Chronic Total Occlusions Essential Toolbox

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

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

Event Estimate Context

Death 0.2-0.9%

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

Stone GW. et al.

Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I.

Circulation . 2005 Oct 11;112(15):2364-72

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

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

Revascularization

Advanced Strategies and Technique

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

Δῶς μοι πᾶ στῶ καὶ τὰν γᾶν κινάσωAρχιμήδης ο Συρακούσιος (περ. 287 π.Χ- περ. 212 π.Χ.)

✓ sheaths

✓ catheters

✓ wires

✓ balloons

✓ microcatheters

✓ dedicated devices

✓ IVUS

✓ other…

…from scratch: sheaths and catheters

PRO CONall TRA cannot always trap Corsair

less bleeding all ADR over long wires

less support

Corsair and trap no Stingray and trap

Stingray and trap

Corsair+branch anchor+trap usually TFA

Stingray and trap uncomfortable

real time IVUS guidance bleeding

7 FR

6 FR

8 FR

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

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

Dual-Wire Antegrade CTO Techniques: Dual Lumen Catheter

guidewire in subintimal space

microcatheterDual lumen microcatheter

second guidewire

second wire into

distal true lumenE. Brilakis

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

2nd Edition, Academic Press 2017

Wired…

Guide Wire Clinical Segmentation

During the course of CTO therapy, a variety of diverse

guidewires are needed to manage both CTO crossing and

subsequent lesion treatment

Guidewire Anatomy: the essentials

Tip styles

Core tapers &

materials

Core diameter

Coils & covers Coatings

CTO Guide Wire Milestones

1999

GUIDANT HT CROSS-IT XT

Tapered Tip Design

2008

1995

ASAHI Fielder XT

Polymer Covered Tapered

Guide Wire

SCIMEDChoice PT

1st Polymer Covered GW

ASAHI Miracle

1st Dedicated CTO spring

coil GW

TERUMOCrosswire

1st Nitinol

Hydrophilic

CTO Guide

Wire

2009

ABBOTT PROGRESS

Polymer Sleeve CTO GWi

incorporating Penetration

Power

1996

ASAHIConfianza/Pro

Tappered hydrophilic

wires

2010/11

ASAHI SION

Fielder XT-A/R

TipDouble Coil GW

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

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

Fielder XT: Precise Tip Shaping due to its Short Soldering Tip

before shaping after shaping

Spinning out of control: Torque Whip

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.

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

EUROCTO CLUB

The Experts Live Workshop, 2017

Parameters Influencing the Deflection

• Stiffer guide wire possess a lot of straight direction force

→ less deflection.

Stiffer tip guide wire

Sianos G.

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

EUROCTO CLUB

The Experts Live Workshop, 2017

The Gaia Series: Anti Trapping Technology

1,7

2

3,5

4

4,5

6

0 2 4 6 8

ASAHI Gaia First

ASAHI Gaia Next 1

ASAHI Gaia Second

ASAHI Gaia Next 2

ASAHI Gaia Third

ASAHI Gaia Next 3

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

Gaia Concept

Deflection And Rotational (Directional-torque) Control

Deflection

Rotation

Intentional control through deflection to stay true lumen

Sianos G.

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

EUROCTO CLUB

The Experts Live Workshop, 2017

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.

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

EUROCTO CLUB

The Experts Live Workshop, 2017

Sion Blue/ Sion

Guide Wire for Epicardial Channel Tracking

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?

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

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

Remember: Its Not (Only) the Size of the Stick, but the Skill of the Magician…

Αγία Τριάδα Θεσσαλονίκης 07/ 09/ 2019

Septal Crossing and Support Catheter: Corsair

tapered soft polyurethane tip

20 cm screw head structure

hydrophilic polymer coating

PTFE inner layer

Small O.D/ OTW microcatheters: Finnecross stainless steel braid structure

hydrophilic coating

PTFE inner layer

tapered diameter

catheter length 130 cm / 150 cm

optimal guidewire support