8th Experts Live CTO Workshop 2016, September, 30th - October 1st, 20116 in Krakow, Poland

1. Antegrade dissection re-entry step
by step
EuroCTO Club
September 30, 2016
Emmanouil S. Brilakis, MD, PhD
Minneapolis Heart Institute
Adj. Professor of Medicine, UT Southwestern
14.00-14.30

2. ES Brilakis: Disclosures
Consulting/speaker honoraria: Abbott
Vascular, Asahi, Cardinal Health, CTI,
Elsevier, GE Healthcare, St Jude
Medical
Employment (spouse): Medtronic
Grants: InfraRedx, Boston Scientific
VA - I01-CX000787-01
VA CSP#571 – DIVA

3. CTO dissection/re-entry
strategies
Antegrade Retrograde
Dissection
Re-entry
Dissection
Re-entry
Knuckle wire
CrossBoss
•STAR
•Contrast-guided STAR
•mini-STAR
•LAST
•Stingray
Knuckle wire
CART
Reverse CART
Michael et al
Circ Intv 2012

5. 1 2
3
4
Extensive dissection/re-entry long-term outcomes

7. Brilakis, Grantham, Rinfret, Wyman, Burke, Karmpaliotis, Lembo, Pershad,
Kandzari, Buller, De Martini, Lombardi, Thompson. JACC Intv 2012
Antegrade dissection/re-entry: WHEN?

8. Nagoya Heart Center
Asian-Pacific CTO Club Algorithm

9. www.crossbossfirst.org

11. Ratchet Handle for
FAST-Spin Technique
Atraumatic 1 mm
Distal Tip
CrossBoss Knuckle wire
Polymer-jacketed
guidewire
Dissection

12. How to form a knuckle
Wire: Fielder XT – Fighter -
Pilot 200
Tip: umbrella handle or no
shaping
Movement: PUSH (hard!)
Do NOT turn

13. Step 1: get to proximal cap

14. Step 2: torquer positioning
2 fingerbreadths

15. Step 3: SPIN (fast!)
CrossBoss does not
advance: ↑ guide
catheter support,
Guideliner, knuckle wire,
use stiff wire
Any direction is fine

16. Step 4: Assess!
A
B
C

17. BridgePoint Procedure

18. Step 5A: wire + stent
A

19. Case 1
RCA
CTO due
to ISR

20. ASSESSMENT
Target vessel: RCA
Proximal cap: clear
Length: ~50 mm
Distal vessel: good landing zone before
the bifurcation
Collaterals: Septal, epicardial
PLAN
1. ADR (Crossboss)
2. Retrograde

21. CrossBoss
with Sion
Blue
Wire inside
CrossBoss

22. Crossing
with
CrossBoss

23. CrossBoss
confirmed
in true
lumen

24. Confirmed
in RAO
Cranial

25. Final result
Procedure time: 65 min
Fluoroscopy time: 14.6 min
AK dose: 0.348 Gray
Contrast: 200 mL

26. N=31 CTOs - Procedural success: 90%
N=6
Procedural success: 83%

27. Step 5B: Re-enter
B

28. 1) Use Stingray LP
2) Aspirate first
3) “stick and swap” (especially in
diffusely diseased vessels)
4) Orthogonal view for re-entry (good
balloon preparation)
5) Minimize area of dissection (using
CrossBoss)
6) select optimal re-entry location
(horizontal part of RCA)
Facilitating Stingray Re-entry

29. Stick and Swap – 1
Stingray wire –
or Gaia 2nd/3rd
Stiff wire cannot track into diffusely diseased vessel

30. Stingray
wire
removed
Stick and Swap – 2

31. Polymer
jacketed wire –
Pilot 200 -
Gladius
Polymer-jacketed wire tracks distal vessel
Stick and Swap – 3

32. Stingray Re-entry
Orthogonal
view
railroad tracks

34. 1) Aspirate through Stingray balloon
2) STRAW
3) Double blind stick and swap
4) Bobsled
5) Retrograde
What to do for subintimal hematoma

