Chronic total occlusion-PTCA

1. Chronic total occlusion-
Management strategies and Wiring
Techniques
Dr V S R Bhupal
Nizam’s Institute of Medical Sciences, India

2. DEFINITION
• >99% stenosed
• Duration >3 months
• TIMI 0-1
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

3. Histopathology
• Organized thrombus.
• Fibrotic plaque
• Calcified lesions.
• Proximal/ distal fibrous cap
• Micro channel in the occlusion segment
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

4. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

5. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

6. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

7. Micro channels inside the occlusion
• Often extend to small side branch & to
adventitia
• Extravascular micro channels in early phase of
occlusion
• More mature CTO –intravascular channels
increase
• Matured CTO - both fewer
• Longitudinal continuity – 85% of entire length
of CTO
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

8. Why Bother to do PCI?
Chronic Total Occlusion (CTO)
Because successful CTO recanalization may result in
Angina/Ischemia relief
Freedom from subsequent CABG
Improved LV function
Improvement in event-free survival
Presence of CTO in CAD Imparts Adverse Prognosis

9. Series
Name/Year
Successful PCI
(N)
FU
(months)
Asymptomatic
(%)
Olivari, 2003 248 12 89
Berger, 1996 139 6 87
Ivanhoe, 1992 264 36 69
Ruocco, 1992 160 24 69
Bell, 1992 234 32 76
TOTAL >1000 >24 mo >80%
CTO Recanalization and Angina Relief
Chronic Total Occlusion (CTO)

10. Symptom relief
• TOAT-GISE (Total Occlusion
An-gioplasty Study–Società
Italiana di Cardiologia Invasiva)
trial, CTO-PCI success - 86%,
70% angina-free survival
(p=0.008)
• Cheng et al. Demonstrated
that 76% of patients with CTO
who were treated with PCI
experienced an improved
angina classification, whereas
17% of patients who were not
treated with PCI improved
(p<0.05).
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

11. Meta-Analysis of CTO Outcomes
Joyal et al., Am Heart J 2010;160:179.
13 Observational Studies, 7288 patients
weighted averaged follow-up 6 years
OR for Success
vs. Failure
95% Cl p Value
Mortality 0.56 0.43-0.72 <0.001
MI 0.74 0.44-1.25 0.26
Subsequent CABG 0.22 0.17-0.27 <0.001
Residual Angina 0.45 0.30-0.67 0.001

12. Evaluation of LV Function 3-Yrs after
Percutaneous Recanalization of CTO
Kirschbaum S et al, Am J Cardiol 2008;101:179
Changes in LV Volume Indexes and EF between Baseline and 3-Yr FU
Measured Using Magnetic Resonance Imaging (N=21)
Mean ejection fraction improved slightly, but end-systolic and end-
diastolic volume indexes decreased significantly.
35
30
86 636078

13. • A 3.8% to 8.4% absolute reduction in mortality
was associated with successful versus failed
CTO-PCI.
Survival advantage
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

14. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

15. Northeast
Georgia
Heart Center
2011 ACCF/AHA/SCAI PCI Guidelines
What We Can Do
• Class IIa Recommendation
• PCI of a CTO in pts with appropriate clinical
indications and suitable anatomy is reasonable
when performed by operators with appropriate
expertise (Level of Evidence: B)
Levine GN, et al. JACC doi:10.1016/j.jacc.2011.08.007
PCI of CTO
CTO-MANAGEMENT AND WIRING
TECHNIQUES

16. • Symptoms
▫ A CTO with well developed collaterals is hemodynamically
similar to 90% coronary stenosis without collaterals –
significant recovery of ventricular function is expected
• Viable myocardium
▫ Recovery of LV function depends on the presence of
hibernating viable myocardium
• Success
▫ If the likelihood of success is moderate to high (>60%)
and the likelihood of complications less, PCI is
encouraging.
Patient selection CTO-MANAGEMENT
AND WIRING
TECHNIQUES

17. Appropriate Use Criteria 2012
Stress test results, Medications Asx CCS 1-2 CCS 3-4
Low risk, No / min meds I (1) I (2) I (3)
Low risk, Max meds I (1) U (4) U (6)
Intermed risk, No / min meds I (3) U (4) U (6)
Intermed risk, Max meds U (4) U (5) A (7)
High risk, No / min meds U (4) U (5) A (7)
High risk, Max meds U (5) A (7) A (8)
CTO (no other CAD)
CTO-MANAGEMENT AND WIRING
TECHNIQUES

