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

1. Antegrade Approach
Step by Step
Gerald S. Werner, MD, FESC, FACC, FSCAI
Medizinische Klinik I
Klinikum Darmstadt GmbH
Darmstadt, Germany

2. Conflict of interest
• I, Gerald S. Werner, MD, have no conflict of
interest to declare with regard to the following
presentation

3. The goal of CTO-PCI
• Ideally: Restore the original anatomy of an
occluded artery
• Open an occluded artery
– with the least damage to the coronary anatomy
– with the least investment of time and material,
reducing procedural risks
• There is no retrograde vs antegrade approach,
there is only the choice of the best strategy for
the specific lesion and patient

4. Strategic options for CTOs in Europe
Bilateral
Maximal Guide
backup
Antegrade
Fielder XT -> Ultimate
or -> Progress
200T/Conf.Pro 9
Penetration, then
step down
Distal good target
Parallel with stiff
wire
Reentrysystem
BridgePoint
Antegrade
no Stump
IVUS for guided
Penetration ?
Retrograde
With feasible collateral
pathways
Ostial CTO
Long CTO
Re-Attempt
Ideal access

5. Strategic options for CTOs in Europe
The antegrade spectrum of technical options
Bilateral
Maximal Guide
backup
Antegrade
Fielder XT -> Ultimate
or -> Progress
200T/Conf.Pro 9
Penetration, then
step down
Distal good target
Parallel with stiff
wire
Reentrysystem
BridgePoint
Antegrade
no Stump
IVUS for guided
Penetration ?
Retrograde
With feasible collateral
pathways

6. J-CTO Score Sheet: Predicting complexity
Morino Y et al. JACC Interv, 2011; 4: 213

7. Examples not likely to work antegrade

8. Likely targets for the antegrade approach

9. Antegrade: Step by Step
• Lesion specific analysis
– Identify the proximal cap
– How long is the lesion
– What is the presumed course of the occluded
segment
– Identify the distal target
• Patient specific considerations
– Previous attempts (which wires, why failed)
– Renal function (limits on contrast use)

10. Basic Setup
• Two catheters (radial and/or femoral route)
• Guide backup: 7F provides all options, in ostial
locations and with IVUS guidance 8F preferred
• Microcatheter selection:
– Finecross: sleek profile, passes deep into lesions
– Corsair: provides additional support for the guide
– Caravelle: sleek profile with tapered tip
– Others to mention: Nhancer, Vascular Solutions

11. UB3UB3
Hard plaque
Severe calcification
Stiffer tip
XT-(A)XT-(A)
ASAHI Gaia FirstASAHI Gaia First
ASAHI Gaia SecondASAHI Gaia Second
ASAHI Gaia ThirdASAHI Gaia Third
Miracle12Miracle12
Confianza Pro 12
Hornet 14;
Progress 200T
Confianza Pro 12
Hornet 14;
Progress 200T
XT-RXT-R
2016: Which wire to use when?

12. The wire selection
• Explore the lesion
– Fielder XT, atraumatic, provides feedback on lesion
rigidity, tracks loose tissue and may even penetrate
noncalcified caps; “you follow the wire”
• Pass the lesion
– Gaia 1-3 to penetrate the cap and steer through the
occluded segment; “the wire follows you”
• Conquer the calcified lesions
– Confianza Pro 12 for penetration
– Others: Hornet 14, Progress 200T
– Pilot 200 to find the soft spots within severe calcium

13. Advance with in the vessel: work horse
Penetrate the cap
Wire tip shape: adapt to the purpose
Remember always: tip shape is lost rapidly
So reshape, whenever you get stuck
Remember always: tip shape is lost rapidly
So reshape, whenever you get stuck
Pass within the occlusion
Pass a collateral

14. Which wire to start with ?
Examples from the Live Cases
Case #4
Tapered lesion
My approach:
Fielder XT(-A) on microcatheter
If stuck -> Gaia 1
If distal target missed ->
Proceed to parallel wire

