This document discusses specific techniques for performing antegrade dissection re-entry (ADR) for chronic total occlusions and troubleshooting difficulties that may arise. It begins with an overview of the ADR procedure and ideal candidates. Techniques covered in more detail include how to start ADR with an ambiguous proximal cap, navigate the body of the occlusion, manage the landing zone, and re-enter the true lumen. The document concludes with descriptions of methods for overcoming challenges like unsuccessful re-entry, navigating side branches, and treating complex bifurcation lesions. Case examples are provided to illustrate some of the techniques.

1. Specific Complications with ADR And
How to Stay Out of Trouble
Dimitri Karmpaliotis, MD,PhD FACC
Associate Professor of Medicine
Columbia University Medical Center
Director of CTO, Complex and High Risk Angioplasty
NYPH/Columbia
Email: dk2787@columbia.edu
EURO CTO CLUB, 11th Live Experts CTO
Berlin, Germany, September 13-14, 2019

2. Disclosures
• As a faculty member for this program,
I disclose the following relationships
with industry:
• Speakers Bureau for Abbott Vascular,
MDT vascular and Boston Scientific

3. Antegrade Dissection Re-Entry (ADR)
1. Who is the ideal candidate for ADR
2. Basic Concept/Description of the Technique
3. Case Examples
4. How to Start, especially with ambiguous Proximal Cap
5. How to Navigate the Body of the Occlusion
6. How to Manage/Protect the Landing Zone
7. How to Re-Enter/Stick and Swap
8. Troubleshooting/Overcoming Difficulties

4. Brilakis et al.
Hybrid Strategy Treatment Algorithm

5. Antegrade Dissection Re-Entry (ADR)
Basic Concept/Tools/Description of the Technique

6. Antegrade Dissection Re-Entry (ADR)
1. How to Start, especially with ambiguous Proximal Cap
2. How to Navigate the Body of the Occlusion

7. The Scratch ‘n Go

15. MOVE THE CAP AND ADR-
STINGRAY FOR ECTATIC AND
TORTUOUS VESSEL
CTO-RCA

16. CTO-RCA Dual Injections
7Fr Slender Sheaths
Right Radial Artery
7Fr EBU 3.5 90cm
Left Radial Artery
7Fr AL0.75 SH 90cm

17. CTO-RCA Dual Injections
7Fr Slender Sheaths
Right Radial Artery
7Fr EBU 3.5 90cm
Left Radial Artery
7Fr AL0.75 SH 90cm

18. Setting up for Reverse CART
Antegrade TurnPike 135cm
Retrograde TurnPike 150cm
Antegrade Pilot 200
Retrograde Pilot 200
Very Hard to get into vessel structure
because of tortuous
and ectatic vessel added to proximal
bridging collaterals and ambiguous
proximal cap

19. “Move the Cap” Technique
Antegrade
4.0 x 12 Balloon inflated
in pRCA
On looped BMW wire
Antegrade TurnPike 135cm
With
Knuckled Fielder XT Wire
NEXT to the Balloon
“Move the Cap” by entering the sub-
intimal place (with your knuckle) more
proximally that the proximal CTO cap

20. “Move the Cap” Technique
Confirm position of your knuckle in the
vessel structure with orthogonal views

21. ADR-StingRay
StingRay LP advanced into that
straighter segment after
TurnPike assisted
knuckled Fielder XT
exchange with Miracle 12

22. ADR-StingRay
StingRay LP
StingRay Wire Fenestrations

23. ADR-StingRay
StingRay LP
Pilot 200 rapidly advanced
with wiring of the
distal true lumen
Into a smaller branch
Retrograde Distal Tip Injections with
Medallion Syringe for visualization

24. After 6Fr Guideliner supported PCI
DES 3.5 x 38 mm
DES 4.0 x 38 mm
DES 4.0 x 18 mm
DES 4.0 x 28 mm

25. Antegrade Dissection Re-Entry (ADR)
1. How to Navigate the Body of the Occlusion
2. How to Manage/Protect the Landing Zone
3. How to Re-Enter/Stick and Swap

30. Stick and Swap
- Method of reentry in
which an initial puncture
into the true lumen from
the Stingray balloon side-
port is performed with the
Stingray wire. This wire is
removed and a Pilot 200
guidewire is advanced
through the same tunnel
created by the Stingray
wire into the distal true
lumen.

33. Antegrade Dissection Re-Entry (ADR)
Troubleshooting/Overcoming Difficulties

34. Bobsledding
- After unsuccessful
StingRay re-entry, the
balloon is deflated and
pushed forward
downstream in the
subintimal space without
a leading guidewire to
allow for a fresh zone to
attempt re-entry

35. Bobsledding
- After unsuccessful
StingRay re-entry, the
balloon is deflated and
pushed forward
downstream in the
subintimal space without
a leading guidewire to
allow for a fresh zone to
attempt re-entry

36. STRAW
- Method used to aspirate
subintimal hematoma
which may develop in the
dissection plane by
placing an over the wire
balloon or microcatheter
next to the Stingray
balloon and aspirating.
Subintimal Transcatheter Withdrawal

37. Knuckle Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by creating
a large knuckle wire (Pilot
200) which is more likely
to follow the parent vessel
architecture, thus allowing
the CrossBoss to be
redirected to the desired
landing zone

38. Knuckle Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by creating
a large knuckle wire (Pilot
200) which is more likely
to follow the parent vessel
architecture, thus allowing
the CrossBoss to be
redirected to the desired
landing zone

39. Knuckle Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by creating
a large knuckle wire (Pilot
200) which is more likely
to follow the parent vessel
architecture, thus allowing
the CrossBoss to be
redirected to the desired
landing zone

40. Knuckle Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by creating
a large knuckle wire (Pilot
200) which is more likely
to follow the parent vessel
architecture, thus allowing
the CrossBoss to be
redirected to the desired
landing zone

41. Pilot Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by using a
Pilot 200 with longer tip
angle which can be
steered away from the
sidebranch and down the
parent vessel, thus
allowing the CrossBoss to
be redirected to the
desired landing zone

42. Pilot Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by using a
Pilot 200 with longer tip
angle which can be
steered away from the
sidebranch and down the
parent vessel, thus
allowing the CrossBoss to
be redirected to the
desired landing zone

43. Pilot Redirect
- Technique employed
when traversing the
subintimal space (usually
with a CrossBoss) to
navigate away from
sidebranches being
erroneously selected.
Accomplished by using a
Pilot 200 with longer tip
angle which can be
steered away from the
sidebranch and down the
parent vessel, thus
allowing the CrossBoss to
be redirected to the
desired landing zone

44. Extreme ADR
Bifurcation LAD/Diagonal

52. Sting Ray 2

60. AfterBefore

61. AfterBefore

63. Thank You

64. Thank You