18. Barriers
• Complications
• Failure rates
• Economic burden
• CIN
CTO-MANAGEMENT
AND WIRING
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19. Economic burden
Repeat procedures
• Fluoroscopy
• Hardware more
CTO-MANAGEMENT
AND WIRING
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20. Complications
• Impairment of collateral flow
▫ spasm, shearing off side-branches and collateral by
dissection, distal embolization
• Dissection with branch occlusion & Perforation
▫ intra-wall balloon expansion, side-branch dilatation,
damage of neochannels connecting vasa vasorum
• Guidewire entrapment
• Subacute vessel reocclusion
▫ 8% of total occlusion within 24hr Vs. 1.8% of non total
occlusion
• CIN
• Radiation
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

21. Reasons
• Not able to cross guidewire – 63%
• Long intimal dissection – 24%
• Dye extravasation – 11%
• Balloon did not cross or dilate – 2%
• Thrombus – 1.2%
Kinoshita I, et al. JACC 1995;26:409-411
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

22. Predictors of failure
• Clinical-
▫ Duration - >3-6 monthS
▫ CRF
• Angiographic
▫ Calcification(at entry point/at distal cap)
▫ Blunt stump
▫ >45 angulation of target vessel
▫ Length of occlusion >15-20mm
▫ Vessel <3mm
▫ Multiple lesions in target artery
▫ Lack of distal vessel filling
▫ Bridging collaterals and side branch
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

23. Predictors of success or failure in PCI of CTO
Predictors of success
Duration < 3 months
Antegrade flow +
Tapered morphology +
Bridging collaterals –
Side branch –
lesion length < 15 mm
Single vessel disease
Predictors of failure
Duration > 3 months
Antegrade flow –
Tapered morphology –
Bridging collaterals +
Side branch +, ostial lesion
lesion length > 15 mm
Multi vessel disease
Vessel & lesion tortuosity &
calcification
Bridging collaterals are more common
in lesions > 3 months old. Extensive
bridging collaterals that form caput
medusae around the occluded vessel
are generally not suitable for PCI
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

24. Predictors of Procedural SuccessTOAT - GISE
CTO-MANAGEMENT
AND WIRING
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25. PROCEDURAL SUCCESS
CTO-MANAGEMENT
AND WIRING
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26. CTO-MANAGEMENT
AND WIRING
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27. CTO MANGEMENT
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

28. Preprocedure planning
Paramount importance – planning reduces difficulties half
way through the procedure
Spend time examining diagnostic films or angiogram & decide on
Approach ,vascular access, guide shape & size
dedicated equipment availability
Discourage routine adhoc CTO PCI
Occluded & contralateral vessel reviewed in multiple projection
frame by frame to
understand complete anatomy
identify proximal & distal cap
vessel course & side branch
calcification
details of collateral circulation
Contrast volume defined prior to procedure - 4xGFR(ml)
EURO CTO club;2012 consensus
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

29. Precautions
▫ Covered stents
▫ Embolization coils
▫ Pericardiocentesis trays
▫ Thrombectomy devices
CTO-MANAGEMENT
AND WIRING
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30. Role of dual injection
Critical for performing CTO PCI–in all cases with good contralateral
collaterals
Allows for optimal visualization of CTO vessel
Crucial for determining lesion length, size & location of distal
target vessel
To assess any bifurcation at distal cap
Assess presence, size & tortuosity of collateral vessel
Best performed
At low magnification ,prolonged imaging exposure
No table panning - allows for optimal delineation of CTO segment
collateral vessel location & course
JACC intrvn2012;5:367-79
CTO-MANAGEMENT
AND WIRING
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31. First inject donor – then occluded vessel – minimize radiation
Septal collaterals best visualized –RAO cranial OR straight RAO
Epicardial collaterals need tailored view
more often from diagonal ,LCX or PLV
LAO & RAO cranial – Best to image distal lateral wall collaterals
(OM-PLV, diagonal to diagonal/OM connections)
RAO & AP caudal- proximal OM collaterals and those in AV groove
JACC intrvn2012;5:367-79
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

32. Guide catheter
• First key to success
• For effective guide wire manipulation :
▫ coaxial orientation of guide catheter important
▫ stability& back up force
• RCA - AL1/0.75 with side holes
• Sheperd crook RCA - AL1or2
• Prox RCA lesion - JR ( avoid ostial damage)
• LCA - Extra back up(XBU,EBU,)
• LCX (short left main) - AL1 or2 (better support,
co-axial)
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

