14th Experts "Live" CTO September 2nd- 3rd, 2022 - Mainz, Germany Main Session - Session 3: Advanced antegrade techniques ADR in 2022 – evolution of device based reentry Dimitrios Karmpaliotis, Morristown, USA Room: Guteberg Hall (Auditorium) - Friday 16:50 Chairmen: Georgios Sianos, Thessaloniki, Greece; Masahisa Yamane, Sayama City, Japan; Jaroslaw Wójcik, Lublin, Poland

1. ADR in 2022– Evolution of device re-
entry
Dimitri Karmpaliotis, MD,PhD FACC
Director of CTO, and Advanced Coronary Therapeutics
Director of the Cardiovascular Rescue and Recovery Program
Morristown Medical, NJ, USA
14th Experts Live CTO, annual EURO CTO Club Congress
Mainz, Germany, September 2-3, 2022
Email: dkarmp@gmail.com
@DKarmpaliotis

2. Within the past 12 months, I have had a financial
interest/arrangement or affiliation with the organization(s)
listed below.
Affiliation/Financial Relationship Company
Consulting Fees/Honoraria Abott Vascular, Boston Scientific
Equity Soundbite, Saranas, Traverse Vascular
Disclosure Statement of Financial Interest

3. Antegrade Dissection Re-Entry (ADR)
1. Evolution of the technique with regards its place in the various
algorithms
2. Technical aspects that have evolved during the original
Stingray based reentry
3. I will not discuss AFR since it is not a device based re-entry
4. I will not discuss dual lumen catheter based re-entry since personally
I have not had reasonable success
5. I will present a new re-entry microcatheter the Traverse Vascular

4. Successful crossing strategy stratified by J-CTO score
88,3%
71,6%
50,6%
31,9%
17,3% 16,9%
5,8%
14,7%
20,5%
24,1%
21,6% 20,2%
3,1%
9,0%
19,7%
35,3%
41,5% 43,6%
0%
20%
40%
60%
80%
100%
J-CTO Score 0 J-CTO Score 1 J-CTO Score 2 J-CTO Score 3 J-CTO Score 4 J-CTO Score 5
Retrograde
ADR
AWE
p<0.0001

5. 4.3
2.1
0.4
1.3
0.6
0.8
1.1
0.3 0.3 0.3
0.1 0.1
0
1
2
3
4
5
MACE MI Stroke Pericardiocentesis Re-PCI Death
Complication
rate
(%)
Retrograde
Antegrade-only
Retrograde vs. antegrade-only: in-hospital MACE
p<0.00
1
p=0.00
3
p=0.999
p=0.03
9
p=0.314
p=0.16
7
Karmpaliotis D, et al
Circ Cardiovasc Interv 2016 Jun;9(6)

6. CTO PCI: the world is converging

7. Antegrade Dissection Re-Entry (ADR)
1. Who is the ideal candidate for ADR
2. Basic Concept/Description of the Technique
3. Case Examples
4. How to Start, especially with ambiguous Proximal Cap
5. How to Navigate the Body of the Occlusion
6. How to Manage/Protect the Landing Zone
7. How to Re-Enter/Stick and Swap
8. Troubleshooting/Overcoming Difficulties

8. Antegrade Dissection Re-Entry (ADR)
Basic Concept/Tools/Description of the Technique

9. Antegrade Dissection Re-Entry
• Subintimal wire position is obtained
• Space is made in subintimal space (SIS) by gentle ballooning
• Re-entry catheter is advanced into (SIS) proximal to desired re-
entry point along supportive wire (Miracle Bros 12)
• Re-entry into true lumen achieved using stiff re-entry wire via
catheter is conduit

10. Antegrade Dissection Re-Entry (ADR)
Case Example

18. Antegrade Dissection Re-Entry (ADR)
1. How to Start, especially with ambiguous Proximal Cap
2. How to Navigate the Body of the Occlusion

19. The Scratch ‘n Go

27. Antegrade Dissection Re-Entry (ADR)
Troubleshooting/Overcoming Difficulties

28. Bobsledding
- After unsuccessful
StingRay re-entry, the
balloon is deflated and
pushed forward
downstream in the
subintimal space without
a leading guidewire to
allow for a fresh zone to
attempt re-entry

29. Bobsledding
- After unsuccessful
StingRay re-entry, the
balloon is deflated and
pushed forward
downstream in the
subintimal space without
a leading guidewire to
allow for a fresh zone to
attempt re-entry

30. STRAW
- Method used to aspirate
subintimal hematoma
which may develop in the
dissection plane by
placing an over the wire
balloon or microcatheter
next to the Stingray
balloon and aspirating.
Subintimal Transcatheter Withdrawal

31. Knuckle Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by creating
a large knuckle wire (Pilot
200) which is more likely
to follow the parent vessel
architecture, thus allowing
the CrossBoss to be
redirected to the desired
landing zone

32. Knuckle Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by creating
a large knuckle wire (Pilot
200) which is more likely
to follow the parent vessel
architecture, thus allowing
the CrossBoss to be
redirected to the desired
landing zone

33. Pilot Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by using a
Pilot 200 with longer tip
angle which can be
steered away from the
sidebranch and down the
parent vessel, thus
allowing the CrossBoss to
be redirected to the
desired landing zone

34. Pilot Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by using a
Pilot 200 with longer tip
angle which can be
steered away from the
sidebranch and down the
parent vessel, thus
allowing the CrossBoss to
be redirected to the
desired landing zone

35. Pilot Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by using a
Pilot 200 with longer tip
angle which can be
steered away from the
sidebranch and down the
parent vessel, thus
allowing the CrossBoss to
be redirected to the
desired landing zone

36. Re: Provisional U.S. Patent Application
Title: REENTRY CATHETER AND METHOD FOR TRAVERSING
CHRONIC TOTAL OCCLUSIONS
Application No.: 62/907299
Filed: September 27, 2019
CEO : Brad Klos
Founder : William Nicholson, MD
Intellectual Property :Gerard von Hoffmann (EVOLVE/MEDTECH)
Advisory Board : William Lombardi, MD
Dimitri Kamparliotis, MD
Michael Wyman, MD
David Kandzari, MD

38. • Current 3Fr catheter
• ID = 0.028"
• 6 ports @ 0.015" x 0.034"
• suction rate = 0.06ml/s or .6ml in 10s

44. Traverse
Vascular
• First in Man Experience
• Device Specifications
• Visibility
• Size
• Device Performance
• Trackability
• Aspiration
• Re-entry

49. Thank You

50. Thank You