Recommended
More Related Content
What's hot
What's hot (20)
Similar to Gregor Leibundgut: When the “uncrossable” becomes crossable
Similar to Gregor Leibundgut: When the “uncrossable” becomes crossable (20)
More from Euro CTO Club
More from Euro CTO Club (20)
Recently uploaded
Recently uploaded (20)
Gregor Leibundgut: When the “uncrossable” becomes crossable
- 1. 14th Experts Live CTO The annual Euro CTO meeting September 2nd - 3rd, 2022. Mainz, Germany Road to CTO expert 2022 – how to build your CTO toolkit When the “uncrossable” becomes crossable Lunch Symposium by Asahi EURO CTO CLUB Gregor Leibundgut, MD University Hospital Basel, Switzerland
- 2. Without wiring no CTO-PCI
- 3. Uncrossable Proximal Cap Power Knuckle Carlino (hydrolic dissection) BASE Side-BASE Scratch & Go Dual Lumen Microcatheter Support Puncture Power Puncture
- 4. Undilatable Proximal Cap BAM Rotational atherectomy Carlino (hydrolic dissection) Stiffer or lower profile microcatheter Antegrade proximal cap external crush Retrograde proximal cap external crush Laser Progressive balloon tracking
- 5. Uncrossable & Undilatable Distal Cap Retrograde Scratch & Go Retrograde Carlino Retro-BASE Retro-BAM Antegrade distal cap external crush Dual lumen microcatheter supported puncture
- 6. Wiring in outer space Dissection re-entry techniques
- 7. The Concept Wiring in outer space (habitable zone) (lower space) (outter space)
- 8. How to travel in the subintimal space? How to travel in the subintimal space
- 9. Travel both ways Wiring in outer space RDR Retrograde Dissection Re-Entry ADR Antegrade Dissection Re-Entry
- 10. The Boss How to travel in the subintimal space CrossBoss Antegrade Only
- 11. Knuckling Wire-based technique of blunt dissection
- 12. The Knuckle-wire Technique Knuckling • The knuckle technique is used to create a deliberate blunt dissection plane in various CTO techniques. • The guidewire, usually a polymer- jacketed guidewire, is pushed until a complex loop is formed and advanced through the lesion
- 13. When should we knuckle? Knuckling • Antegrade dissection Re-entry (ADR) - Whenever the wire escalation strategy (parallel wiring) failed - In tortuous anatomy - Ambiguous vessel course - Ideally NO sidebranches - NO distal bifurcation • Retrograde dissection Re-entry (RDR) - Preferably do retrograde knuckling (safer, more predictable) - Modified reverse CART (controlled antegrade and retrograde subintimal tracking)
- 14. Tip load is a function of the core wire Knuckling 10mm gap
- 15. Guidewire Tips Knuckling • non-tapered & round tip - Workhorse wires • non-tapered & pointed tip - Gaia family - Pilot 200 • tapered & round tip - Fielder XT, XT-A, XT-R - Confianza Pro 12 • tapered & pointed tip - Stingray wire
- 16. Penetration Power Knuckling Penetration Power = Tip load / Tip area mm2 g
- 17. The Knuckle Analogy Knuckling Penetration wire (e.g. CP12) Knuckle wire (e.g. Gladius MG)
- 18. Trust the Knuckle! Tip load vs Penetration power Knuckling High Tip load non-polymeric wire High Tip load polymeric wire with knuckle VS
- 19. Polymer Jacket Knuckling Polymer Jacket Coils
- 20. Specialty Guidewires Knuckling COATING Polymeric jacket Soft Non-tapered Soft Tapered-tip Harder Non-tapered Whisper Pilot 50 Fielder FC Sion Black Pilot 150 Fielder XT-R Fielder XT Bandit Fielder XT-A Fighter Pilot 200 Gladius EX Raider Gladius MG SUOH 03 Sion Turntrac Samurai RC Gaia 1st Gaia 2nd Gaia 3rd Progress 200T Confianza Pro 9 Confianza Pro 12 Hornet 14 Warrior Infiltrac Plus Astato 20/40
