Friday 1200 – tsuchikane - retrograde std and cart approach

CTO Toyohashi Heart Center
Retrograde std and CART approach, New
micros, and specific devices to increase
support or to penetrate
Etsuo Tsuchikane, MD, PhD
Toyohashi Heart Center
Nagoya Heart Center
Gifu Heart Center

Disclosure
Within the past 12 months, the presenter or their
spouse/partner have had a financial interest/arrangement or
affiliation with the organizations listed below.
Physician Name
Etsuo Tsuchikane, MD, PhD
Company/Relationship
Abbott Vascular, Japan Consultant
Boston Scientific, Japan Consultant
Asahi Intecc, Japan Consultant

Agenda
1. New devices for retrograde channel crossing
2. Contemporary retrograde CTO crossing
3. Specific devices for antegrade penetration

Collateral channel crossing
48%
19%
11%
10%
11%
SION XT-R
SION blue Fielder FC
SUOH SION black
other
2012 61
%
18
%
7%
60%
26%
7%
Septal
Epicardial
AC
Ipsilateral
Bypass graft
68
%
17
%
7%
2013
Total (1329) 2012 (490) 2013 (538) 2014 (301) P
Guidewire cross
success
77% (1025) 78% (380) 76%(411) 78%(234) 0.8702
2012 2013
Successful guidewire
Successful collateral route
69
%
18
%
7%
2014
54
%
9%
7%
11
%
2014
Channel cross success rate

Toyohashi Heart CenterCTO
The 1st step of retrograde approach is
the collateral channel wire crossing

Reason why collateral channel crossing is difficult
Small side branch
at a bend of the artery
Acute bend
Continuous tortuosity
Invisible branch

Understand the necessity of guide wire performance
in each situation
Small side branch
Acute bend
Invisible branch
 Torque ability
 Tip lubricity
 Tip flexibility
 Tip lubricity
 Push transmission
 Tip flexibility
 Tip lubricity
 Tiny tip curve Lower tip profile
 Tip lubricity

Epicardial channel
Wire automatically go into
small side branch at a bend of
the artery
Acute bend
 maneuverability
 lubricity
 maneuverability
 lubricity
 tip flexibility
 lubricity
SION
SUOH03
SION

Acute bend
 tip flexibility
 lubricity
SUOH03
Epicardial channel

 Coating: Full Hydrophilic Coating 52cm
 Usable Length 190cm
 Radiopaque Length 3cm
 Tip Load 0.3gf
 Tip Shape Straight/ Pre-shape
ASAHI SUOH 03 Specification
Radiopaque length:
3cm
Hydrophilic coating: 52cm
SLIP-COAT®

ASAHI SUOH03 is a very flexible wire from the tip to distal.
It becomes easy to cross the small bended vessel by increasing its trackability.
ASAHI SUOH 03 Specification
Tip FlexibilityTip Load(gf)
Distance from the tip(mm)
High
Stiffness

Guidewire selection for complex channel tracking
Anatomy
Recommendable GW
Septal Epicardial
①SION
②SUOH 03
③XT-R
①SUOH 03
②SION
③XT-R (if a small channel)
SION black (if a large channel)
Small side branch
①SION
②SUOH 03
③XT-R (if a small main vessel)
SION black (if a large main vessel)
①SUOH 03
②SION
③XT-R (if a small main vessel)
Acute bend
①SUOH 03
②SION
③SION black
①SUOH 03
②SION
③SION black
Crossing invisible channel
①XT-R
②SION black
③SION
Don`t touch
Performance
which is need
Recommendable 1st.GW
Septal Maneuverability
To select side branch
SION
Epicardial Tip flexibility
To avoid perforation
SUOH 03

