12th Experts Live CTO The annual Euro CTO meeting September 11th –12th, 2020 - Berlin, Germany

1. CrossBoss to bypass a fractured knuckle wire
during antegrade dissection re-entry for heavily
calcified LAD CTO
Dr Abdul Mozid
BMedSci (Hons) FRCP MD

2. History
• 67 year old man
• Known stable angina with LAD CTO on angiogram since 2002 with
failed attempt at PCI in 2005
• Crescendo angina culminating in chest pain at rest
• Global ischaemia on admission ECG- settled with ACS therapy
• Troponin I 170 (normal range <15 ng/l)
• Normal renal function and full blood count
• Echocardiogram: preserved LV function, inferior wall hypokinesia,
mild AS

3. Coronary angiogram- left coronary artery
Flush ostial LAD
occlusion
Severe LMS/Cx disease
Dominant Cx

4. Retrograde collateral from conus

5. Retrograde collateral from marginal branch

6. MDT/Heart Team Discussion
• Syntax I score 49.5
• PCI
SYNTAX Score II: 34.2
PCI 4 Year Mortality: 9.5 %
• CABG
SYNTAX Score II: 38.8
CABG 4 Year Mortality: 13.7 %
• Treatment recommendation : CABG or PCI
• Referred for CABG but patient unwilling to undergo CABG so
accepted for complex PCI

7. PCI to LMS, Cx and LAD CTO
• Biradial 7FR
• 7FR VL3.5 to LCA and 6FR JR4 guide to RCA
• Dual catheter injections showed long occlusion length with tortuous
retrograde collaterals- not felt to be “interventional”
• Antegrade dissection re-entry strategy
• Ambiguous proximal cap so IVUS guided proximal cap puncture

8. LMS/Cx predilated

9. IVUS guided cap puncture

10. Astato 20g wire cap puncture

11. Turnpike spiral advanced- tough!

12. Carlino

13. Pilot 200 knuckle

14. Mid vessel Gaia3rd wire exit

15. Knuckle wire unable to advance

16. Carlino again

17. Fielder XT knuckle

18. Unable to retract knuckle

19. Knuckle wire fractured

20. Fractured knuckle wire
Knuckle wire entrapped in
calcium

21. Re-knuckle with Pilot 200

22. Predilated with 1.2mm balloon

23. CrossBoss catheter- blunt dissection to distal vessel

24. CrossBoss adjacent to distal lumen

25. Stingray catheter placed

26. Stingray ‘stick-and-swap’

27. Pilot 200 successfully to distal vessel

28. Stented distal LAD

29. Stented mid LAD

30. Cx predilated

31. Minicrush bifurcation stenting

32. Kissing inflations

33. IVUS guided post-dilations- OPN balloon

34. Final result

35. Final result

36. Summary
• Beware knuckling in heavy calcification
• CrossBoss catheter can still be useful to overcome difficult anatomy

37. Summary
• Beware knuckling in heavy calcification
• CrossBoss catheter can still be useful to overcome difficult anatomy