This document discusses case selection and strategies for antegrade dissection and re-entry (ADR) for chronic total occlusions. It recommends ADR as the primary approach when there is a good proximal cap and landing zone and lesion length is greater than 20 mm. Retrograde wiring or dissection re-entry may be better for ambiguous caps, tortuous lesions, or heavy calcification. The document reviews equipment options and techniques for ADR including re-entry devices like CrossBoss and Stingray. It emphasizes protecting the subintimal space during the procedure.
Case Selection for Antegrade Dissection and Re-Entry
1. Case Selection for Antegrade
Dissection and Re-Entry
Tony DeMartini MD
Edward Heart Hospital, Naperville, IL, USA
September 14, 2018
2.
3. Retrograde approach
Primary use of KWT and/or dissection re-entry
• Ambiguous course in CTO
• Tortuous CTO segment
• Heavy calcification
Rescue use of KWT and/or dissection re-entry
• Length >20 mm
• Previous failed attempt
Consider stopping if >3 hours, 3.7 x eGFR ml contrast, Air Kerma > 5 Gy unless procedure well advanced
Proximal cap ambiguity IVUS guided entry
No
Poor quality distal vessel or
bifurcation at distal cap
Careful analysis of angiogram / MSCT
No
Yes
Yes
No
Interventional collaterals present
Yes
No
Yes
In-stent restenosis
Consider use of CrossBoss as
primary crossing strategy
for straight ISO
Antegrade wire
based approach
Dissection Reentry
(Stingray)
Parallel wiring
If suitable
re-entry
zone
IVUS guided wiring
4. Retrograde approach
Primary use of KWT and/or dissection re-entry
• Ambiguous course in CTO
• Tortuous CTO segment
• Heavy calcification
Rescue use of KWT and/or dissection re-entry
• Length >20 mm
• Previous failed attempt
Consider stopping if >3 hours, 3.7 x eGFR ml contrast, Air Kerma > 5 Gy unless procedure well advanced
Proximal cap
ambiguity
IVUS guided entry
No
Poor quality distal vessel or
bifurcation at distal cap
Careful analysis of angiogram / MSCT
NO
Yes
Yes
No
Interventional collaterals present
Yes
NO
Yes
In-stent restenosis
Consider use of CrossBoss as
primary crossing strategy
for straight ISO
Antegrade wire
based approach
Dissection Reentry
(Stingray)
Parallel wiring
If suitable
re-entry
zone
IVUS guided wiring
5. ADR
• Ideal anatomy is good proximal cap with good landing zone
• Mostly used when lesion length greater than 20 mm
• Secondary strategy when AWE is planned
• Not a bailout for AWE
23. Conclusions
• ADR preferred approach with:
• Good Proximal Cap
• Good Landing Zone
• Lesion length greater than 20 mm
• Learn the gear to allow for safe, successful and efficient procedures
• Secondary strategy for AWE; not bailout strategy
• Protect the Subintimal Space
