This document discusses techniques for percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) with heavy calcification. It notes the difficulties posed by calcification, including inability to penetrate caps or advance wires and devices. Strategies discussed include long sheaths, large guiding catheters, stiff wires, guideliners, small balloons, microcatheters like Tornus and Turnpike, rotablator, laser, subintimal dissection with reentry, anchoring balloons, and wire escalation. Case examples demonstrate successful crossing with anchoring balloons, guideliner support, Turnpike catheter, and modified dissection and reentry. The conclusion stresses perseverance, augmented backup,

1. CTO with Heavy
Calcifications
Karl ISAAZ
University of Saint Etienne
France
Euro CTO Club The expert Live Workshop 2016

2. Presenter: Karl Isaaz
No conflict of interest

5. Predictive Factors of Success
From the EuroCTO Club EuroInterv 2007; 3: 30-43

6. Predictive Factors of Success
EuroCTO Club EuroInterv 2007; 3: 30-43
Simple CTO > 90% success rate
Complex CTO 60-70% success rate

7. Angiographic Predictors
From the EuroCTO Club EuroInterv 2011; 7: 472-79

8. Angiographic Predictors of PCI failure
from Tsuchikane et al. CTO In Nguyen Editor, Practical handbook of
advanced interventional cardiology tips and tricks, 3rd Edition 2008
• Severe calcifications
• Very long CTO
length
• Marked tortuosity
• Long occlusion duration
• Antegrade bridging
collaterals
• Blunt stump occlusion
• side branch at occlusion
site
• Absence of antegrade
flow and no or poor
distal vessel visibility
Most important predictors
Other predictors for
less-experienced operators

9. J-CTO SCORE from the Multicenter CTO Registry of Japan
Morino Y et al. JACC Interv 2011; 4: 213-21

10. J-CTO SCORE
Morino Y et al. JACC Interv 2011; 4: 213-21

11. CTO with heavy calcifications
1. Difficulties to penetrate the proximal
or distal cap with the wire
2. Difficulties to advance and
manipulate the wire inside the CTO
3. Difficulties to advance the
microcatheter
4. Difficulties to cross the lesion with the
balloon
5. Difficulties to well expand the stent
Impact on the procedure

12. CTO with heavy calcifications
Tools Strategies
Success or failure

13. 1. Long sheath (45 cm)
2. Large size guiding catheter (7f/8f)
3. Stiff wires (Confianza pro 12/Progress 200T)
4. Guideliner/Guidezilla
5. Small balloons
6. Tornus microcatheter
7. New microcatheter (turnpike) and anchoring
catheters (centercross and multicross)
8. Rotablator
9. Laser
Tools
CTO with heavy calcifications

14. CTO with heavy calcifications
1. Crossing the lesion from true to true
2 basic strategies
2. Dissection Reentry

15. Retrograde approach
Reverse CART
Antegrade approach
Modification of the CAP

16. 1. BASE: balloon assisted subintimal dissection
2. Scratch and go
3. Hydraulic dissection
Modification of the CAP
CTO with heavy calcifications

17. 1. BASE: balloon assisted subintimal dissection
2. Scratch and go
3. Hydraulic dissection
Modification of the CAP
CTO with heavy calcifications

18. BASE
1. Adequate proximal vessel length
1. Balloon diameter slightly larger than
reference diameter of proximal vessel
1. End result is intimal dissection of proximal
cap
 Knuckle wire
 Dissection-reentry technique
 Crossboss + stingray
CTO with heavy calcifications

19. 1. BASE: balloon assisted subintimal dissection
2. Scratch and go
3. Hydraulic dissection
Modification of the CAP
CTO with heavy calcifications

20. Scratch and Go
1. Stiff wire to create subintimal space
1. Corsair to subintimal space
 Knuckle wire
 Dissection-reentry technique
 Crossboss + stingray
CTO with heavy calcifications

21. 1. BASE: balloon assisted subintimal dissection
2. Scratch and go
3. Hydraulic dissection
Modification of the CAP
CTO with heavy calcifications

22. Break the CAP: Hydraulic dissection
1. Corsair into subintimal space
2. 3 ml seringe with 1-2 cc injection of contrast
3. Knuckle wire or crossboss for DR
CTO with heavy calcifications

23. Techniques of anchoring balloon
1. Antegrade guiding catheter anchoring
balloon
1. Antegrade or retrograde GW trapping
balloon
2. Subintimal distal anchoring balloon
CTO with heavy calcifications

24. CTO with heavy calcifications
Techniques of anchoring balloon
1. Antegrade guiding catheter anchoring
balloon
1. Antegrade or retrograde GW trapping
balloon
2. Subintimal distal anchoring balloon

25. Trapping of the
Antegrade guidewire

26. EBU 4.0 7f for the left system
with guideliner to augment support
AR2 7f for the saphenous graft
Whisper + CORSAIR in the saphenous graft
Planned Recanalization of LCX CTO
Mr Str. G.

