Dedicated CTO kit: microcatheters, balloons, adjunctive devices Kambis Mashayekhi, Germany The Experts “Live” Workshop 2017 Friday, September 15th, 2017

1. Kambis Mashayekhi
University Heartcenter Bad Krozingen
Euro CTO Club 2017: Friday 13h40
Dedicated CTO kit: microcatheters,
balloons, adjunctive devices

2. 2
Microcatheters for antegrade CTO approach
Finecross 130/150cm
Corsair Pro 135/150cm
M-Cath 135cm
Turnpike Spiral 135/150cm

3. Microcatheters for antegrade CTO approach
Less Guiding Back up
Ostial or very proximal lesions,
planned ADR
Good Guiding Back up
Not very calcified CTO lesions
Finecross
M-Cath
Corsair
Turnpike Spiral
Rotatable MCPushable MC

4. Turnpike Spiral - active support

5. Turnpike Spiral - active support

6. Microcatheters for septal crossing
Corsair 150cm
Turnpike 150cm

7. Microcatheters for epicardial crossing
Finecross 150cm

8. Microcatheters for retrograde CTO approach
Septal Crossing Epicardial Crossing
Rotatable MC Low profile MC
Corsair
Turnpike
>1,5mm < 1,5mm
Finecross
Turnpike LP
Caravel
Mirco 14

9. Septal crossing with channel dilatator
Thanks to Nicolas Boudou for the great organization and invitation of the JIF CTO in Toulouse 2016

10. Corsair Pro: push and rotation force

11. Over-rotation of MC in calcified lesion:
Wire and MC entrapment: Corsair-TIP with Confianza 12g

12. Complications in collaterals – Over-rotating the MC
Do not force an
over-rotation of the
MC in tortuosity
www.youtube.com: Case 64: Manual of CTO Interventions, 2nd edition

13. 1) Do not use a MC which you
have to push in tiny
collaterals and severe
angulations
2) A rotatable MC may be safer
(Turnpike LP, Corsair)
Complications in collaterals – Pushing MC in
tortuosity

14. Epicardial Crossing

15. Tip Configurations
SuperCross Angled Tips
– 130cm & 150cm lengths with 45°, 90° & 120° angles
– XT = extended tip lengthened from 0.65mm to 1.75mm to achieve
more secure cannulation – 130cm & 150cm lengths

16. Angled Tip - RCX-CTO 09/17

17. Angled Tip - RCX-CTO 09/17

18. 0,48 (mm)
2.3F
Round shaft
0.97 (mm) crossing
profileOval shaft
Minor axis
2.3F (0.75 (mm)) =
Crossing profile
Major axis 3.3F (1.1 (mm))
Duallumen Microcatheters
Round shaft
1.2 (mm) crossing
profile
© IMDS 2017
6.5 mm
3.3F

19. Reverse wire technique
1. 2. 3.
5. 6.
Bifurcation CTO wiring
Dual lumen applications
Wiring acute angulated
bifurcations
Parallel wiring technique
4.

20. Trapping Devices
© IMDS
Shaft stopper Trapper
Shaft stopper TrapIt

21. Trapping Balloon compatibility chart
© IMDS
Product TrapIt
Guiding Catheter compatibility
Single Lumen Micro catheters
NHancer Pro X; Corsair, FineCross,
Caravelle, Turnpike
6F
Dual Lumen Micro catheters
NHancer Rx; FineDuo; Crusade
6F
Dual Lumen Micro catheters
TwinPass Torque
7F
Stingray LP CTO Re-Entry System 6F

22. Usefulness of the Shaft Stopper

23. Usefulness of the Shaft Stopper

24. Low Profil Balloons

25. Design
Balloon
0.6 x 5 (mm)
30 ATM rated
Shaft
OD ≤ 1.5F
High push shaft
Best in class shaft profile
5. Scoring design
Short Rx section
Guidewire used as scoring
element
Tip
Low profile
High penetration
95 cm and 105 cm exit markers

26. Calcified RCX 13.09.2017
After Scoring with Blimp 30 ATM, Finecross, Rotawire, 1,5mburr

27. Calcified RCX 13.09.2017
Hornet 14g, Finecross couldn’t pass, Scoring with Blimp 30 ATM

28. Calcified RCX 13.09.2017

29. Fibrotic tissue: Laser Calcification: Rotablation
Uncrossable and calcified lesion:

30. Ultra-high pressure balloon: OPN NC
(SIS Medical)
2 balloon layers
Manometer for
high-pressure inflation
2,45 F

31. 60%
50%
25%
36%
15% 14%
0
10
20
30
40
50
60
70
Max. pressure pre Max. pressure post
35 - 40 atm
41 - 45 atm
46 - 50 atm
Maximum pressures for pre- and post-dilatation
10/2010 – 10/2015 n=176 patients n=238 OPN NC balloons
[%]
Data collection by Achim Büttner – Heartcenter Bad Krozingen

32. Rotablator assisted revers CART
NC-Balloon at 24 ATM

33. Rotablator assisted revers CART
1,5mm burr

34. NC Balloon 26 atm SIS Medical 45 atm
Ultra high pressure balloon

35. SIS Medical 50 atm SIS Medical 55 atm
Ultra high pressure balloon

36. Final result

37. NovaCross MC
Walsh S et al., Efficacy and Safety of Novel NovaCross Microcatheter for
Chronic Total Occlusions: First-in-Human Study, J Invasive Cardiol, 2016 Mar.