33. Guide catheter
• 7F or 8F guide catheter
▫ Superior backup support (needed in CTO)
▫ Inter twining is less common while using parallel wires
▫ Switching over to devices like rotablator is easy
▫ Permit better contrast injection.
▫ Radial approach,usually is not preferred for CTO.
• Side hole guide catheter is useful for RCA
▫ Maintains perfusion to the sinus node artery & conus
branch
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

34. CTO WIRES
CTO-MANAGEMENT
AND WIRING
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35. CTO-MANAGEMENT
AND WIRING
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36. CLASSIFICATION OF CTO WIRES
CTO-MANAGEMENT
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37. COMMONLY USED CTO WIRES
CTO-MANAGEMENT
AND WIRING
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38. CTO-MANAGEMENT
AND WIRING
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39. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

40. Fielder™ / Fielder FC™ (Asahi Intec Co.)
• Special guidewire - distal coil coated with
polymer sleeve & further coated with a
hydrophilic coating
• Provides advanced slip performance &
trackability for highly stenosed lesion & tortuous
vessels
• Very good torque performance
• Combines both slide and torque performance
• Primary wire used in the retrograde technique of
recanalization of CTO
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

41. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

42. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

43. Whisper
• Durasteel™ Core-to-tip designed to improve
steering, durable shape retention and tactile
feedback
• Full Polymer cover with Hydrophilic coating
intended for deliverability and smooth lesion access
• Responsease™ “transitionless” core grind designed
to provide improved tracking and better torque
response
• Tip coils designed to provide softer, shapeable tip
and also improve tactile feedback
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

44. CONQUEST SERIES
CTO-MANAGEMENT
AND WIRING
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45. Pilot 200 guidewire (Abbott Vascular).
▫ Polymer-jacket
▫ Moderately high– gram-force (4 to 6 g),,
▫ Non tapered
▫ 0.014-inch guide wire.
• For complex lesion crossing, long lesions,
knuckle technique, and dissection/re-entry.
• Performs well in very tortuous segments with an
ambiguous course
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

46. GAIA WIRES
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

47. Micro catheters
• Wire exchange[floppy to dedicated stiffer]
• Torque to tip & improve feedback
• Tip stiffness of guide wire
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

48. Corsair micro catheter (Asahi Intecc)
• 2.7-F catheter with OTW hybrid catheter
• Both micro catheter and support
• Bidirectional wire braiding for torque
transmission, and an inner polymer lumen with
soft tip for optimal wire control
• Cross collateral channels and provides the
primary basis for conventional retrograde
procedures.
• Super selective injection for collaterals
• Antegrade direction for wire support.
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

49. The Corsair catheter is advanced by rotation in either direction.
The Corsair should not be over-rotated (10 consecutive turns without
release) as over-rotation could cause catheter kinking
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

50. Tornus micro catheter (Asahi Intecc)
• Braided-wire mesh OTW microcatheter with left-
handed thread allowing for channel preparation and
lesion crossing in resistant occlusions.
• Advanced using counterclockwise rotation and
removed using clockwise rotation.
• Guidewire should remain within the Tornus inner
lumen during manipulations, and over-rotation
should be avoided to minimize the risk of kinking.
• Contrast injections should not be performed
through the Tornus, as the contrast escapes through
the wire braid.
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

51. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

52. Finecross microcath
terumois.com
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

53. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

54. Lesion crossing and lumen re-entry
technologies
• CrossBoss catheter (BridgePoint Medical,
Plymouth, Minnesota)
• Stingray balloon and Stingray guidewire systems
(BridgePoint Medical).
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

55. STRATEGIES
Antegrade approach Retrograde approach
▫ SINGLE WIRE
▫ DOUBLE WIRE
 Parallel wiring
 Seesaw wiring
 Subintimal tracking and
reentry
 IVUS guided approach
 Retrograde wire crossing
 Kissing wire technique
 Knuckle wire technique
 CART
 Reverse CART
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

56. Wire escalation strategy
• 1. Floppy wire as the 1st wire
• 2. Intermediate or MIRACLE 3
• 3. MIRACLE 6
• 4. MIRACLE 12 or Conquest Family
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