27. Unstable support: Guideliner
in the AR2 7f to augment the support
Retrograde FIELDER XT in the CORSAIR
to cross the CTO: failure

28. Retrograde partial crossing of the CTO with a MIRACLE 3 but despite AR2 + Guideliner:
failure to crosse retrogradely the CTO with the CORSAIR due to heavy calcifications

29. Antegrade Finecross + FIELDER XT
for kissing wire technique with
Retrograde MIRACLE 3: failure
Antegrade Finecross + PROGRESS 200T
for kissing wire technique with retrograde
MIRACLE 3: success

30. Antegrade Finecross + PROGRESS 200 with kissing wire technique with a retrograde
MIRACLE 3: success with antegrade crossing of the CTO by the PROGRESS 200 which
is positionned in the saphenous graft
Guideliner saphenous graft
Guideliner left main
Antegrade PROGRESS 200
FINECROSS
CORSAIR + MIRACLE 3

31. Then, failure to cross the CTO over the PROGRESS 200 with a TAZUNA
1.25 balloon then an ACROSTAK 1.1 balloon and TORNUS 2.1/2.6
Anchoring of the antegrade PROGRESS 200T by a 2.0 20mm balloon advanced
retrogradely in the saphenous graft; crossing of the CTO with an ACROSTAK 1.1
Anchoring balloon
Antegrade ACROSTAK balloon

32. Antegrade Ballooning

33. FINAL RESULT

34. Trapping of the
Retrograde guidewire

35. Septal connection crossed by a SION +
Finecross
Mr Bur. M.

36. Advancement with difficulties (frictions) of a Pilot
200 after failure of Fielder XT/Gaia2/Miracle 12

37. Use of a Guideliner. Pilot 200 advanced into the
Guideliner

38. Pilot 200 advanced in the antero guiding but
Failure to advance a Finecross, Corsair
and Turnpike

39. Trapping of the retro Pilot 200 by an
antegrade Maverick balloon in the Guideliner
Anchoring
balloon in the
Guideliner

40. Advancement of the Finecross into the
Guideliner and externalization

41. CTO with heavy calcifications
Techniques of distal anchoring balloon
Subintimal distal anchoring balloon

42. 1. Long sheath (45 cm)
2. Large size guiding catheter (7f/8f)
3. Wire escalation (Confianza 12/Progress 200)
4. Anchoring balloon (antero and retro)
5. Guideliner/Guidezilla
6. Small balloons
7. Tornus microcatheter
8. New microcatheter (turnpike)
9. Rotablator
10. Laser
Tools
CTO with heavy calcifications

43. Mr CON. J
Coronary Angiogram on
April 21, 2016
Transradial Approach
Heavily calcified RCA lesion

44. PCI Procedure
Transradial Approach
 Attempt of RCA ad hoc angioplasty using a 6Fr
AR2 guiding catheter through the transradial
access.
 Easy crossing of the lesion by a BMW guidewire
but failure of crossing the lesion by a 1.5 mm
diameter Maverick ballon and then by a Minitrek
1.20mm diameter balloon.

45. PCI Procedure
Re-attempt on April 25, 2016
 Right trans-femoral approach with a
long 45 cm 7fr Cook introducer
 AR2 7Fr guiding catheter
 Easy crossing of the lesion by a BMW
guidewire
 Use of a Guideliner

46. PCI on April 25, 2016
Failure of crossing the
lesion with
successively:
 a Minitrek 1.20 ballon
 a Finecross
 a Corsair
 a Tornus catheter
and despite the use of a
Guideliner advanced at
the contact of the lesion Guideliner
Tornus 2.1

47. PCI on April 25, 2016
Successful crossing with a Turnpike catheter

48. PCI on April 25, 2016
 After Turnpike passage, a Maverick 1.5
diameter balloon is easily advanced and
inflated at 18 Atm
 Successive inflations with 3.0 mm and 3.5
mm non compliant QUANTUM balloons at
20 atm
 Stenting with a RESOLUTE 3.5 15mm drug-
eluting stent deployed at 28 atm

49. PCI on April 25, 2016
Post–DES implantation at 28 atm. Insufficient result
due to lack of radial force of the stent (arrow)

50. PCI on April 25, 2016
Final result (arrow) after instent implantaiton of a BMS
Driver 3.5 12mm deployed at 28 atm and post-dilatation
with a Quantum 4.0 8 balloon at 25 atm

51. Total failure!

52. Mr Str. G.

53. Heavy calcifications
Mr Str. G Mr Str. G.

54. Heavy calcifications
Mr Str. G Mr Str. G. Two 7f GC
Retrograde approach
Successful antegrade crossing wi
with a Miracle 12 using kissing GW
Then, failure to cross:
 Finecross
 Corsair
 Acrostak 1.1 balloon
 TORNUS 2.1/2.6
 Guideliner 6f/7f
Despite anchoring antegrade GW by
a retrograde balloon
RotaW failed to cross
Anchoring of the antegrade GW by
a retrograde balloon

55. Watch the distality of your wire
while trying to cross the lesion
CTO with heavy calcifications

56. CONCLUSION
Heavy Calcifications in CTOs
1. Persevere, don’t get discouraged
2. Use of many techniques and tools to augment the
backup support
1. Use of dissection-reentry technique to circumvent
the calcified zone when you can’t get from true to
true but you need a good landing zone
1. Watch the tip of your guidewire during efforts for
crossing the CTO with the balloons or other devices