2. If possible, be prepared…
• Identify calcium distribution with CT scan upfront
• “donut” like: try to remain intraplaque
• “pancake” like: go around
• Collaboration with RX/own expertise
15. Cap entry modification:
• Robust (screw- in) MC (Tornus, TP spiral, TP gold)
• Small profile balloon, if it tips in, balloon rupture (grenado-
angioplasty)
• If the MC tips in, consider Carlino (contrast injection induced
dissection)
16. MC/Balloon do not enter/cross
wire true to true
knuckle goes beyond the cap
• If wire is intraplaque, balloon and MC do not cross:
• Side branch at the cap: IVL (sesame facilitated opening technique)
• No side branch at the the cap: laser the cap entrance (0.9 mm)
• If wire is extraplaque, MC do not cross:
• consider knuckling of an extra support wire, repeat steps (MC/balloon)
• consider knuckling of a rota-wire, use 1.25 mm burr
• consider external cap modification with a balloon/IVL
17. Cap entry modification
one wire is true to true and MC/B does not cross
second wire is extra-plaque
Balloon
IVL
Rota
External plaque crush/modification Distal subintimal anchor
24. Part 3
Move the cap: Balloon Assited Subintimal Entry (BASE)
Guiding and contrast induced dissection of the ostium (RAC) (R. Garbo)
25. All “cap attacks” fail…move the base of
operations, with dissection
BASE Retro knuckle or Carlino
If SB at cap entry, S-BASE
26. CTO RAC
• Blunt cap
• at the bifurcation with the RV branch
• Lenght: short
• No bend
• No clear calcium
• Second attempt
• Antegrade attempt
• Ipsicollaterals
• J-CTO 2
28. BASE knuckle entry at proximal shoulder of
balloon
• Multiple inflations with a
properly (or even oversized)
sized balloon are needed to
create dissection planes
• Tip of MC can be at the middle
or at the shoulder of the balloon
• A knuckle is pushed from the tip
of the MC, with the balloon
inflated
29. Confirmation of ”cap crossed”
• Confirm the knuckle crosses the
bifurcation in the direction of
the distal RAC
30. Re-entry needed after BASE @ S-BASE
Puncture with Hornet 14, down (dot/wire separation)
33. Do you have a retrograde option?
• Any intervention from retro can modify the prox cap:
• Knuckle retro beyond the prox cap
• Retrograde microcatheter
• Balloon from retro (if collateral allows)
• Retrograde Carlino
34. Retrograde techniques
• Retro wire
• Kissing wires to create (wire) space
• Tip-in & Rendez-vous with wire in ante or retro MC to change where you
come from (ante vs retro)
• Retrograde OTW balloon (to create space for your antegrade material)
• Reverse CART
• Rota over an externalised RG3 wire