Chronic Total Occlusions Antegrade Approach...CTO Revascularization Evidence Considerations from a...

Chronic Total Occlusions Sceptical Considerations and Technical Approach

Α-Δ. ΜΑΥΡΟΓΙΑΝΝΗΚΑΡΔΙΟΛΟΓΟΣ

AIMOΔΥΝΑΜIΚΟ ΕΡΓΑΣΤΗΡΙΟΓ.Ν.Θ. «Γ.ΠΑΠΑΝΙΚΟΛΑΟΥ»

ΘΕΣΣΑΛΟΝΙΚΗ

Disclosure Statement of Financial Interest

none whatsoever…

The Late Open Artery Hypothesis: Rationale and Dilemmas of CTO PCI

• Reduction in ischemic burden

• Enable completeness of revascularization

• Improvement of symptoms

• Improvement in LV function

• Reduced predisposition to arrhythmic

events and ischemic events

• Avoidance of procedures and reduced

medications

• Survival benefit

• Technical and procedural challenges

• Misperceptions regarding viability,

collateral flow

• Uncertainty regarding which patients may

benefit balanced by

• Concern for complications in patients who

may not derive clinical benefit

Disclaimer: Capability to perform CTO PCI imparts clinical wisdom to decide when it is and is not indicated

CTO Revascularization Evidence Considerations From A Patient Perspective

In what Clinical Settings might CTO PCI Improve my Outcome?

Objective In Favor Against

Symptom Improvement 7 trials (1 RCT,6 single-arm)

demonstrating benefit relative to

procedural failure or medical therapy

alone and comparable to non-CTO PCI

1 RCT showing no symptom benefit or

reduction in medicines

Event Free Survival 16 observational studies (~32,500 pts)

reporting improved survival;

4-5 yr TLR 9%

1 RCT showing no difference in MACCE

compared with medical therapy

Improvement in LV Function Meta-analysis of 34 studies and at least

9 additional studies demonstrate

improvement in LV function and/or LV

dimensions

Outcome may depend on viability and

extent of baseline impairment;

EXPLORE RCT no difference; REVASC

no difference in regional or global LV

function but improved MACE

Other Avoidance of need for CABG (>80%);

Reduction in ventricular arrhythmic

events (VACTO)

Limited alternative evidence

CTO Revascularization Evidence: Evolution of CTO PCI - What is Known

• Several observational studies: improved

survival with CTO PCI

• Improvement in LV function: suggestive

but inconsistent

• Most but not all CTO trials examining

health status have associated a benefit

with CTO PCI

• Debate exists regarding what evidence,

trial design and endpoints and study

conduct needed to advance CTO PCI

CTO revascularization remains uncommon in the interventional community despite its prevalence in ~20% of patients with coronary

artery disease

CTO Revascularization Evidence Considerations from a Patient Perspective

What is the Procedural Success and Safety Following Contemporary CTO PCI?

Event Estimate Context

Death0.2-0.9%

Source: OPENCTO¹, PERSPECTIVE²,

RECHARGE³

1.5%

ACC NCDR SVG PCI

Procedural MI 1.8% to2.8%

Source: OPENCTO¹, PERSPECTIVE²,

RECHARGE³

EXPERT CTO4

3.6%

LM PCI EXCEL Trial 6

Technical Success86% to90%

Source: OPENCTO1, PERSPECTIVE2,

RECHARGE3, EXPERT CTO4, PROGRESS5

74%

Mayo Clinic 2003-20057

Clinical Success 86% to 96%

Source: PERSPECTIVE2, EXPERT CTO4 85,9%

ACC NCDR

1Sapontis. JACC Intv2017; 2 Kandzari. TCT 2017; 3 Maeremans. JACC 2016; 4 Kandzari. JACC Intv2015; 5 Karmpaliotis. CCI 2016; 6 Stone. NEJM 2016; 7 Prasad JACC 2007; 8 Brilakis JACC Interventions 2015

CTO Revascularization Evidence

Patient Reported Health Status: PERSPECTIVE Trial

0%

25%

50%

75%

100%

Baseline N 243 1 Year N 210

34

8226

15

40

3

84,1

% A

ppro

pri

ate

by A

UC

SAQ Angina Frequency Scale

None Monthly Daily

Kandzari D.

