Experts "Live" CTO Workshop 2015 Septemper, 18th – 19th , 2014 in Istanbul, Turkey

1. EuroCTO Club 2015
Saturday, September 19, 2015
How to use intravascular imaging to
guide antegrade dissection/re-entry
during CTO PCI
2.00 – 2.15 pm
Emmanouil S. Brilakis, MD, PhD
Director, Cardiac Catheterization Laboratories
VA North Texas Health Care System
Professor of Medicine, University of Texas
Southwestern Medical School, Dallas, Texas

2. Speaker honoraria/consulting fees:
Abbott Vascular, Asahi, Boston
Scientific, Elsevier, Somahlution, St
Jude Medical, Terumo
Research funding: InfraRedx
Employment (spouse): Medtronic
Grants: VA - CLIN-007-11F
VA CSP#571 – DIVA
Disclosures

3. CTO dissection/re-entry
strategies
Antegrade Retrograde
Dissection
Re-entry
Dissection
Re-entry
Knuckle wire
CrossBoss
•STAR
•Contrast-guided STAR
•mini-STAR
•LAST
•Stingray
Knuckle wire
CART
Reverse CART
Michael et al
Circ Intv 2012

4. Imaging for ADR
1) Facilitate re-entry (IVUS):
– Select re-entry zone
– Explain failure to re-enter
– Confirm re-entry
2) To stent or not to stent (IVUS):
– Echo contrast
– Antegrade flow
3) Assess final result (IVUS – OCT):
– Distal disease vs. dissection
– Optimal stent expansion

5. Balancing act
Guide re-
entry
Subintimal
hematoma

6. Case 1
RCA
CTO

7. RCA
CTO

8. CrossBoss
into side
branches
Knuckle
for
advancing

9. In distal
cap now

10. Stingray

11. Are we in?

12. Are we in?

13. Should we
deploy it?

14. IVUS

16. Restick

17. Are we in?

18. IVUS 2

19. Final result

20. Imaging for ADR
1) Facilitate re-entry (IVUS):
– Select re-entry zone
– Explain failure to re-enter
– Confirm re-entry
2) To stent or not to stent (IVUS):
– Echo contrast
– Antegrade flow
3) Assess final result (IVUS – OCT):
– Distal disease vs. dissection
– Optimal stent expansion

21. Case 2: baseline

22. Subintimal crossing

23. Stingray balloon

24. Knuckle redirection

25. Stingray for re-entry

27. STRAW: Subintimal TRAnscatheter Withdrawal
Smith EJ, Di Mario C, Spratt JC, Hanratty CG, de Silva R, Lindsay AC, Grantham JA. JIC 2015

28. STRAW: Subintimal TRAnscatheter Withdrawal
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

29. Stick and Swap

30. Stick and Swap
Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

31. Wire position confirmation

32. Contralateral injection to guide stenting

33. Poor outflow after stenting

34. After ballooning into PLV

35. OCT

37. Final

38. Case 2: Conclusions
1. Distal re-entry may compromise
side branches
2. OCT useful in determining re-
entry site
3. Minimize distal stenting to avoid
distal side branch loss

39. Case 3: baseline 1

40. Case 2: baseline 2

41. Antegrade wire escalation

42. CrossBoss

43. CrossBoss – RAO view

44. Knuckle wire

45. Knuckle redirection

46. Distal true lumen compression

47. Blind stick and swap: Up

48. Blind stick and swap: Down

49. Pilot 200 into distal true lumen

51. Exchange for workhorse wire

52. Workhorse wire into SVG-PDA

53. After stenting

54. OCT

55. Final

56. Case 3: Conclusions
1. Blind stick+swap can be
successful in cases with
diffusely diseased distal vessel
2. OCT useful in confirming no
dissection distal to stents

57. Case 4: Right coronary artery CTO

58. Subintimal crossing

59. Stingray re-entry

60. After stenting

61. OCT performed distal to stent

62. Visconti G, Focaccio A, Donahue M, Briguori C. CCI 2015;85:382–390
Spontaneous echo contrast

63. Visconti G, Focaccio A, Donahue M, Briguori C. CCI 2015;85:382–390
Spontaneous echo contrast

64. 2.5 x 28 mm EES x 2
2.75 x 28 mm EES x 1
2.75 x 23 mm EES x 1ADR
Baseline
Final
Final

65. 8-month angiographic follow-up
Patient asymptomatic

67. Imaging for ADR
1) Facilitate re-entry (IVUS):
– Select re-entry zone
– Explain failure to re-enter
– Confirm re-entry
2) To stent or not to stent (IVUS):
– Echo contrast
– Antegrade flow
3) Assess final result (IVUS – OCT):
– Distal disease vs. dissection
– Optimal stent expansion