Antegrade dissection and haematoma Elliot Smith, London, United Kingdom 10th Experts „Live“ CTO Workshop - Day2

1. Elliot Smith MD FRCP
Barts Heart Centre, London, UK
Antegrade Dissection and Haematoma
How to Avoid and How to Resolve
EURO CTO CLUB
Toulouse 2018

2. Iteration and Quantum leaps in
the CTO space
Antegrade wiring Retrograde
collateral access
EURO CTO CLUB
Toulouse 2018

3. Iteration and Quantum leaps in
the CTO space
Wire/balloon/stent
INTIMAL PLAQUE
SUB INTIMAL /
SUB ADVENTITIAL
TRACKING
EURO CTO CLUB
Toulouse 2018

4. Antegrade Dissection and Re-entry (ADR)
Crossboss
Stingray
1mm blunt tip
multi wire coiled shaft
rapid spin motion
OTW balloon design
‘Flat’ balloon
180° exit ports
0.014 wire
Stiff with barb

6. Re-entry
– CB / SR 70%
(SR 56%: CB T – T 15%)
– Wire based / LAST 25%
– STAR 4%
Antegrade Dissection Re-entry ADR (24%)
UK Hybrid CTO Database n=1389
Wilson et al.
EURO CTO CLUB
Toulouse 2018

7. ADR failure modes
Haematoma
47%
Calcification
21%
Other
19%
Proximal cap
penetration
13%
UK Hybrid CTO Database n=1389
Wilson et al. In press
EURO CTO CLUB
Toulouse 2018

8. The problem

9. The mechanism

10. Haematoma Management
• Risk factors for loss of visualisation
– Anatomical
– Procedural
• Prevention
• Intervention

11. Distal
Tissue
Resistance
Collateral Filling
Pressure
No Progression Dissection propagation
Knuckle size /
Mechanical force
Pressure
Active
Pressure
Passive
The Balance of Sub-intimal Dissection
EURO CTO CLUB
Toulouse 2018
Modified from figure Courtesy James Spratt

12. – Poor collateral filling (CC0 / 1)
– Small, diseased distal vessel
– Location of collateral entry
– High dependence on ipsilateral collaterals
Predictors of haematoma - anatomical

13. Sub-intimal Rule No 1
• NO antegrade injections
– Cover or disconnect the antegrade manifold
– No antegrade catheter flush
Pressure - Active

14. No Antegrade Injections
Use Dual Catheter Contralateral Injections

15. Avoid micro catheter Injections

16. High dependence on
ipsilateral collaterals
Small, diseased distal vessel
Poor collateral filling (CC0 / 1)
Predictors of hematoma - anatomical
EURO CTO CLUB
Toulouse 2018

17. Solution - Control / manage the space
EURO CTO CLUB
Toulouse 2018

18. Control the space?
• Use of CrossBoss for blunt
dissection
– Small controlled dissection plane
• Limit proximal dilatation or at the
cap (1.5mm balloon)
• Preparation - to reduce
microcatheter exchanges (e.g.
CrossBoss to Stingray)
• Guide Extension / Trapliner

19. Diffuse landing zone
High dependence on ipsilateral
collaterals
Poor collateral filling (CC0 / 1)
Location of collateral entry
Small, diseased distal vessel
EURO CTO CLUB
Toulouse 2018

20. Diffuse landing zone
Solution: Understand that some retrograde collaterals filling the
dissection plane – limit retrograde injections

21. Predictors of hematoma - procedural
• Ante-grade injection /
flush
• Propagation / large
knuckle
• Cap dilatation

22. Knuckle Wires
• Manage resistant
lesions
• Negotiate side
branches
• Negotiate
tortuosity

23. Case Illustration
Ambiguous Cap, calcium, >20mm

24. Proximal cap puncture – Pro 12

25. De-escalate to XT
Wire tracks Pro 12 space, conforms to vessel

26. Knuckle wire, then finish landing zone
with CrossBoss
Antegrade knuckle Rapid progression of Cross Boss

27. Managing the Space
Knuckle wire CrossBoss

28. Stingray balloon
Note proximal anchor

29. Stingray re-entry
Stingray re-entry - DOWN

30. Stingray re-entry stick and drive

31. Final result outflow all branches

32. Long calcific CTO

33. Formation of XTA knuckle

34. Knuckle for tortuosity, NOT beyond bifurcation

35. Distal
Tissue
Resistance
Collateral Filling
Pressure
No Progression Dissection propagation
Force
Mechanical
Pressure
Active
Pressure
Passive
The Balance of Sub-intimal Dissection
EURO CTO CLUB
Toulouse 2018
Courtesy James Spratt