Procedural, clinical and health status outcomes in chronic total coronary occlusion revascularization with zotarolimus-eluting stents:

results from the PERSPECTIVE trial.

Presented at: SCAI 2018. April 26, 2018. San Diego, CA.

CTO PCI: at the Intersection of Evidence and Experience in Clinical Practice

The Basics

• CLINICAL INDICATION

• DUAL ACCESS AND DUAL INJECTIONS

• STUDYING THE LESION

• GUIDE SUPPORT

• EQUIPMENT KNOWLEDGE AND USE

• COMPLICATION MANAGEMENT KNOWLEDGE

Predictors of Anterograde Procedural Failure

Univariate Predictors Multivariate Predictors

OR 95% CI p OR 95% CI p

Dyslipidemia 0.5 0.375-1.456 0.52

Diabetes 0.2 0.186-2.356 0.71

Hypertension 0.7 0.452-1.856 0.36

Smoking 0.6 0.532-1.156 0.44

Previous MI 0.8 0.620-1.030 0.08

Previous CABG 0.7 0.569-1.050 0.16

In stent CTO 0.7 0.345-1.756 0.54

Severe tortuosity 0.4 0.332-1.876 0.45

Severe calcification 0.43 0.348-0.686 <0.001 0.35 0.241-0.515 <0.001

CTO length >20mm 0.49 0.301-0.619 <0.001 0.52 0.352-0.790 0.002

CTO diameter <3mm 1.1 0.850-1.775 0.32

Blunt stump 0.63 0.490-0.816 <0.001 0.59 0.435-0.807 0.001

Galassi AR. et al.

In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion:

insights from the ERCTO (European Registry of Chronic Total Occlusion) registry.

EuroIntervention. 2011 Aug;7(4):472-9

Final Strategy per J CTO Score

AWE antegrade wire escalation ADR antegrade dissection reentry RW retrograde wiring RDR retrograde dissection reentry

Luo C. et al.

Predictors of Interventional Success of Antegrade PCI for CTO.

JACC Cardiovasc Imaging. 2015 Jul;8(7):804-13

Angiographic Assessment for CTO-PCI

Procedure Planning

Dual Catheter Angiography

Antegrade Retrograde

1.Ambiguous proximal cap

2. Poor distal target

3. Interventional collaterals

Wire

Escalation

Dissection Reentry

( Cross Boss Stingray )

Wire

Escalation

Dissection Reentry

( Reverse CART )

Yes

Yes Yes

No

No No

fail fail fail fail

fail fail

Brilakis ES. et al.

A percutaneous treatment algorithm for crossing coronary chronic total occlusions.

JACC Cardiovasc Interv. 2012 Apr;5(4):367-79

4. Length < 20mm

When There' s a Will There' s a WayThe BUSHI DO (Bipoint Unilateral Sheathless catheter Insertion via Distal & prOximal radial artery)

Technique

Yoshimachi F., Takagava Y., Sakai K., Ikari Y.

EuroPCR 2018

Antegrade Wire Escalation: Step By Step

• Select a microcatheter

• Getting to the CTO with a workhorse wire &

microcatheter

• Advance the microcatheter to the proximal

cap

• Selecting a Guidewire for CTO Crossing

Pearls of Wisdom

The best way to prolong ( or fail) a case is by taking shortcuts…

W. Lombardi

CTO Expert

E. Brilakis

Manual of Chronic Total Occlusion Interventions: A Step-by-Step Approach

2nd Edition, Academic Press 2017

Support: Guide Catheter Extension

E.Brilakis

Manual of Coronary Chronic Total Occlusion Interventions. A Step-by-Step Approach.

Academic Press 2014, 1st Edition

Support: Microcatheter & OTW Balloon

Microcatheters & OTW Balloons:

• enhance the wire-penetrating capacity

• improve wire torque response

• allow wire tip reshaping without losing

wire position

• facilitate wire exchanges

Microcatheter 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

Support: Microcatheter

Ron Waksman, Shigeru Saito Chronic Total Occlusions: A Guide to Recanalization

2nd Edition, Apr 2013 Wiley-Blackwell

CTO Toolbox-Wires

❖ Tapered, soft (~1) plastic jacketed GW (XT/XT-A/XTR)

➢ Antegrade/Retrograde microchannel/soft plaque probing

➢ Facilitation of quick wiring Dissection Re-entry in abmbigous vessel anatomy/soft plaque (Knuckle wire technique)