38. CenterCross and MultiCross
Jalal S et al, Novel CenterCross and MultiCross devices for
the treatment of infrainguinal chronictotal occlusions: initial single-
centre experience. EuroIntervention. 2016 Jan

39. Snares
EnSnare
Merit Medical
One Snare (2mm-
35mm)
Merit Medical
150 cm
6F compatible
Vascular
Solutions

40. Snaring in ostial RCA – CTO (2x6F unlar/radial)

41. Snaring: “KAM-Snare”
Wire Externalization Techniques for Retrograde Percutaneous Coronary Interventions of Chronic Total Occlusions, K.
Mashayekhi et al. 2017, accepted in EuroIntervention

42. Snaring: “KAM-Snare”
Wire Externalization Techniques for Retrograde Percutaneous Coronary Interventions of Chronic Total Occlusions, K.
Mashayekhi et al. 2017; accepted in EuroIntervention

43. Avoid blood loss !!
OKAY II

44. • Microcatheters for antegrade approach and septal or epicardial
crossing
• Duallumen catheters
• Low profil balloons
• Rotablator
• Ultra high pressure balloons
• Snares
• Special Y-connectors to avoid blood lost
CTO toolkit

45. Thank you for
your attention!

46. Thank you!

47. CTO Wiring Back up force Calcification
and
tortuosity
Subintimal
tracking
Finecross 1,8F Very good
feedback on the
wire tip, due to
low resistance in
the MC
Low active back
up, good push
Very flexible
shaft, low
profile,
Crossing success
depending on
guiding back up
force
Requires almost
very good
guiding back up
Corsair 2,6F Over-rotation of
the wire and MC
may cause wire
and device
entrapment
Very good active
back up
Attention! Do
not over-rotate
Very good
performance in
subintimal;
Power knuckle
may cause tip
prolaps
Turnpike Spiral 2,9F Over-rotation
may cause
device
entrapment
Best active back
up
Excellent in
fibrotic tissues,
like In-Stent-
Occlusion
Excellent back
up in subintimal
space
Antegrade Microcatheter

48. The is a CTO Scoring Balloon intended to create Initial Opening in heavy calcified/
fibrotic occlusions where the primary crossing is an issue.

49. Jalal S et al, Novel CenterCross and MultiCross devices for
the treatment of infrainguinal chronictotal occlusions: initial single-
centre experience. EuroIntervention. 2016 Jan

51. NovaCross

52. NovaCross

53. © IMDS
Trapping mechanism comparison
Unique patented shaft bend
mechanism
Telescopic shaft stop
mechanism
Two product codes guiding
catheter length specific
One product code not guiding
catheter length specific
No trapping mechanism setup
required
Trapping mechanism
(telescopic) need to be
adjusted to guiding catheter
length
Free insertion and retraction
of devices into guiding
catheter
Restricted inserion and
retraction of devices into
guiding catheter

54. © IMDS
Radiopaque Shaft profile ≤2F Hemostasis valve Hub
tip hard stop
2.5 x 15 (mm) balloon 90 (cm) guiding catheter
6-8F compatible marker (T-100 only)
Hemostasis hard stop principle
Trapping Balloon
Required pressure for trapping 6 ATM

55. Trapping Devices
© IMDS
Shaft stopper Trapper
Shaft stopper TrapIt
TrapIt trapping mechanism does not
interfere with devices in the guiding
catheter- no increase in profile. New
devices can be entered in guiding
catheter without interference.
Shaft stop profile 10F ~ 3 (mm)
Trapper trapping mechanism uses high shaft
profile (10F) hemostasis valve blockage. High
profile can potentially interfere with devices in
guiding catheter and limits entry of new
devices.

56. Overview
OTW catheters with dual-layer coil + braid shaft
design for superior flexibility & torque for
delivery over 0.014" wires
56
Turnpike
superior tracking
in tortuous vessels
Turnpike Spiral
rotational assistance,
trackability
Turnpike Gold
metallic tip for
enhanced advancement
Turnpike LP
low profile & flexible
for extreme tortuosity

57. OTW distal exit guidewire angle lift comparison
Guide wire exit
angle
6-7 degree
3-4 degree
6-7 degree