- 21. Suitable guidewires for the knuckle technique Knuckling • Polymer jacketed guidewires • large knuckle - Pilot 200 (4.7g) - Gladius EX (4.2g) - Raider (g) • small knuckle - Fielder XT (0.8g) - Fielder XT-A (g) - Bandit (g) • powerfull intermediate knuckle - Gladius MG Large knuckle = subintimal space Small knuckle = intimal (vessel lumen)
- 22. Types of knuckles Knuckling Tiny Small Large Huge Fielder XT-A Gladius MG Fielder XT-A Gladius EX Gladius EX Pilot 200
- 23. After Knuckling Knuckling • The knuckle permanently deforms the guide wire due to a bend in the core wire • Gladius MG is the only guidewire that can be reused for regular wiring after knuckling (e.g. tip-in)
- 24. Gladius EX • Non-tapered, ACT ONE • Tip load 3.0 g • Tip radiopacity 3.0 cm • Polymer jacket: 40 cm Gladius MG Knuckling Gladius MG • Non-tapered, ACT ONE • Tip load 3.0 g • Tip radiopacity 3.0 cm • Polymer jacket: 41 cm • Knuckle point at 8 mm Preshaped micro-bend (similar to Gaia family) “Knuckle point”
- 25. Key feature: Micro gap The micro gap 0. 100. 200. 300. 400. 500. 1.5 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Load (mN) Distance from the tip (mm) Comparison of tip rigidity Gladius MG PILOT200 8 mm 300 mN 30 mm 250 mN
- 26. Bench model performance _ Gladius MG Pilot 200 | Gladius EX
- 27. HOW TO GET BACK?
- 28. How to get back Subintimal wire position
- 29. STAR/miniSTAR How to get back Subintimal tracking and re-entry
- 30. LAST How to get back Limited antegrade subintimal tracking
- 31. AFR How to get back Antegrade fenestration and re-entry
- 32. Stingray based Re-entry How to get back Contemporary ADR
- 33. Stingray based Re-entry How to get back Stick and swap & stick and drive
- 34. New Methods How to get back Device based targeted re-entry with ReCross dual-lumen microcatheter
- 35. Subintimal Hematoma How to get back MAP 80 mmHg Capillary pressure 15 mmHg True lumen compression
- 36. How to get back STRAW Subintimal Transcatheter Withdrawal (of Hematomas) Aspirate
- 37. Reverse CART Retrograde re-entry Controlled antegrade and retrograde tracking and dissection
- 38. Reverse CART Retrograde re-entry Controlled antegrade and retrograde tracking and dissection
- 39. Reverse CART Retrograde re-entry Controlled antegrade and retrograde tracking and dissection
- 40. Reverse CART Retrograde re-entry Controlled antegrade and retrograde tracking and dissection
- 41. WHAT CAN GO WRONG? Space Shuttle Columbia, February 1st 2003
- 42. Precautions What can go wrong on re-entry? • Never spin the knuckled guidewire → creates a knot • Knuckles tend to go into side branches → risk of perforation • Big knuckles can weaken/rupture the vessel • Small knuckles can cause distal perforations • Knuckles with non-polymeric wires, especially penetration wires can damage the microcatheter on retrieval and get stuck. • In general, knuckles cause large subintimal hematomas - Block antegrade flow, Do NOT inject antegradely, STRAW
- 45. _ Retrograde knuckle • Fielder XT-A retrograde in proximal RCA
- 47. Controled retrograde knuckle • Gladius MG retrograde • Push until knuckle forms • Keep pushing without twisting
- 48. • Retrograde Gladius MG • Excellent tip retention Enter the antegrade guide
- 49. • Use same Gladius MG • Or fresh straight workhorse wire without tip shape Tip-in
- 50. • Advance antegrade microcatheter • If drilling needed feed antegrade guidewire into the mc to prevent lumen collaps Antegrade conversion
- 51. Case 3 Calcium and tortuosity _
- 52. Tandem CTO of the LAD Septal collaterals from ipsilateral
- 53. Antegrade wiring Teleport control & Fielder XT-A
- 54. Retrograde knuckling with Fielder XT-A
- 55. Retrograde knuckling with Gladius MG Small knuckle!
- 56. Reverse CART with Gladius MG
- 57. Retrograde re-entry with Gladius MG Unfolds nicely from the knuckle!