14th Experts "Live" CTO September 2nd- 3rd, 2022 - Mainz, Germany Main Session - Session 2: Selecting the patient and planning the procedure B New developments in wire based antegrade approach Abdul Mozid, Leeds, United Kingdom Room: Guteberg Hall (Auditorium) - Friday 13:20 Chairmen: Alexander Bufe, Krefeld, Germany; Leszek Bryniarski, Krakow, Poland; Hans Bonnier, Nuenen, Belgium

1. New developments in wire based
antegrade approach
DR ABDUL MOZID
CONSULTANT INTERVENTIONAL CARDIOLOGIST
LEEDS GENERAL INFIRMARY, UK

2. Disclosure Statement of Financial Interest
• Abbot Vascular
• Boston Scientific
• IMDS
• SMT
Consulting/speaker honoraria:

3. EuroCTO Club
algorithm

4. Why do we need new antegrade
techniques?
EuroCTO Registry
Success rates
plateaued at around
88-90% in registries
Is there room for
improvement?

5. Why do we need new antegrade
techniques?
Progress CTO Registry
Higher
complication rate
with retrograde
procedures
Is there room for
improvement?
AWE J-CTO score 2.28 ADR J-CTO score 2.86 RDR J-CTO score 3.12

6. Why do we need new antegrade
techniques?
No retrograde or ADR
options
Case needs to be
completed by
antegrade wiring

7. Evolution of antegrade techniques
 Antegrade wiring
 Parallel wiring Ochai et al 2005
 Sub-intimal tracking and re-entry (STAR) Colombo et al 2005
 Mini STAR Galassi et al 2012
 Stingray Antegrade Dissection Reentry (ADR) Thrompson et al 2012
 Antegrade Fenestration and Reentry (AFR) Carlino et al 2017
 Dual guidewire balloon AFR (DGB-AFR) Galassi et al 2022

8. AFR Technique
By Dual Guide Wire Balloon
First RX guidewire
in dissection
Balloon
Second OTW guidewire for re-entry
Courtesy of Prof Galassi

9. Galassi et al, CCI 2022

10. DGB-AFR Example Case RCA CTO
Courtesy of Professor Alfredo Galassi

11. Gaia 2
(Asahi Intecc)
Corsair
(Asahi Intecc)
Penatration CTO body by stiff guide wire

12. Saphire 2.0x15
(Orbus Neich)
Enlarging space in sub-intima by bigger balloon inflation
for AFR technique
Gaia 2
(Asahi Intecc)

13. Dual
Guidewire
Balloon
in place
2.5x 20 mm
Balloon
Inflation for
Antegrade
Fenestration
Dual Guide Wire Balloon (2.5x20 mm)
in place for AFR technique

14. Mode of
action
Searching
for Reentry
by second
polymeric
wire
Pilot 150
(Abbott)
Dual Guide Wire Balloon (2.5x20 mm)
for AFR technique

15. Final result
Dual Balloon Guide Wire AFR technique

16. Antegrade
wiring
algorithm
Azzalini et al CCI 2020

17. ReCross Catheter

18. My ReCross Experience
ReCross introduced Aug 2021:
• ReCross taken as upfront MC in 23% of cases
• 27 of 29 CTO ReCross cases successful
• Predominant use for wire redirection/parallel wiring
ReCross Case Characteristics:
• J-CTO Score 1-4
• (mean 2.1)
• Occlusion length 15-40mm
• (mean 19.7mm)

19. Personal success rates
0
10
20
30
40
50
60
70
80
90
100
2018/19 2019/20 2020/21 2021/22
Antegrade Retrograde ADR
% of
cases
% of
success
ReCross
catheter
introduced
August 2021

20. ReCross catheter versatility
 Antegrade wiring
 Guidewire redirection
 Parallel wiring
 Antegrade dissection re-entry
 Dual lumen catheter

21. Case 1 LAD CTO
ReCross assisted
antegrade wiring
with side branch
anchor wire
Baseline

22. Distal wiring
Case 1 LAD CTO
ReCross antegrade wiring with side branch
anchor wire
ReCross: Sion blue in septal via blue hub
XTA from white hub to tip port

23. Final
Case 1 LAD CTO
ReCross antegrade wiring with side branch
anchor wire
Rota 1.5mm burr

24. Baseline dual injection: LIMA and LCA
Case 2 LMS
and Cx CTO
ReCross
assisted
antegrade
wiring- multiple
uses

25. ReCross 1st use: MC for LAD wiring Pilot 200 Recross 2nd use: Side port wiring of LCX
Case 2 LMS and Cx CTO
ReCross assisted antegrade wiring- multiple uses

26. ReCross 3rd use: Dual lumen catheter
proximal LCX/OM
ReCross 4th use: Dual lumen catheter
distal LCX/OM
Case 2 LMS and Cx CTO
ReCross assisted antegrade wiring- multiple uses

27. Case 2 LMS and Cx CTO
ReCross assisted antegrade wiring- multiple uses

28. Baseline
Case 3 LAD CTO
ReCross assisted
guidewire
redirection at
proximal cap

29. ReCross- Pilot 200- Subintimal
Case 3 LAD CTO
ReCross assisted wire redirection proximal cap
Wire redirect: Recross plugs SIS: Pilot 200
from proximal side port

30. ReCross crossed with anchor balloon
Case 3 LAD CTO
ReCross assisted wire redirection proximal cap
Final result, DEB to outflow

31. Baseline dual injection
Case 4 RCA CTO
ReCross assisted
intraplaque wire
redirection

32. Baseline dual injection
Pilot 200 subintimal
AWE: ReCross XTA,
Pilot200-> CP12
Case 4 RCA CTO
ReCross assisted wire redirection

33. Proximal side port: wire redirection
Case 4 RCA CTO
ReCross assisted wire redirection

34. Final
Case 4 RCA CTO
ReCross assisted wire redirection

35. Case 5
Intermediate
artery CTO
ReCross
assisted
extraplaque
wire
redirection

36. Case 5 Intermediate artery CTO
ReCross assisted extraplaque wire redirection

37. Case 5 Intermediate artery CTO
ReCross assisted extraplaque wire redirection

38. Baseline
Case 6 LAD CTO
ReCross assisted
ADR

39. Baseline
Wiring out distal side port CP 12 Subintimal
Case 6 LAD CTO
ReCross assisted ADR

40. Recross subintimal on top Re entry Astato 20
Case 6 LAD CTO
ReCross assisted ADR

41. Final
Case 6 LAD CTO
ReCross assisted ADR

42. Baseline dual injection
Case 7 LAD CTO
ReCross assisted
ADR

43. Difficult antegrade wiring
Crossed with Confienza
Sub-intimal into SVG
ADR with ReCross IVUS: Long subintimal passage
Case 7 LAD CTO
ReCross assisted ADR

44. Retrograde septal wiring with Sion
ReCross as Dual lumen to wire true lumen
Confirmed on IVUS
Case 7 LAD CTO
ReCross assisted ADR

45. Final result
Case 7 LAD CTO
ReCross assisted ADR
Final result

46. Case 8
Circumflex
artery CTO
ReCross
assisted
parallel wiring

47. Case 8 Circumflex artery CTO
ReCross assisted extraplaque wire redirection

48. Conclusion
Azzalini et al CCI 2020

49. Thank you

50. Thank you