Proximal LAD CTO, 2nd Attempt

Epicardial channel from LCx to Dx2

Channel tracking with SUOH03

Coil embolization

AC channel
Proximal RCA CTO, 2nd
Attempt

RA before retrograde access

Tip Injection

SUOH03 crossed, but Corsair didn’t…

Caravel 135

Final angiogram

24
ⒸASAHI INTECC CO., LTD 2014; This document is for training of staff and contains confidential or privileged information.
Any distribution, copying, forwarding or citation is strictly prohibited.
Product structure
Hydrophilic coating： 75cm
Caravel Prox.
0.55mm 0.85mm
PTFE
Products Length
Coating
LengthEntry Distal Proximal Entry Distal Proximal
ASAHI Caravel
0.48 mm
(1.4 Fr)
0.62 mm
(1.9 Fr)
0.85 mm
(2.6 Fr)
0.40 mm
(0.016inch)
0.43 mm
(0.017inch)
0.55 mm
(0.022inch)
135cm 75cm
ASAHI Corsair
0.42 mm
(1.3 Fr)
0.87 mm
(2.6 Fr)
0.93 mm
(2.8 Fr)
0.38 mm
(0.015inch)
0.45 mm
(0.018inch)
0.45 mm
(0.018inch)
135cm
150cm
60cm
0.62mm
Caravel Dis.
0.43mm
PTFE

Antegrade C12 went outside…
Mid LAD CTO, 2nd Attempt

CTO exit
Tip injection

XTR crossed, but Corsair didn’t… Caravel easily crossed!
Tip of Caravel

GAIA 2nd puncture!
Contemporary reverse CART
Final angiogram

Agenda
SUOH03, Caravel microcatheter

51%
35%
14%
1%
61%
26%
13%
1%
0%
20%
40%
60%
Reverse CART Retrogradewire
cross
Kissing wire
cross
CART
2012 2013
Sumitsuji et al. JACC Cardiovasc Interv 2011
Patterns of Success in Retrograde Approach
Procedure characteristics (3)
CTO crossing
Total (1028) 2012 (490) 2013 (538) P
Guidewire cross 65.5% (673) 69.0% (338) 62.3%(335) 0.0033

Guidewire for CTO crossing (1)
Retrograde cases
Reverse CART
29%
16%
12%
8%
8%
7%
21%
FFC
SION
ULTIM3
XT-R
Gaia 1
Gaia 2
other
30%
15%
13%
10%
6%
27%
Gaia 2
SION
ULTIM3
Gaia 1
XT-R
Other
Retrograde wire cross
25%
11%
10%
9%
7%
7%
31%
ULTIM3
FFC
ConPro
Gaia 1
XT-R
Gaia 2
other
27%
19%
13%
11%
5%
25%
Gaia 2
Gaia 1
ULTIM3
SION
XT-R
other
P<0.05
2012 2013
2012 2013

Kissing wire cross
36%
16%10%
7%
32%
ConPro
Gaia 1
Gaia 2
ULTIM3
other
33%
30%
10%
10%
17% Gaia 2
ConPro
Gaia 1
Gaia 3
Other
P<0.05
2012 2013
Guidewire for CTO crossing (2)
Retrograde cases

Mid RCA CTO, 2nd Attempt

RA 1.5
Before antegrade preparation…

Ultimate 3
Crusade
Antegrade preparation with non-tapered wire in DLC

occlusion
RV wire
Ultimate 3
outside vessel!

GAIA 2
Contemporary reverse CART

EES 2.5*28
Extravasation!
After EES implantation

BVS 3*28
7Fr Guideliner
Long BVS delivery through Guideliner

BVS 3.5*18 EES 3.5*23
Another BVS and EES delivery

Traditional bilateral wiringGuideliner DeliveryGuideliner reverse CART
7Fr Guideliner
Final angiogram

Limitations of
Contemporary Reverse CART
 Short CTOs
 Long CTOs w/wo ambiguous vessel course
 Impossible case
 Difficult antegrade ballooning for rCART

RCA CTO

Difficult for reverse CART because of short occlusion

Attempt at retrograde direct wire crossing by GAIA 2nd

Successful retrograde wire crossing by GAIA 2ndManipulation of GAIA 2nd

Final angiogram

Limitations of
 Short CTOs
 Impossible case
 Careless antegrade preparation is dangerous!