36. Stingray re-entry

37. Final result

38. Ante-grade injection or
flush
Micro catheter injection
Propagation / large
knuckle
Cap dilatation
Intervention for Haematoma?

39. Intervention for Haematoma
Anchor
Balloon
Lesion
undilatable
Progression of knuckle

40. Intervention for Haematoma
Further Progression of knuckle

41. Subintimal TRAnscatheter Withdrawal of
compressive hematoma (STRAW)
Smith EJ et al. Subintimal TRAnscatheter Withdrawal (STRAW) of hematomas compressing the distal true lumen: a novel
technique to facilitate distal reentry during recanalization of chronic total occlusion (CTO).
J Invasive Cardiol. 2015 Jan;27(1):E1-4.

42. STraW
Decompression &
Re-entry
Sub-intimal hematoma
Distal lumen compression
Aspiration

43. Successful decompression and re-entry
Smith EJ et al. Subintimal TRAnscatheter Withdrawal (STRAW) of hematomas compressing the distal true lumen: a novel
technique to facilitate distal reentry during recanalization of chronic total occlusion (CTO).
J Invasive Cardiol. 2015 Jan;27(1):E1-4.

44. Compatibility and Reproducibility

46. TOMA set up: Modified STRAW aspirating through SR restores
visualization
Courtesy Catalin Toma

47. TOMA set up: Modified STRAW aspirating
through SR restores visualization
Courtesy Catalin Toma

48. Courtesy Catalin Toma
Loss of visualization

49. TOMA set up: Modified STRAW aspirating through SR restores
visualization
Courtesy Catalin Toma

50. EURO CTO CLUB
Toulouse 2018
Uncomplicated re-entry

51. • DON’T let knuckle progress beyond distal cap
• Keep knuckle tight
• XT tight, better penetration, more side branches
• Pilot 200 bigger knuckle greater power
Prevention remains better than cure

52. ◼ Wire trap prevents
inadvertent wire
propagation
Prevention remains better than cure

53. Same rules for retrograde
Propagation of
antegrade
knuckle

54. Managing outflow compression
Allow the antegrade flow to re-pressurise
EURO CTO CLUB
Toulouse 2018

55. Courtesy of Minh Vo
Managing outflow compression

56. Use of Cutting Balloon
Courtesy of Minh Vo

57. Conclusions - Haematoma
• Haematoma most common failure mode for ADR
• No Antegrade injections
• Control knuckle
– Not too big, Not too far
• Meticulous control of position during exchange
– Use trap technique
• Use of CB catheter
• Control inflow to sub-intimal space –guide extension
• Use of STRAW or modified STRAW to aspirate haematoma
• Outflow – re-pressurize the vessel, consider cutting balloon release
EURO CTO CLUB
Toulouse 2018

58. Thanks
Colleagues
• James Spratt
• Adrian Brown
• Craig Thompson
• Aaron Grantham
• Bill Lombardi
• Tony Demartini
• Carlo DiMario
• Minh Vo
• Catalin Toma
• Mauro Carlino
• UK Hybrid CTO operators
• CTO fundamentals community
• Barts Heart Centre, Hammersmith

59. Formation of XTA knuckle

60. Finish landing zone with CrossBoss to keep dissection
plane small
Preparation of Landing Zone with Cross
Boss

61. Why knuckle?
• Negotiate Calcification
• Tortuosity
• Anatomical ambiguity
• Distance
• Safely
Principle
Pressure = Force / Area
Adventitia distensible, but easily penetra

62. 1.Cap puncture / proximal entry
2.Formation of knuckle
3.Follow with micro catheter
4.Advance to base of operations
(distal / proximal cap)