➢ Very small and tortuous collateral chanel crossing epicardial and septal(retrograde access)

❖ Non-tapered, soft plastic jacketed GW (Fielder FC/Pilot 50/Whisper)

➢ Multi-tasking (Mainly work in the body of the occlusion-getting less fashionable)

❖ Non tapered, medium gram force plastic jacketed wire (Pilot 150/200)

➢ Body of the occlusion

➢ Facilitation of quick wiring in complex lesions and/or dissection-reentry in ambiguous vessel anatomy

❖ Non-tapered, soft, composite core, hydrophilic coated GW (SION)

➢ Multitasking

➢ Access to difficult take-off collaterals

➢ Crossing of non challenging collaterals channels

➢ Subintinal spaces connection and GC engagment in retrograde technigues (CART/XCART)

❖ Non-tapered, medium gram force (<6g), non coated, sliding wires (Miracle 3/4.5/6)

➢ Used to be workhorse wires for lesion crossing-tend to be abandoned

❖ Non-tapered, medium gram force (<6g), hydrophilic coated, sliding wires (Miracle Ultimate)

➢ For lesion crossing (body of the occlusion) in hard but not severely calcified plaques and non tortuous anatomy

❖ Tapered, medium gram (<6g), composite core, hydrophilic coated GW (GAIA family)

➢ Are becoming the workhorse wires for lesion crossing (body of the occlusion) in hard but not severely calcified plaques even in tourtous anatomy

➢ Subintima space connection in Retrograde techniques

❖ Tapered and not tapered w-w/o hydrophilic coating, high gram(>9) GW penetration wires (Confianza fm, PROGRESS 200T)

➢ Crossing of severely calcified spots, exchanged to other categories afterwards

Wire Options For Antegrade Wire Escalation

Polymer jacketed tapered

Fielder XT Fighter

Course of occluded

vessel known?

Stiff tapered

Gaia 2nd Confianza Pro 12

Stiff polymer jacketed

Pilot 200

Yes No

E. Brilakis



Composite Core technology

• Anti kinking structure

• Higher torque performance with W core

Tip load

XT-A = 1.0g XT-R = 0.6gW-Coil structure

SLIP-COAT® Coating 170mm0.36mm

(0.014”)30mm20mm

straight taper

“Composite core”0.26mm

(0.010”) PTFE Coating

Compatible for retrograde approach ; Length 190cm

Soft Polymeric Tappering Jacket Guide Wires

FIELDER XT-R, FIELDER XT-A

Introduced in 2012-Fusion of Technology

Description of the Deflection

In compliant lesions, stress is applied to the shaped portion of the wire;

thus, the direction in which the tip advances changes.

Sianos G.

New Wires; What we have, What is essential, What is in the horizon.

EUROCTO CLUB

The Experts Live Workshop, 2017

• Softer guide wire tends to have more deflection.

• Much easier to use deflection in order to cross the lesion.

Softer tip guide wire

Parameters Influencing the Deflection

Sianos G.


EUROCTO CLUB


Parameters Influencing the Deflection

• Stiffer guide wire possess a lot of straight direction force

→ less deflection.

Stiffer tip guide wire

Sianos G.


EUROCTO CLUB


Gaia Concept

Deflection And Rotational (Directional-torque) Control

Deflection

Rotation

Intentional control through deflection to stay true lumen

Sianos G.


EUROCTO CLUB


The Gaia Series: Anti Trapping Technology

6.

4.5

4.

3.5

2.

1.7

0. 1.5 3. 4.5 6. 7.5

ASAHI Gaia Next 3

ASAHI Gaia Third

ASAHI Gaia Next 2

ASAHI Gaia Second

ASAHI Gaia Next 1

ASAHI Gaia First

Tip Load Line Up

ACT ONE High torque performance while ensuring tip flexibility

Gaia micro-cone tip High penetration ability

XTRAND coil Anti trapping feature to avoid coil damage

Asahi Gaia Third？ Or Confianza Pro？

Plaque=intima

Lumen

Tough tissue…

Asahi Gaia ⇒ Pass by GW control ＜Deflection & Rotation＞Confianza Pro ⇒ Pass by penetration force

Ca++

Confianza Pro

Gaia

Sianos G.


