3. EURO CTO CLUB
Toulouse 2018
False lumen
GW
Subintimal tracking
as close as possible to the true lumen
True lumen
4. EURO CTO CLUB
Toulouse 2018
False lumen
GW
Creating fenestrations
by false lumen ballooning
True lumen
False lumen
balloon dilatation
5. EURO CTO CLUB
Toulouse 2018
True lumen
Immediately after false lumen ballooning
Fenestrations are widely open
0
sec
False lumen
Multiple
fenestrations
6. EURO CTO CLUB
Toulouse 2018
True lumen
False lumen
Multiple
fenestrations
Fenestrations are collapsing
3-4
sec
7. EURO CTO CLUB
Toulouse 2018
True lumen
False lumen
Fenestrations have collapsed
Collapsed
fenestrations
Collapsed
true lumen
10
sec
8. EURO CTO CLUB
Toulouse 2018
Proximal to mid RCA CTO
(bridging collateral)
AFR technique
Septal collaterals from LAD
Epicardial collaterals from LCx
9. EURO CTO CLUB
Toulouse 2018
First attempt of antegrade wire
escalation
1st wire was crossing into subintimal space
10. EURO CTO CLUB
Toulouse 2018
STEP 1
A guidewire is advanced inadvertently antegradely in the subintimal space.
The distal tip of the guidewire is located beyond the distal cap.
11. EURO CTO CLUB
Toulouse 2018
STEP 2
The microcatheter is removed leaving the first guidewire in place and the
occlusion is wired again still through the subintimal space.
12. EURO CTO CLUB
Toulouse 2018
A balloon (sized 1:1 with the artery diameter) is advanced on the first guidewire,
and is placed across the distal cap.
STEP 3
Balloon sized 1:1
14. EURO CTO CLUB
Toulouse 2018
Immediately after balloon deflation, the second wire is advanced into the true
lumen through the fenestrations created by the balloon inflation.
STEP 5
Balloon
deflation Wire into true lumen
15. EURO CTO CLUB
Toulouse 2018
Guidewire buckling
Immediately after balloon deflation
Distal true lumen wiring through the fenestrations
16. EURO CTO CLUB
Toulouse 2018
True lumen
False lumen 2nd wire in
false lumen
1st wire in
false lumen
False lumen
balloon dilatation
False lumen
balloon dilatation
Making fenestrations by false lumen ballooning
Distal Proximal
17. EURO CTO CLUB
Toulouse 2018
True lumen
False lumen
2nd wire in
false lumen
1st wire in
false lumen
Wire negotiation of re-entry to the distal true lumen
through the fenestrations
Distal Proximal
18. EURO CTO CLUB
Toulouse 2018
True lumen
False lumen
2nd wire in
false lumen
1st wire in
false lumen
Successful wire re-entry to the distal true
lumen through the fenestration
Distal Proximal
19. EURO CTO CLUB
Toulouse 2018
Distal true lumen wiring through fenestrations, immediately after balloon deflation.
Wiring through the fenestrations
20. EURO CTO CLUB
Toulouse 2018
Confirmation of distal true lumen wiring
Wiring through the fenestrations
21. EURO CTO CLUB
Toulouse 2018
Subintmal tracking
True lumen tracking
IVUS evaluation of the wire tracking route
Proximal true lumen (TL)
Patent side branch (SB)
Entry point of
subintimal tracking
Collapsed True Lumen (CTL)
Sub-occluded side branch (SOS)
False lumen (FL)
Distal true lumen
Patent side branch
SB
TL
TL
SB
SB
TL
SB
TL
SOS
CTL
CTL
FL
FL
33. EURO CTO CLUB
Toulouse 2018 Tips & Tricks
Choose the 1° guidewire according to your
preferences but the second guidewire should
be a polymer-jacketed, low-tipload guidewire
(e.g., Sion Black or Fielder family).
34. EURO CTO CLUB
Toulouse 2018
Re-entry should be attempted across distal cap of the
occlusion, and far from the takeoff of side branches.
This will allow minimizing the subintimal track and the
risk of losing side branches, and maximizing the
likelihood of achieving a good distal runoff, which are
key aspect in ADR-based CTO PCI to ensure long-term
patency rates.
Tips & Tricks
35. EURO CTO CLUB
Toulouse 2018
Re-entry into the true lumen is an iterative process, and
a few attempts might be needed before effectively
crossing, as usually happens in conventional R-CART.
Tips & Tricks
36. EURO CTO CLUB
Toulouse 2018
A 2-mm, 45° bend will provide good maneuverability and maximize likelihood of
engaging a fenestration and entering into the distal true lumen.
Recommended guidewire tip shape to perform re-entry
Tips & Tricks
38. EURO CTO CLUB
Toulouse 2018 Conclusions
• AFR is safe, relatively easy to perform
for operators familiar with subintimal
techniques.
• AFR does not preclude alternative
bailout techniques
• Even in case of failure, it acts as
investment procedure
• AFR has the potential to become part of
the expanded hybrid algorithm
39. EURO CTO CLUB
Toulouse 2018 Conclusions
• A dedicated dual-lumen balloon catheter
could further improve and simplify the
procedure, potentially facilitating the
widespread adoption of the AFR
concept.
Editor's Notes
We have developed a novel targeted ADR technique which aims at complementing the CTO operator’s armamentarium.
AFR consists in creating multiple fenestrations of the dissection flap separating the false and true lumen.
This is achieved by advancing a balloon (sized 1:1 with the artery diameter) onto the antegrade wire into the subintimal space, and inflating it at the level of the distal cap.
A second wire is therefore quickly advanced through the dissection tears and into the distal true lumen before the dissection flap collapses.
Intravascular ultrasound (IVUS) imaging immediately after antegrade fenestration and re-entry. Proximal true lumen (arrowhead indicates side-branch ostium). (B) Entry point from true to false lumen (wire in false lumen). (C)Wire in false lumen (arrowhead indicates side-branch ostium). (D)Wire in false lumen (arrowhead indicates collapsed true lumen). (E, F) Wire in distal true lumen (arrowheads indicate ostia of side-branches). (A’, C’, E’, F’) Final result corresponding to the sites indicated in (A, C, E, F).
Arrowheads indicate side-branches. The subintimal track measures 21 mm
Intravascular ultrasound (IVUS) imaging immediately after stent implantation.
A further improvement of this technique could stem from the development of a dedicated device, with a balloon component and a two lumen
structure, which could streamline the maneuvers required to
perform it.
