14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany Main Session - Lunch Symposium by Asahi: Road to CTO expert 2022 – how to build your CTO toolkit DL MC short Jo Dens, Genk, Belgium Room: Guteberg Hall (Auditorium) - Saturday 13:30 Speaker: Gerald Werner, Darmstadt, Germany; Kambis Mashayekhi, Lahr, Germany; Jo Dens, Genk, Belgium; Gregor Leibundgut, Bâle, Suisse

1. DLC Masterclass: beyond the
basics
J. Dens, Euro CTO, Asahi symposium

2. 2
ASAHI’s Double Lumen Catheter to maximize stability & control

3. Use of DL-MC in CTO
Antegrade
• Intra-plaque antegrade wiring
• (alternative parallel wiring)
• Extra-plaque antegrade re-entry
• +/- IVUS guided
• Failed stingray delivery
• Proximal CTO-cap at bifurcation
• SB anchor
• Distal CTO-cap at bifurcation
• SB access
Retrograde
• Collateral crossing
• Retroflex collaterals
• Redirection
• Retro distal CTO-cap penetretation
• At bifurcation
• Wiring the distal vessel over the
externalized wire

4. DL MC antegradely: SB @ prox cap
…to enter/cross the cap…increases support

5. 3 techniques
• WH-wire is in the open SB (low penetration force wires)
• Dual lumen side port is used for second wire, proximal from the CTO
• Dual lumen catheter will increase support @ orientation away from SB wire
• WH-wire is in the open SB (low + high penetration force wires)
• Dual lumen exit port is positioned in front of the CTO
• Puncture with second wire
• WH-wire is in the open SB (high penetration wires)
• Dual lumen is delivered in the SB, a stiff wire is delivered in the SB
• Dual lumen is pulled back
• CTO wire is pulled back up to the bifurcation, directed towards the cap

6. CTO distal Cx: J-CTO 0 (tapered, short, no bend, no
calcium), @ bifurcation with L 1 (0,0,1)

7. Wiring L1Cx – Corsair – Gaia 2

8. Pick-up of distal Cx via DL-MC

9. Result CX

10. DL MC antegradely: SB @ distal cap
…to pick up an important SB…

11. Baseline angio
CTO:
long
tapered entry
mild calcification
no bend
no reattempt
Distal cap at a bifurcation:
PL 90° take off

12. Crossing CTO
Corsair pro 135
Confianza pro 12 towards PD

13. Ballooning of the CTO with 2.0 mm
Crossing CTO with corsair
Exchange of Confianza to Sion
2.0 mm balloon to create space

14. Wiring of PL with Fileder XT-R from Sasuke
Deliver Sasuke into PD (rapid exchange part) (distal from bifurcation)
Advance Fielder via over the wire port in PD (distal from bifurcation)
Pull back Sasuke and Fielder XT-R proximal from the bifurcation
Wire the PL from the side port

15. Final result

16. Use of DL MC in dissection
techniques
…to redirect wires (knuckles)…

17. CTO RAC: blunt, side branch, ⑅ 20 mm, bend, calcium
(J-CTO = 4) – distal old open stent

18. RAO view: calcium, lenght > 20 mm

19. Double lumen:
distal exit port: sion wire in SB
second wire, Gaia 3° from sideport (SI) in cap

20. XT-R Knuckle via side port, DL trapped out and re-advanced
over the knuckle reaching distal target for re-entry

21. Knuckle removed
Confianza pro 12 exits side port up

22. Re-entry from subintimal to true lumen: confianza
reaches old implanted but open stent

23. Endresult RAC after 2 additional stents

24. DL MC:
retrograde
hair pin or reverse
wiring technique
…retro access to
reverse septals…

25. Reverse wiring
Reverse take off of diagonal Advancement of Sasuke + wire

26. Reverse wiring
Engagement of diagonal Exchange @ advancement of corsair

27. Reverse wiring
Correct position of wire Final result after Crush stenting

28. Sasuke in retrograde
procedures

29. CTO of RAC: blunt, bend, calcium, long

30. Diverging septal connection

31. Caravel, sion wire, wrong track

32. Wiring of parallel septal from Sasuke

33. Suoh in correct track, crosses

34. Exchange to Caravel (Suoh comes from SP)

35. Final result after BASE @ R-CART

36. DL MC in retrograde procedures
…when a retrograde pathway is needed and the distal cap is blunt and in a
bifurcation…
Often crux of RAC
CTO body

37. Complex CTO of RAC
Unclear cap, distal bifurcation Septal connection

38. Retrograde approach
Supercross needed to enter septal
Alternative DL (hairpin wiring), Venture Caravel follows Sion black

39. Retrograde procedure
Tip injection from Caravel GE fascilitated R-CART
Exchange Caravel for Sasuke, use side port to puncture cap (Gladius was used)
Tip: if very resistent, leave stiff wire from side port in place, trap out Sasuke, reintroduce Sasuke over stiff wire, use side port for
soft wire

40. Final result

41. DL MC in retrograde procedures
…when a retrograde pathway is needed and the distal cap is close to the retrograde
entry…
Often post bypass, often LAD…
CTO body
Distal vessel

42. CTO of LAD: blunt cap – small distal diameter
Mid LAD occlusion (island) Antegrade wiring

43. CTO LAD, failed AW
Retrograde Sion black goes to distal LAD
Septal connection is close to distal CTO cap Gladius will cross retro f. by externalisation

44. CTO LAD
Dual lumen advanced over RG3, via side port gladius will pick
up distal LAD (ballooning of CTO body was needed to cross
with retro caravel, sion and fielder failed to pick up distal LAD

45. Final result

46. Conclusions
• Double lumen microcatheters: valuable tool in treatment of complex
CTOs
• To enter the proximal cap @ a bifurcation
• To pick-up an important side branch at the distal cap
• To re-direct wires (intra- and extraplaque)
• To puncture the distal cap @ bifurcation from retro
• To wire (antegradely) the distal vessel in the direction of a retro marker wire
• To wire (antegradely) the distal vessel over an externalized wire
• For retro procedures Sasuke is the longest MC
Look at Eurointervention 2021:17, Pyxaras S, DL MC

47. Conclusions
• Double lumen microcatheters: valuable tool in treatment of complex
CTOs
• To enter the proximal cap @ a bifurcation
• To pick-up an important side branch at the distal cap
• To re-direct wires (intra- and extraplaque)
• To puncture the distal cap @ bifurcation from retro
• To wire (antegradely) the distal vessel in the direction of a retro marker wire
• To wire (antegradely) the distal vessel over an externalized wire
• For retro procedures Sasuke is the longest MC
Look at Eurointervention 2021:17, Pyxaras S, DL MC