EUROCTO CLUB


UB3/Pilot 150-200

Hard plaque Severe calcification

Stiffer tip

XT-A

ASAHI Gaia First

ASAHI Gaia Second

Miracle6-9

ASAHI Gaia Third

Confianza Pro12

Progress 200T

Confianza Pro

XT-R

Current Algorithm: What to Use When?

CTO (Single) Guide wire Advancement

• Sliding

• Drilling

• Penetration

• Advance - deflect - rotate - advance

CROSSING THE CTO

• Crossing the proximal cap

• Navigating through the occlusion

• Distal entry into the lumen

ACCESS WIRE POSITION

• True lumen

• Subintimal space

• Outside the vessel architecture

• 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

• 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

• 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

GW:• tapered polymer coated GW (Fielder XT, Gaia 1)

• tapered hydrophilic GW (Runthrough NS)

Dual-wire Antegrade CTO Techniques: Parallel-Wire

guidewire in subintimal space

microcatheter

initial wire left in place

crossing attempted with second guidewire

successful entry into

distal true lumenE. Brilakis



Dual-Wire Antegrade CTO Techniques: Dual Lumen Catheter

guidewire in subintimal space

microcatheterDual lumen microcatheter

second guidewire

second wire into

distal true lumenE. Brilakis



Complex Antegrade CTO Techniques: ADR

Dissection & re-entry strategies:

▪ dissection:

• Knuckle wire

• CrossBoss catheter

▪ re-entry:

• wire-based re-entry:

- STAR technique

- contrast enhanced

- mini-STAR & LAST technique

• device-based re-entry:

- Stingray balloon and guidewire

- IVUS guided

well defined proximal cap

>20 mm long CTO

good distal vessel with no side branches

at distal cap (visible via contralateral)

E.Brilakis

Manual of Coronary Chronic Total Occlusion Interventions. A Step-by-Step Approach.

Academic Press 2014, 1st Edition

How To Use The Cross Boss Catheter

Step1. deliver Cross Boss to th proximal cap

Step 2. Cross Boss torque attachment

Step 3. Fast spin

Step 4. Assess

Cross Boss in side

branch

Cross Boss partially

crosses occlusion

but does not reach

distal cap

Cross Boss crosses

CTO into distal

subintimal

space

Cross Boss partially

crosses CTO into

distal true lumem

Modify proximal cap

Increase support Redirect Advance guidewire Stingray reentryInsert workhorse

guidewire

Cross Boss does

not advance

How To Use Knuckle Wire Step by Step

Step1. decision to proceed with knuckle wire

Step 2. knuckle formation

Step 3. knuckle advancement

Step 4. Assess

Knuckle partially

reaches occlusion

but not distal cap

Knuckle crosses

CTO into distal

subintimal space

Knuckle crosses CTO

into distal true lumen

*Knukle advancement

distal to the distal cap

should be avoided as it

may create large

hematoma

Redirect • CrossBoss

• different wire

• guide support

• #microcatheter

Stingray reentry Stingray reentry if

distally

PTCA/ Stent if close

to distal cap

Knuckle in

sidebranch

Contemporary ADR vs Classic ADR

Classic ADR 2011 Contemporary ADR 2018

Set Up 8Fr. Femoral with supportive guides

AL 0.75 EBU 3.5

8 Fr. Femoral with Trapliner or 6 Fr.

Radial without guide extension

Initial Microcatheter CrossBoss Corsair/ Turnpike family 135 cm but

still end with CrossBoss to limit

dissection

Re entry Catheter Stingray Stingray

Re entry Wire Stingray wire More flexible approach: Stingray wire/

CP12/ Hornet 14/ Gaia 3/ Astato

Re entry Technique Stick and Go Stick and Swap with Pilot 200

Hematoma Management STRAW if loss of visualization of

distal vessel

Active management with Trapliner

upfront and preemptive STRAW

Pershad A.

Chronic Total Occlusion Summit 2018

Use CrossBoss to Prepare Re-entry Zone

Following knuckle Wire Following CrossBoss

Deal With Your Complications!

Φυριπλάκα Μήλος 30/ 06/ 2020

MILESTONES IN CTO WIRE TECHNOLOGIESSianos et al. BMC Cardiovascular Disorders (2016) 16:33

Chronic Total Occlusions Antegrade Approach...CTO Revascularization Evidence Considerations from a...

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