12th Experts Live CTO The annual Euro CTO meeting September 11th –12th, 2020 - Berlin, Germany

1. Plan the approach based on
the angiogram
J.Dens
EuroCTO 2020
Berlin

2. Within the last 3 years
• I have recieved no grant from a company/institution
• I have been a speaker for Abbott, BSCI
• I have been a consultant for Asahi, BSCI, IMDS, Terumo
• I do not hold stocks/shares of involved companies
• Board member EuroCTO, BWGIC, BWGCTO

3. Plan is based on the angio but don’t forget the patient
• Access?
• Single remaining donor vessel?
• LV function?
• Renal function?

4. The diagnostic is not the interventional angiogram
• The diagnostic angio gives an idea about treatment possibilities, but
never is the final one.
• The interventional angio (double injection) is the angio that will
determine your first and following strategies.
• Use nitrates, low magnification (13 inch), no panning, long acquisition, donor
vessel first (MC selectively in donor branch)

5. Decide on different techniques from an ante/retro approach
wiring techniques (escalation/de-escalation) vs. dissection techniques

6. The 4 points to look at:
one has to go from A to B (or B to A)
A = proximal cap
B = distal target
C = CTO body
D = collaterals

7. Part 1: the proximal cap:
Different approaches according to angio

8. Proximal cap absence: go retro
• Aorto-ostial occlusion
• J-CTO 5
• Blunt stump: ostial occlusion
• Calcified
• Bend > 45? Guide position?
• LL> 20 mm
• Re-attempt
• Hybrid & Pacific & Progress
• No cap = retro

9. Proximal cap ambiguity: go retro unless solved
Can it be solved?
Continue antegrade
if not: retro

10. Solve cap ambiguity by IVUS

11. Solve cap ambiguity by “move the cap
techniques”

13. Solve cap ambiguity by retrograde gear: you can
switch strategy: antegrade cap puncture
Solved prox cap
ambiguity…
decreasing
complexity

14. The proximal cap: clear entry point and vessel
course: go antegrade
Tapered Blunt

15. WiringCTO
withTapered
Cap
WiringCTO with
Blunt Proximal
Cap
WiringCTO +
Navigating
Calcium
Wiring
Collaterals
Fielder/Fighter Confianza/Hornet/Astato Gaia/Judo/UB… Sion / Suoh03 /
Sion Black
Tapered polymer wire Heavy penetrativewire SteerableWire Flexiblehydrophilic/
polymer wire
Different caps = different wire to start (ante + retro)
N
Ambiguity needs to be
solved:
IVUS
BASE – SBASE
Scratch & go
Retro

16. Additional proximal vessel/cap features
• Diseased proximal segment
• Pressure dampening (ischaemia, dissection, thrombus…)
• Side branch proximal or at the cap:
• Anchoring (RAC conus, LAD S1…)
• Allows double lumen catheter use (SB wire from SP, will increase support to
puncture)
• Allows IVUS use to perform IVUS guided cap penetration
• IVUS device dependent on lenght/diameter SB
• Allows SIDE-BASE

17. Antegrade cap preparation first (before retro)
yes
• Occlusion is long/complex
• Tolerability is a potential issue
• Prox cap is haevely calcified
No
• Occlusion is short
• Proximal vessel is of good quality
• RWE is the initial strategy
Reduced time the retro system is engaged (reduction of ischaemia, donor artery
issues)
Quick swich to reverse CART
Reference for retro wire cross

18. Part II: crossing the CTO-body

19. WiringCTO
withTapered
Cap
WiringCTO with
Blunt Proximal
Cap
WiringCTO +
Navigating
Calcium
Wiring
Collaterals
Fielder/Fighter Confianza/Hornet/Astato Gaia/Judo/UB… Sion / Suoh03 /
Sion Black
Tapered polymer wire Heavy penetrativewire SteerableWire Flexiblehydrophilic/
polymer wire
Different bodies = different wire to continue (ante + retro)
Wire-escalation Wire-de-escalation

20. CTO body course
• Lenght (often overestimated)
• >20 mm = increasing difficulty to wire intra-plaque – be prepared for other
techniques
• Quality
• Calcification = landmarkers of the course, but more difficult to cross
intraplaque
• Tortuosity (risk of perforation/exit)
• Contrast islands = landmarkers

21. CTO body: if the wire is extra-plaque (subintimal)
• Redirection needed:
• Clear (non-ambiguous) vessel course:
• paralel wiring
• Double lumen catheter redirection (Sasuke, Nhancer RX, twinpass, fine duo…)
• Triple lumen redirection (Recross)
• Unclear (ambiguous) vessel course: might require knuckle first
• Stingray re-entry
• IVUS guided re-entry
• STAR/LAST

22. ADR

23. IVUS-guided re-entry

24. STAR

25. Part III:
distal vessel & landingzone/target

26. Distal vessel quality and approach
• Size
• Small, diffuse disease: if AW not possible, retro needed
• Calcification
• Re-entry = difficult, retro prefered if possible
• Bifurcation
• Re-entry = difficult, lower treshold for retro or “pick-up” needed
• Anastomosis of previous graft
• Distortion, tenting, difficult SI-crossing

27. Part IV: Collaterals
Are they suitable to cross? If not you can only go antegrade (wiring, dissection)

28. Collaterals
Ipsi vs contralateral
Septal/epicardial/grafts

29. Retrograde: interventional collaterals
Brilakis et al, Cath CV Intv 2012

30. Retrograde Collateral Quality
Courtesy of Dr. Spratt, Walsh, Hanratty

31. Retrograde Angle
Courtesy of Prof Paul Hsien-Li Kao

33. CONCLUSIONS
PUTTING IT ALL TOGETHER…

34. Brilakis, Hybrid algorithm
If prox cap not clear, solve the ambiguity

35. Harding, Asia-Pacific algorithm
Prox cap ambiguity
solved with IVUS
Q of distal vessel
ADR/PW/Ivus guided re-entry

36. Harding, Asia-Pacific algorithm
Prox cap ambiguity
solved with IVUS
Q of distal vessel
ADR/PW/Ivus guided re-entry