57. • Wire shaping
1ºbend of 30-45º
1-2mm from tip
Find softest part
2ºbend-10-15º
@3-6mm
Work as a navigator
to orient tip
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

58. Tip curve should be just larger than lumen diameter
CTO, the lumen diameter = 0 mm
For CTO lesion – Guide wire-tip curve should be very small
Larger curve may hurt the vessel wall during direction control
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

59. Guide wire negotiation
• Different methods
• Sliding AT proximal cap
• Drilling inside CTO
• Penetration Distal cap
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

60. •Simultaneous rotation & probing of lesion
•High chance of entering to subintimal space ( tactile
response - nil )
SLIDING
•Recent occlusion
•Predominance of micro channels
•Extremely low friction wires for picking micro channels
used
• Recent total, subtotal occlusion ,ISR attempted with this
strategy
•Long duration – Micro channels replaced by fibrotic
tissue
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

61. BEWARE bridging collaterals masquerading as microchannel
Polymer sleeved wires NOT forced against resistance, small tip bend,
probing with mild rotation
Soft wires with polymer sleeve – Fielder series/ Whisper/ PT II
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

62. Drilling Strategy
• If discrete entry point present
•Technique
short curve(2mm) @45-60º to distal tip
sometimes a secondary curve given proximally
wire advanced with rapid rotational tip and gentle probing
start with MOD stiffness – progressive increase in stiffness
Entry to false lumen judged by tactile feel on pulling stiff wire
•Reserved for the most skilled and experienced operator
•Ineffective with Blunt entry ,heavily calcific & resistant lesions
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

63. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

64. Penetration
•Technique
Pushing stiff wire slowly& gradually – minimum rotation to target
direction
Tapered tip wires
Softer tip intially progressively stiffer wires
Route determined – various angio findings in multiple views, not by
tactile feel
•Useful for blunt ,heavily calcific or resistant lesions
•Not for CTO with tortuous angulated or bridging collaterals because
of higher chance of perforation
Drilling & penetration – guide support & tipload important
Tip load - success - chance of perforation
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

65. Penetration power = tipload/tiparea
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

66. • Tactile sensations
▫ Feeling of the dimple at the entry point,
especially in the abrupt type of CTO entry
▫ Feeling of strong resistance when pulling back
the wire inside the CTO body, —in this situation, the
wire tip has most likely migrated into the subintima.
▫ Feeling of no resistance the wire tip moves
freely—this most likely means that the wire tip is
either in the true lumen or in the extravascular space
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

67. Anchoring wire technique
▫ Guiding catheter is unstable
▫ One wire is positioned in a prox side branch
▫ Other wire for crossing of the occlusion
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

68. Anchoring wire
• Side branch protection
▫ Occlusion is long/ distal to side branch
• Correction of tortuosities
▫ Proximal tortuosities
• Buddy wire technique
▫ Facilitate passage of stent in complex lesions
▫ Serves as rail support.
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

69. Double wire
• Parallel wire technique
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

70. 1st wire in false channel
left in situ
2nd stiffer wire advanced parallel to first wire in same path
redirected to enter distal true lumen
main pitfall is wire twisting each other
Support catheter use, appropriate wire selection& handling –essential to
avoid wire twisting
Main purpose : - redirecting a wire inside body of a cto & puncturing distal
fibrous cap
Important prerequisite – distal vessel visualization
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

71. See-Saw Wiring
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

72. See-Saw Wiring
• Modification of parallel wire technique
• Uses 2 microcatheters or OTW baloons
• When first wire fails , 2nd wire with
microcatheter or OTW baloon is inserted
• Risk – false lumen may enlarge – procedure
failure
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

73. Side branch technique
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

74. Success
• (1) Angle between direction in which the wire
lies and the bifurcating side branch is less than
90°;
• (2) No diffuse plaque build-up about the true
lumen in the distal portion of the CTO
• (3)True lumen to the ostium of the side branch,
the wire must be just to the side of the true
lumen in the distal part of the CTO
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

75. Open sesame technique
• Hard plaque
• Failed even with conquest pro 8-20
• Side branch just in front of proximal cap
• Pass stiff guide wire and/ or a balloon into side
branch.
• Distortion of geometry
• Enables guide wire to advance into true lumen.
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

76. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

77. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

78. Dissection reentry techniques
• STAR -Uncontrolled
• LAST - Somewhat controlled
• Dedicated systems -Controlled
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