Simultaneous injection

Antegrade wiring using GAIA 2nd

Antegrade GAIA looks outside the vessel…

Retrograde wiring using Ultimate 3

Successful reverse CART

Type 1 perforation

Limitations of
 Short CTOs
 Impossible case
 Still we need non-tapered wire or knuckle wire

calcification

Calcification disturbed retrograde direct crossing and kissing wire.

Calcification disturbed retrograde knuckle wiring.

Calcification disturbed antegrade balloon crossing.
diffuse plaque
Impossible reverse CART!

Original CART!

Retrograde balloon trapping enabled antegrade balloon crossing.
antegrade balloon

Limitations of
 Short CTOs
 Impossible case
 Still we need non-tapered wire or knuckle wire
 Traditional CART

Agenda
Mainly reverse CART, but don’t forget CART!

Multifunction Catheter having two Guidewire lumen (RX / OTW)
for Side Branch Access; especially helpful for GW manipulation in
Bifurcation Stenting procedure

Use of Double Lumen Catheter (DLC)
In CTO-PCI
 Antegrade approcah
1. Increase penetration force
2. Change penetration position
3. Parallel wiring
4. Retrieve side branch
5. Reverse wiring
6. Side branch technique
 Retrograde approcah
1. Second system through collateral channel

The outcome of the evaluation
- Guidewire support -
Floppy
Stiff
(courtesy of Dr. Ochiai)

Case: Proximal LAD-CTO

GAIA with Corsair

Crusade in proximal branch

GAIA with Crusade GAIA with Corsair

GAIA with Crusade

GAIA in diagonal branch

Case: Proximal LCx tandem CTOs

GAIA with Caravel in subintimal space

Another GAIA with Crusade (parallel wiring)

Successful parallel wiring

The outcome of the evaluation
Guidewire Support
(courtesy of Dr. Ochiai)

Use of Double Lumen Catheter (DLC)
In CTO-PCI
 Antegrade approcah
1. Increase penetration force
2. Change penetration position
3. Parallel wiring
4. Retrieve side branch
5. Reverse wiring
6. Side branch technique
 Retrograde approcah
1. Second system through collateral channel
Advantage
The 1st wire is quite stable.
Penetration force of the 2nd wire becomes
higher.
Disadvantage
Predilatation is sometimes required.
Seesaw wiring is unavailable.

Agenda
Mainly reverse CART, but don’t forget CART!
Double lumen microcatheter

17th CTO Club
June 17-18, 2016, Nagoya, Japan
www.cct.gr.jp/ctoclub

Guide wire selection for complex channel tracking
Anatomy Performance
which is need
Recommendable GW
Septal Epicardial
 maneuverability
 tip flexibility
 lubricity
①SION
②SUOH 03
③XT-R
①SUOH 03
②SION
③XT-R (if a small channel )
SION black (if a large channel)
Small side branch
 non tapered tip
 maneuverability
 lubricity
①SION
②SUOH 03
③XT-R (if a small main vessel )
①SUOH 03
②SION
③XT-R (if a small main vessel )
Acute bend
 tip flexibility
 lubricity
 maneuverability
①SUOH 03
②SION
③SION black
①SUOH 03
②SION
③SION black
Crossing invisible
branch
 low tip profile
 lubricity
 tip flexibility
①XT-R
②SION black
③SION
Don`t touch
Performance
which is need
Recommendable 1st.GW
Septal Maneuverability
To select side branch
SION
Epicardial Tip flexibility
To avoid perforation
SUOH 03

RCA tandem CTOs, 2nd Attempt

Epicardial channel
SUOH03
Corsair/Finecross failed…

Caravel easily crossed without anchoring.
Final angiogram
Finecross 150 followed.

CTO length
28.87mm
CPR
Proximal LAD CTO, 2nd Attempt

Fielder FC with Corsair

SION crossed, but Corsair didn’t…

Finecross 150

Friday 1200 – tsuchikane - retrograde std and cart approach

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