35. STRAW: Subintimal TRAnscatheter Withdrawal
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

36. LCX CTO

37. ASSESSMENT
Target vessel: LCX
Stump: Tapered
Length: ~20 mm
Distal vessel: Bifurcation
Collaterals: Ipsilateral
J-CTO score: 2
Stump: 0
Length: 0
Calcification: 1
Tortuosity: 1
Previous attempt: 0

38. CrossBoss

39. Some
progress

40. Crossed

41. Confirmed

42. Corsair
with a Sion
Blue

43. Stingray to
open OM
1st

44. Re-entry
with “stick
and swap”
Stingray
with Pilot
200

45. Predilation

46. Kissing
balloons

47. 3.0x38 mm
DES

48. Postdilation

49. Final result
Procedure time: 73 min
Fluoroscopy time: 29.7 min
AK dose: 1.608 Gray
Contrast: 100 mL

50. Step 5C: Redirect
C

51. RCA
CTO
Case 2

52. RCA
CTO
Case 2

53. CrossBoss
into side
branches
Knuckle
for
advancing
Case 2

54. In distal
cap now
Case 2

55. Stingray
Case 2

56. Are we in?
Case 2

57. Case 2

58. Restick
Case 2

59. IVUS 2
Case 2

61. RCA CTO

62. Retrograde
failed

63. Proximal
cap??

64. Lateral

65. Confianza
Pro 12
“scratch
and go”
Aka
“move the
cap”

66. Proximal
dissection
1.5x8 mm
anchor

67. Knuckle
started

68. Distal RCA
ISR

69. Wire is out!

70. CrossBoss
Pilot 200

71. Some
progress..

72. Getting
closer..

73. Going the
wrong
way…

74. Gaia
redirection

75. Gaia
redirection

76. Threader

77. 1st line
2nd line
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013
Approach to “balloon uncrossable” CTO
“Balloon Uncrossable” CTO
• Inflate 1.20-1.5 mm balloon, Threader, Glider
• Rupture balloon in vessel (grenadoplasty)
• Tornus, Corsair, Finecross
• Wire “cutting”
• Guide catheter extensions
• Anchor balloon strategies
• Laser
• Rotational atherectomy
• Subintimal: external “crush” - retrograde
• Subintimal: distal anchor
combinations
3rd line
4th line

78. Sticking UP

79. Sticking
down

80. Swap

81. Confirm 1

82. Confirm 2

83. IVUS post crossing

84. Final

85. IVUS after stenting

87. RAO
Case 3

88. Hybrid CTO crossing algorithm
Brilakis, Grantham, Rinfret, Wyman, Burke, Karmpaliotis, Lembo, Pershad, Kandzari, Buller, De Martini,
Lombardi, Thompson J Am Coll Cardiol Intv 2012;5:367-379

89. Knuckle
started

90. Fielder XT

91. Stuck!

92. Carlino

93. Next step?

94. Aggressive
knuckle

95. Gaia 2nd

96. Stick down!

97. Stick up!

98. Swap

99. Orthogonal
view

100. Final
Contrast: 450 mL iodixanol
AK dose: 5.8 Gray
Fluoro time: 56.9 min

102. Antegrade crossing
Finecross
Pilot 200
Finecross and 1.5 mm balloon: No crossing

103. Subintimal wiring
2nd wire

104. “Subintimal” Distal Anchor
Subintimal
distal
anchor

105. Final result

106. COMPLICATIONS

107. STAR

108. After
balloon

109. Fielder XT

110. Stuck…

111. Parallel
wire

112. Crossed?

114. Visconti G, Focaccio A, Donahue M, Briguori C. CCI 2015;85:382–390
Spontaneous echo contrast

115. Visconti G, Focaccio A, Donahue M, Briguori C. CCI 2015;85:382–390
Spontaneous echo contrast

116. 2.5 x 28 mm EES x 2
2.75 x 28 mm EES x 1
2.75 x 23 mm EES x 1ADR
Baseline
Final
Final