79. • Subintimal tracking and rentry technique
Used when attempts to recanalize true lumen failed
0.014 hydrophilic wire with J configration used(whisper,pilot)
Hydrophilic wire pushed through subintimal dissection plane
When pushed distal to occlusion J tip directed to truelumen
In an attempt to reenter the true lumen
•Successful in those with previous attempt failed
•High chance of perforation
STAR Technique
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

80. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

81. Knuckle wire technique
•Polymer jacket wire (fielder XT or pilot-
200)manipulated
• To create wire loop – advanced subintimally across
CTO
•OTW system advanced to this area- rentry to true
lumen with a stiffer wire or pilot 200
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

82. LAST technique
• To initiate subintimal angioplasty and to
enter CTO body to limit long false lumens
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

83. Cross Boss catheter
• Metal OTW micro catheter with rounded tip to prevent
vessel exit
• Device rotated rapidly in either direction using fast spin
• Can advance through the CTO without a wire in the lead
• Subintimal position- true lumen reentry performed
• Smaller subadventitial space – less likely to accumulate
blood
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

84. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

85. Sting ray balloon & guide wire system
1mm flat balloon with 3 exit ports connected to the same lumen
Distal exit port – for balloon positioning
Uses guide wire with extreme tapered tip (0.0025) for reentry
Distal true lumen entry confirmed by contralateral injection
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

86. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

87. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

88. RETROGRADE APPROACH
• Initially used after a failed antegrade approach
• Now used as initial strategy in challenging cases
▫ Ostial occlusion
▫ Large side branch at proximal cap
▫ Long occlusion (>30mm)
▫ Severe tortuosity or calcification
▫ Without stump
▫ Visible continuous collaterals
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

89. Collateral selection
Preference - Bypass graft > septal > epicardial
Selective injection of collateral
Surfing technique for crossing invisible septal collateral
Wiring collateral – achieved with OTW system or dedicated
septal dilator(corsair)
Contrast injection to assess best connection
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

90. Hydrophillic polymer jacket wire with <1mm 30-45º tip used
to cross recipient artey
Fielder FC,Pilot-50,Whisper, Choicept,Runthrough
Wire should move freely - difficulty to advance – perforation?
whipping of wire - RV or LV entry (rarely pericardium)
Of no consequence if recognized before advancing OTW system
Collateral dilatation using 1.5 mm balloon @ 1-2 atm or Corsair
Epicardial collaterals
size most important factor in wiring success
should never be dilated
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

91. Antegrade crossing
• Simplest form of retrograde technique
• Retrograde wire advanced to distal cap
• Acts as a marker of distal true lumen
• Serves as a target for antegrade wire
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

92. Kissing wire
Manipulation of both antegrade and retrograde wires in CTO until they
meet
Antegrade wire follow channel made by retrograde wire in true lumen of
distal vessel
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

93. Retrograde true lumen puncture
Most pure form of retrograde technique(only in 40% retro tech)
Hydrophilic wire advanced to the lesion
Advancement of microcatheter or OTW baloon – additional support
CTO crossed retrogradely using hydrophillic wire or stiffer wire
Maneuvers to enhance chance of crossing
Inflating retrograde baloon - coaxial anchor
Stiffer tapered tip or hydrophilic wires
IVUS facilitation of retrograde wire to proximal true lumen
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

94. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

95. • Basic concept –create subintimal dissection with
limited extension only at the site of a CTO.
• Antegrade wire advanced into CTO then to
subintimal space.
• Retrograde wire through collateral with
microcatheter to distal end of CTO - into the
CTO- then to subintimal space.
• Baloon inflation inside CTO using small balloon
over the retrograde wire in subintima
• Balloon inflated inside CTO
• To keep inflated space open deflated baloon left
in subintimal space
C A R T Controlled antegrade & retrograde subintimal tracking
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

96. Two subintimal dissection provide reentry space for
antegrade wiring
Antegrade wire advanced along deflated retrograde
balloon into the distal true lumen
Limited subintimal tracking (dissection) only in CTO
segment
Avoids difficulty of reentering distal true lumen
Dilatation and stent implantation after successful
recanalization
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

97. CTO-MANAGEMENT
AND WIRING
TECHNIQUES

98. Use smallest sized baloon inside CTO to create sufficient
wire reentry space
Access to distal CTO mainly via septal collatrels,
by polymer jacket wire over microcatheter or otw
baloon
Septal channel dilatation at 1.25mm baloon at low
pressure
Major limitations
Limited access of collateral channels to target CTO
Empiric estimation of retrograde baloon size
Overall unpredictable procedure time
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

