade CTO PCI IMAGING Angiography Coronary CT EQUIPMENT Guidewires Support TECHNIQUE Single-wire Dual-wire Complex antegrade CTO techniques
24 Single-wire antegrade CTO techniques drilling penetrating sliding advance deflect rotate - advance
25 Single-wire antegrade CTO techniques: drilling controlled rotation of the GW in both directions. small tip bend (to avoid the creation of a large subintimal space). GW: moderate tip stiffness escalation to stiffer wires Ochiai M et al, Ital Heart J 2005;6:
26 Single-wire antegrade CTO techniques: penetrating forward GW advancement intentionally steering (directing) Indications: lesions with a calcified, hard-to-penetrate, proximal cap short occlusions with well understood vessel courses GW: Miracle 12 Confianza Pro 12 Gaia 3 Ochiai M et al, Ital Heart J 2005;6:
27 Gaia family GW concept advance deflect rotate - advance
28 Single-wire antegrade CTO techniques: Gaia Gaia 3 rd
29 Penetration of proximal cap with stiff wire to allow introduction of microcatheter and soft wire to CTO body
30 Single-wire antegrade CTO techniques: sliding micro-channels (up to 250µm in diameter) Sumitsuji S, J Am Coll Cardiol Intv 2011;4:941 51
31 Single-wire antegrade CTO techniques: sliding support by a micro-catheter gently advancement and rotation to find micro-channels check for the wire position in 2 orthogonal planes avoid entry into sub-intimal space tapered polymer coated GW (Fielder XT, Gaia 1) tapered hydrophilic GW (Runthrough NS)
32 Dual-wire antegrade CTO techniques parallel-wire see saw dual lumen catheter
33 Dual-wire antegrade CTO techniques: parallel-wire Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
34 Dual-wire antegrade CTO techniques: see-saw Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
35 Dual-wire antegrade CTO techniques: dual lumen catheter Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
36 Complex antegrade CTO techniques Dissection & re-entry strategies: dissection: Knuckle wire CrossBoss catheter re-entry: wire-based re-entry: o STAR technique o contrast enhanced o mini-star & LAST technique device-based re-entry: o Stingray balloon and guidewire o IVUS guided
37 Dissection strategies: knuckle wire Fielder XT Pilot 200 Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
38 Dissection strategies: device based (CrossBoss catheter) 3F (1.0 mm) atraumatic tip 6F Guide Catheter compatible 0.14 in GW compatible Boston Scientific
39 CrossBoss catheter vs. knuckle wire Smaller & more controlled sub-intimal dissection space! more predictable and controlled re-entry into the distal true lumen CrossBoss catheter tends to advance along a longitudinal path parallel to the artery axis #GW sometimes wrap around the artery circumference
40 Re-entry strategies: wire-based Pilot 200 Confianza Pro 12
41 Re-entry strategies: STAR often results in side-branch loss is less predictably successful high re-occlusion rates rarely used as a definitive technique (never in LAD) Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
42 Re-entry strategies: mini-star & LAST mini-star re-entry GW: the Fielder FC or XT LAST re-entry GW: Pilot 200 Confianza Pro 12 lower success rates because of difficulty in reliably re-entering the true lumen Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
43 Re-entry strategies: device based (Stingray balloon + wire) Brilakis E, 2014, Coronary Chronic Total Occlusion Interventions
44 Re-entry strategies: device based (Stingray balloon + wire) Self-orienting, flat balloon hugs the vessel automatically positioning one exit port toward the true lumen Boston Scientific
45 Re-entry strategies: device based (Stingray balloon + wire)
46 CTO anatomy suited to antegrade dissection re-entry strategy
47 Re-entry strategies: device based (CrossBoss + Stingray system) FAST-CTOs trial Whitlow Pet al.. Journal of American College of Cardiology Intervention. 2012;5:
48 Re-entry strategies: IVUS guided technique
49 Re-entry strategies: IVUS guided technique García-García HM, EuroIntervention Aug;3(2):188-96
50 Re-entry strategies: IVUS guided technique Alfredo R. Galassi, Euro CTO Insights, TCT 2015
51 Antegrade alone cases: successful crossing strategy
52 Antegrade escalation GW algorithm Wilson W, Current Cardiology Reviews, 2014, 10,
53 Revascularization in CTO
54 Treat the Lesions that Need to Be Fixed, Not Just the Ones that You Can Fix
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