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New developments in antegrade dissection/re-entry approach
1. New developments in antegrade
dissection-reentry approach
Stéphane Rinfret, MD, SM
Chief of Interventional Cardiology
Complex PCI and CTO program
2. Disclosure Statement of Financial Interest
•Boston Scientific: Proctorship
•Abbott Vascular: Proctorship, Research grants
•Terumo: Proctorship, symposiums
•Medtronic Canada: Proctorship, Research grants
•SounBite Medical: Consultant
•Abiomed: Consultant
All modest
3. Antegrade dissection-reentry: when?
1. Long CTO without retrograde option, and good landing zone
•No other options
2. AWE attempt but sub-adventitial tracking (with any wire)
• Usually not the initial intention of the operator
• Alternative: parallel wires, retrograde
4. 1. Wire-based: Variation on a same theme
• LAST (Limited Antegrade Sub-Intimal tracking)
• STAR (Sub-intimal Tracking and Reentry)
• Mini-STAR
• Contrast-guided STAR
All involve less predictable reentry site with wires (either knuckled or straight)
2. Device-based (with StingRay)
Allows for more predictable and controlled reentry points
Wire-based ADR vs. Device-based
5. What’s is new?
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-aventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space
6. What’s is new?
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-aventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space
9. Long-term outcomes: all techniques
Azzalini L et al, Eurointervention 2017, in press
True-to-true: either antegrade or retro
Modern DR: StingRay, Reverse CART
Old DR: CART, LAST, STAR, Contrast-guided STAR
10. What’s is new
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-adventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space
11. Sub-adventitial trauma and hematoma
risk factors
• Less trauma and hematoma is associated with more effective reentry
In order:
1. Contrast-guided dissection
2. Knuckle-wire
3. CrossBoss dissection
4. Straight-wire next to the true lumen
• Large inflow (from balloon dilation, injections)
Rinfret S. Percutaneous Intervention for Coronary Chronic Total Occlusion: the Hybrid
approach. 1st ed. Switserland: Springer International Publishing, 2016.
12. What’s is new
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-adventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space
13. • Guide extension catheter with an integrated trapping
balloon for maintaining GW position during catheter
exchanges
• Same GuideLiner V3 functionality for:
• Coaxial alignment & backup support
• Distal device delivery
• Selective delivery of contrast
• Offered in 6F, 7F & 8F
14. Advantages
• You can trap all devices even in 6F
• Makes ADR possible and easier through 6F
• Can serve as an inflow occluder during ADR
• Readily available to increase support,
including power anchoring
• Can be used retrograde to improve support
and ease exchange of microcatheters
• Can be used to perform TrapLiner-X CART
15. What’s is new
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-aventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space
52. What’s is new
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-aventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space
53. Access to SI plane with ambiguous cap
• ‘Move the cap’ or ‘create your own cap’
• Scratch and go vs. BASE (balloon-assisted SI entry)
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