14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany Main Session - Session 6: The Calcified CTO – The ultimate challenge Plaque modification: IVL, atherectomy, balloons Florim Cuculi, Luzern, Switzerland Room: Guteberg Hall (Auditorium) - Saturday 13:20 Chairmen: Nicolas Boudou, Bordeaux, France; Roberto Garbo, Turin, Italy; Sudhir Rathore, Guildford, UK

1. Key to success Lumen

2. Why does PCI fail?
It‘s the mechanics, stupid ...!
Kastrati et al. - Predictive factors of restenosis after coronary stent placement – JACC 1997
Diabetes
ISR
CTO
Long lesions
Small
diameter

3. Impact of calcification on PCI outcomes
5-year TLR after sirolimus eluting stent implantation in
patients on dialysis.
Nishida et al. Am J of Cardiology - 2013

4. 5
• IVL?
• Rotational atherectomy?
• Orbital atherectomy?
• OPN NC?
• Cutting balloon?
How do we best treat a
highly calcified lesion?

5. Unable to cross the lesion with a balloon?
Highly calcified CTO
Gladius MG 14 crossed easily
No balloon crossing possible (despite all
tricks applied)
Rotablation with 1.25 mm burr
Total burr time: 4 minutes

6. Combination
- Wolverine 2.5
- OPN 2.5 and 3.0
- Selution 2.5 and 3.0

7. Balloon choice matters
atmospheres
mm
Exponential growth
of semi-compliant balloons

8. The OPN NC ultra-high pressure balloon
9

10. Downsize the diameter - Upsize the pressure
11
• This LAD was stented
with a 3.5 mm stent but
the 1 mm thick calcium
ring was cracked with a
2.5 mm OPN NC balloon
@ 40 atm (30 atm was
not enough).

11. 74 years old gentleman – STEMI 2017
12

13. 14
3 years later …

14. Guideliner support needed to cross tiny balloons! Highly calcified, highly thrombotic but now flow…

15. OPN NC 2.5 @45 atm, Shockwave 4.0 mm balloon
And OPN NC 3.5 @ 45 atm
3x DES 4.0 and 4.5 mm implanted
Post-dilatation with OPN 4.5 @ 40 atm

17. 18 months later

19. Rotational atherectomy does not guarantee stent expansion!
You need to break the Calcium!!!

20. Cut & Crack  they key to success when using DCB
21
Calcified
Thrombotic
Large diameter

22. Coronary angiography 7 weeks later

24. OCT pre-PCI
MLA 1.2 mm2
OCT post-PCI with the Selution DCB
MLA 6.3 mm2
OCT at 7 week follow-up
MLA 12.4 mm2

25. Another example of Cut & Crack & DCB

29. Postponing stent optimization in CTO?

30. Subintimal tracking . . .

31. Stent optimization 6 weeks post recanalization

32. When do I use shockwave?
33
• When OPN NC +/- Wolverine fails
• When I don’t want to risk a balloon rupture  air embolism …(e.g. last
remaining vessel etc)

33. When do I use orbital atherectomy?
34
• I used a few times and was not impressed …
• Let’s see what the future brings …

34. What do we need?
35
• Trials comparing different lesion preparation modalities in
calcified and non-calcified lesions
• VICTORY Trial on the way: Shockwave vs. OPN NC

35. Must have
- Rotational atherectomy
- OPN NC
Nice to have
- Cutting balloon
- Shockwave
- Orbital atherectomy

36. Take home messages
• Rotablation saves the day in an uncrossable lesion but it’s often not enough  combine!
• In a crossable lesion with a calcium ring («undilatable lesion») use OPN NC @ high pressure 
downsize diameter, upsize pressure. Alternatively IVL could be used.
• Shockwave can make the difference in specific situations but will still need NC balloons and high
pressure to achieve lumen  combine!
• If you want to avoid stents apply: cut & crack!
• In some situations you can’t crack or expand the lesion  gain lumen and use DCB!
• Consider postponing stent optimization if you are «deep» in subintimal space …

37. Take home messages
• Rotablation saves the day in an uncrossable lesion but it’s often not enough  combine!
• In a crossable lesion with a calcium ring («undilatable lesion») use OPN NC @ high pressure 
downsize diameter, upsize pressure. Alternatively IVL could be used.
• Shockwave can make the difference in specific situations but will still need NC balloons and high
pressure to achieve lumen  combine!
• If you want to avoid stents apply: cut & crack!
• In some situations you can’t crack or expand the lesion  gain lumen and use DCB!
• Consider postponing stent optimization if you are «deep» in subintimal space …