117. 8-month angiographic follow-up
Patient asymptomatic

119. 1/2012 to 6/2016
15 centers, 1,810
lesions
Technical success: 88%
Major complications: 2.5%
•Appleton Cardiology, WI
•Baylor Heart and Vascular Hospital, TX
•Columbia University, NY
•Central Arkansas VAMC, AR
•Dallas VAMC/UTSW, TX
•Henry Ford Hospital, MI
•Massachusetts General Hospital, MA
•Medical Center of the Rockies, CO
•Minneapolis VAMC, MN
•PeaceHealth St. Joseph MC, WA
•Piedmont Heart Institute, GA
•San Diego VAMC and UCSD, CA
•St Luke’s Mid America Heart Institute, MO
•Torrance Medical Center, CA
•UPMC Medical Center, PA
49%
24%
27%
Antegrade wiring
Antegrade dissection/re-entry
Retrograde
75.9%
34.6%
39.9%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
Techniques Used
Antegrade
Antegrade DR
Retrograde
Successful technique
PROspective Global REgiStry for the Study of CTO interventions
0.6% mortality, 0.9% MI
0.8% pericardiocentesis, 0.2% stroke
0.1% CABG, 0.2% re-PCI

120. J-CTO score and CTO PCI
approach
PROspective Global REgiStry for the
Study of CTO interventions
J-CTO score validation
Procedural time and J-CTO
score
1/2012 to 7/2014
6 centers, n=650
lesions
Christopoulos, Wyman, Alaswad, Karmpaliotis, Lombardi, Grantham, Yeh, Jaffer, Cipher, Rangan,
Christakopoulos, Kypreos, Lembo, Kandzari, Garcia, Thompson, Banerjee, Brilakis
Circ Cardiovasc Interv 2015;8:e002171

121. N=1313
11 US centers
ADR=458 (34.9%), ADR after exclusion of retrograde cases=248 (32.3% of 767
antegrade-only cases)
Complications 2.9 vs. 2.2% all cases, 1.5 vs. 0.6% antegrade-only
Danek, Karatasakis, Karmpaliotis, Alaswad, Yeh, Jaffer, Patel, Bahadorani, Lombardi, Wyman, Grantham, Doing,
Moses, Kirtane, Parikh, Ali, Kalra, Kandzari, Lembo, Garcia, Rangan, Thompson, Banerjee, Brilakis.
Int J Cardiol 2016
Antegrade Dissection Re-entry
PROspective Global REgiStry for the Study of CTO interventions
89.9
87.0
93.2 91.8
70
80
90
100
Technical success Procedural success
%
ADR Non-ADR
Δ=3.3%
P<0.01
89.9 87.0
93.2 91.8
70
80
90
100
Technical success Procedural success
%
ADR AWE-only
Antegrade-
only cases
All cases
Δ=5.7%
P<0.01
Δ=2.3%
P=0.23
Δ=1.5%
P=0.43

122. PROspective Global REgiStry for the
Study of CTO interventions
Retrograde vs. antegrade-only: in-hospital MACE
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
Complicationrate(%)
Retrograde
Antegrade-only
p<0.001
p=0.003
p=0.999
p=0.039
P=0.314
p=0.167

123. UK Hybrid CTO registry
7 centers
2012-2014
1,156 pts
30-day MACE: 1.6%

125. Martinez-Rumayor et
al. JACC Intv 2012
How CTO
equipment can
help in non-CTO
cases!

126. ADR gives you (safe) options
Options are good for life and
CTO PCI!
hence…
ADR is good!!!

127. 1.Subintimal dissection/re-entry
techniques have revolutionized CTO
PCI (success + efficiency) – critical
part of the hybrid algorithm
2.ADR safer than retrograde
3.No increased risk for restenosis
Conclusions