99. Reverse CART technique
• Engage a guidewire retrogradely in the distal cap of the CTO
• Another wire anterogradely in the proximal cap of the CTO
• Retrograde wire advanced in subintimal space into CTO lesion
• Subintimal channel is enlarged by anterograde balloon
• Plaque dissection and modification of the lesion
• Retrograde wire advanced to cross the dissection
• Link up with the anterograde wire in proximal true lumen
• Wire externalized (Exchange length)
• Anterograde PCI done
CTO-MANAGEMENT
AND WIRING
TECHNIQUES

100. CTO-MANAGEMENT
AND WIRING
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101. KNUCKLE WIRE TECHNIQUE
Best suited for long segment of occlusion
Retrograde wire usually a polymer jacket wire
manipulated to form a loop at wire tip advanced in
subintimal space across CTO
Eg: Fielder XT or Pilot-200
Rounded wire loop advanced in subintimal space across
CTO without causing perforation
OTW system advanced to this area followed by attempt to
reenter true lumen using a stiff wire with short bend or
hydrophillic wire
Eg: Confianza Pro 12 or Pilot 200
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102. CTO-MANAGEMENT
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103. CTO-MANAGEMENT
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104. CTO-MANAGEMENT
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105. CTO-MANAGEMENT
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106. Antegrade vs retrograde
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107. Treating lesion after crossing
CTO crossed by antegrade wiring (kissing wire,CART)
Antegrade CTO PCI can be done
Retrograde balloon can trap antegrade wire to facilitate procedure
Retrograde wire crosses to true lumen
Options : Antegrade wiring
Retrograde wire externalization
Retrograde stent delivery
DES is preferred in CTO PCI
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108. CTO-MANAGEMENT
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109. BVS IN CTO
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110. APPROACH
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111. CTO-MANAGEMENT
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112. IVUS Navigated Wiring
IVUS – Depict cross sectional view of coronary tree
IVUS focus on plaque distribution, calcification, reference vessel size &
side branch anatomy
Applicability of IVUS in CTO PCI
1)Side branch method to navigate CTO wire into true lumen from
proximal cap
2)Subintimal rentry from the proximal true lumen
IVUS guided subintimal rentry – Last resort for getting a subintimal wire
into distal true lumen
Applicable even after losing site of distal vascular bed on angio
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113. •1.5-2mm baloon dilatation in presumed subintimal space
•IVUS is advanced into the space monitored to orient 2nd wire to
true lumen
Key points
a) Ability to translate cross sectional image into 3D needed
b) 2nd stiff tapered wire over micro catheter - 8f guide mandatory
c) Reentry point should be closer to proximal cap
d) Contrast injection should be withheld esp after small ballon
dilatation
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114. CTO-MANAGEMENT
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115. CTO-MANAGEMENT
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116. Forward looking IVUS
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117. Forward looking IVUS
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118. Forward looking IVUS
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119. Optical coherence reflectometry
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120. CTO-MANAGEMENT
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121. CTO-MANAGEMENT
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122. CTO-MANAGEMENT
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123. n
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124. CTO-MANAGEMENT
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125. CTO-MANAGEMENT
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126. CTO-MANAGEMENT
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127. CTO-MANAGEMENT
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128. CTO-MANAGEMENT
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129. Debulking of calcific lesion
• Rotational atherectomy
• Directional atherectomy
• Silverman plaque excision system
• Excimer Laser atherectomy
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130. Collagenase plaque digestion
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131. Magnetic navigation
• Magnetic navigation wire
• Stereo taxis Magnetic Radio Frequency Guide
wire
• Magnetic navigation micro robot
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132. Complications
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133. Northeast
Georgia
Heart Center
CTO PCI
• Have clear cut indications for PCI
• Proper case selection for operator skills
• Have pre-defined limits for stopping
• Avoid preventable complications
• excess contrast, radiation
• Failed PCI is not a bad outcome
• Stage 2 may yield better result
Summary
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134. Northeast
Georgia
Heart Center
FINALLY
STOP QUESTIONING
Why should we open the occluded vessel?
CTO-MANAGEMENT AND WIRING
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135. Northeast
Georgia
Heart Center
• START QUESTIONING
What is the justification to leave the vessel closed?
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136. Northeast
Georgia
Heart Center
THANK YOU
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