15. Gaia 1st controlled wire passage

16. Gaia 1st controlled wire passage

17. Which wire to start with ?
Examples from the Live Cases
Case #8
Faint notch at side branch
My approach:
Fielder XT(-A) to deliver the
microcatheter to the proximal
cap, exploring, but penetration
unlikely
Gaia 2 as starter
If distal target missed ->
Proceed to parallel wire

18. The parrallel wire
technique is classic
Crossit
200-400 or
Conquest
3g-6g
N.Reifart/O.Katoh 1996

19. Why parallel wiring works well in the RCA:
the wire straightens the vessel architecture

20. Why parallel wiring works well in the RCA:
the wire straightens the vessel architecture

21. When and why parallel wire works
• If the 1st wire is close to the target, the 1st wire
straightens the vessel course, and allows
passage of the 2nd (stiffer) wire
• If the 1st wire is far from the target, the 2nd
wire needs to find a new course, especially in
bent segments
• Often the entry point into the proximal cap
needs to be changed
• Parallel wire is not a reentry technique

22. When and why parallel wire may fail
• The distal target is diffusely diseased and
narrow
• The distal target is severely calcified and
prevents entry even with a stiff wire tip
• Failure of the operator to check orthogonal
views frequently: biplane systems are helpful

23. Which wire to start with ?
Examples from the Live Cases
Case #5
Blunt occlusion at side branch
Possible approach:
Pass wire in side branch, dilate
proximal and advance IVUS
IVUS guided penetration with
Gaia 2
Bailout: retrograde

24. RCA CTO: Strategic options
Torino. 16.4.15
Retrograde approach in mind as
most likely strategy
Chair of session: “antegrade
approach nonsense”
Agreed, but still we need an
antegrade wire for a successful
retrograde approach
The further the antegrade wire
reaches, the shorter the
retrograde wire needs to
travel….

25. RCA CTO: Strategic options
Torino. 16.4.15

26. Puncture of the cap with Gaia 2
Torino. 16.4.15

27. Then via Finecross wire downgraded to Sion Black
Torino. 16.4.15

28. Complex long RCA CTO
Torino. 16.4.15

29. 20 years Post CABG: Ostial RCA CTO
Additional information from MSCT
Retrograde options are challenging

30. Moderate calcification -> medium-strength wire

31. If parallel wiring fails: StingRay reentry device
H.B. 30.1.15

32. Parallel fails, then StingRay
H.B. 30.1.15

33. Strategic options for CTOs in Europe
Bilateral
Maximal Guide
backup
Antegrade
Fielder XT -> Ultimate
or -> Progress
200T/Conf.Pro 9
Penetration, then
step down
Distal good target
Parallel with stiff
wire
Reentrysystem
BridgePoint
Antegrade
no Stump
IVUS for guided
Penetration ?
Retrograde
With feasible collateral
pathways
Ostial CTO
Long CTO
Re-Attempt
Ideal access

34. Parallel fails, then StingRay
H.B. 30.1.15

35. Parallel fails, then StingRay
H.B. 30.1.15

36. StingRay wire passed before the stent
H.B. 30.1.15

37. Antegrade: Step by Step
• Lesion specific approach
– Start with the softest possible wire
– Step up if necessary
– Use parallel wire as an early and easy bailout
– If retrograde is difficult, early decision for guided
reentry technique (StingRay)
• Patient specific approach
– Select the most likely strategy to solve the lesion
– Do not attempt complex lesions without the
option for retrograde conversion

38. Antegrade: Step by Step
• Lesion specific approach
– Start with the softest possible wire
– Step up if necessary
– Use parallel wire as an early and easy bailout
– If retrograde is difficult, early decision for guided
reentry technique (StingRay)
• Patient specific approach
– Select the most likely strategy to solve the lesion
– Do not attempt complex lesions without the
option for retrograde conversion