Where is the role for Antegrade dissection reentry? Elliot Smith, London, Great Britain 11th Experts Live CTO The annual Euro CTO meeting September 13th –14th, 2019 - Berlin, Germany

1. Where is the role for
Antegrade dissection
and re - entry?
Elliot Smith MD FRCP
Consultant Cardiologist
Barts Heart Centre London, UK
Anthony'
Ca

2. Conflicts
• Proctor CTO PCI / Speaker / Honoraria
– Boston Scientific
– Abbott Vascular
– Terumo
– Teleflex
– Vascular Perspectives
– Biosennsors Intl
• Early adopter ADR Bridgepoint Medical >> BSCI
• Trainer since 2013
C

3. Aims
• What is ADR?
• Optimal Patient Selection
• The Hybrid Algorithm
• Iteration, Innovation, Evolution
• Outcomes
• Case Illustrations
C

4. ADR Concept
• Some cases CAN’T wire
• Some cases NO retrograde options
ANTEGRADE DISSECTION
& RE-ENTRY (ADR)

5. Antegrade Dissection and Re-entry (ADR)
CrossBoss
Stingray
1mm blunt tip
multi wire coiled shaft
rapid spin motion
OTW balloon design
‘Flat’ balloon
180° exit ports
0.014 wire
Stiff with barb

7. Antegrade Wire Escalation
Antegrade
Dissection Re-entry
Retrograde Dissection Re-entry
Retrograde
Wire escalation

8. Anatomy Dictates Strategy: The 4 Questions
1. Proximal cap: Clear / Ambiguous
2. Length: > 20mm?
3. Landing zone: presence / absence of disease
Major bifurcation? YES / NO
4. Interventional collaterals YES / NO
Algorithm:

9. Anatomy Dictates Strategy: The 4 Questions
1. Proximal cap: Clear / Ambiguous
2. Length: > 20mm?
3. Landing zone: presence / absence of disease
Major bifurcation? YES / NO
4. Interventional collaterals YES / NO
Algorithm: ANTEGRADE DISSECTION AND RE-ENTRY

10. Concept - Fail early Switch fast

11. ADR (24%)
Re-entry
– CB / SR 70%
(SR 56%: CB T – T
15%)
– Wire based / LAST 25%
– STAR 4%
UK Hybrid Registry - > 3000 cases

12. CrossBoss technique

13. Knuckle Wires: ‘Re-learn wires’
• Manage resistant
lesions
• Negotiate side
branches
• Negotiate
tortuosity without
wire exit
Wire: Fielder XTA
0.7g Polymer Jacket Tapered .008”
Wire: Pilot 200
4.7g Polymer Jacket

14. Formation of XT knuckle

15. Tracking round calcium 2 views

16. Knuckle wire, then finish landing zone
with CrossBoss
Antegrade knuckle Rapid progression of Cross Boss

17. SR position
Stingray balloon
Note proximal anchor

18. SR re-entry
Stingray re-entry - DOWN

19. Stingray re-entry stick and
drive

20. Final result outflow all branches

21. Really predictable?
Clinical Outcomes?
Vessel Healing?

22. 85-90% success
Trained operators
Algorithm based
Anatomical
complexity
Patient Complexity

23. Improved Angina
Improved QOL /
Health Status
Low MACE
Low TVR
Vessel healing

26. Are the outcomes better?
CONSISTENT - CTO

27. SYMPTOMS
VIABILITY +/- ISCHAEMIA
Could this approach expand the range of indications?
TYPICAL
10% >20%0%
ATYPICAL
SEVERE
ABSENT
CONSISTENT
DECISION CTO
DECISION CTO

28. Successful CTO PCI – Barriers to adoption ADR Training
‘I could but I won’t
‘I can’t but I should

29. Equipoise Retrograde vs ADR…??

30. Equipoise Retro vs ADR…??

31. Difficulties with ADR?

32. Haematoma
47%
Calcification
21%
Other
19%
Proximal cap
penetration
13%
ADRfailuremodes

33. Control the space?
• Use of CrossBoss for SMALL blunt dissection
• Preparation - to reduce time between microcatheter
exchanges (e.g. CrossBoss to Stingray)
• Guide Extension / Trapliner

34. Innovation, Iteration, and Evolution
• Size / deliverability – Stingray LP / 7F delivery
• Adjunctive techniques / technologies
– SR wire vs. Hornet 14
– Guide X
– Facilitated ADR

35. Co-registration

37. IVUS

38. Final Angio

39. What ADR is?
• An enabling technique
• Complementary to other approaches
• Sits within an algorithmic approach
• Up to 20% contemporary cases

40. What ADR isn’t?
• Religion – you don’t need to believe in it
• Dangerous – you are already operating in a high risk
environment
• A last resort when all else fails – success dependent
on appropriate anatomical selection / rules of
engagement