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Gerald Werner - AntegradeApproach Step by Step
- 1. Antegrade Approach Step byStep Gerald S. Werner, MD, FESC, FACC, FSCAI Medizinische Klinik I Klinikum Darmstadt GmbH Darmstadt, Germany
- 2. Conflict of interest •I, Gerald S. Werner, MD, have no conflict of interest to declare with regard to the following presentation
- 3. The goal ofCTO-PCI • Ideally: Restore the original anatomy of an occluded artery • Open an occluded artery – with the least damage to the coronary anatomy – with the least investment of time and material, reducing procedural risks • There is no retrograde vs antegrade approach, there is only the choice of the best strategy for the specific lesion and patient
- 4. Strategic options forCTOs in Europe Bilateral Maximal Guide backup Antegrade Fielder XT -> Ultimate or -> Progress 200T/Conf.Pro 9 Penetration, then step down Distal good target Parallel with stiff wire Reentrysystem BridgePoint Antegrade no Stump IVUS for guided Penetration ? Retrograde With feasible collateral pathways Ostial CTO Long CTO Re-Attempt Ideal access
- 5. Strategic options forCTOs in Europe The antegrade spectrum of technical options Bilateral Maximal Guide backup Antegrade Fielder XT -> Ultimate or -> Progress 200T/Conf.Pro 9 Penetration, then step down Distal good target Parallel with stiff wire Reentrysystem BridgePoint Antegrade no Stump IVUS for guided Penetration ? Retrograde With feasible collateral pathways
- 6. J-CTO Score Sheet:Predicting complexity Morino Y et al. JACC Interv, 2011; 4: 213
- 7. Examples not likelyto work antegrade
- 8. Likely targets forthe antegrade approach
- 9. Antegrade: Step byStep • Lesion specific analysis – Identify the proximal cap – How long is the lesion – What is the presumed course of the occluded segment – Identify the distal target • Patient specific considerations – Previous attempts (which wires, why failed) – Renal function (limits on contrast use)
- 10. Basic Setup • Twocatheters (radial and/or femoral route) • Guide backup: 7F provides all options, in ostial locations and with IVUS guidance 8F preferred • Microcatheter selection: – Finecross: sleek profile, passes deep into lesions – Corsair: provides additional support for the guide – Caravelle: sleek profile with tapered tip – Others to mention: Nhancer, Vascular Solutions
- 11. UB3UB3 Hard plaque Severe calcification Stiffertip XT-(A)XT-(A) ASAHI Gaia FirstASAHI Gaia First ASAHI Gaia SecondASAHI Gaia Second ASAHI Gaia ThirdASAHI Gaia Third Miracle12Miracle12 Confianza Pro 12 Hornet 14; Progress 200T Confianza Pro 12 Hornet 14; Progress 200T XT-RXT-R 2016: Which wire to use when?
- 12. The wire selection •Explore the lesion – Fielder XT, atraumatic, provides feedback on lesion rigidity, tracks loose tissue and may even penetrate noncalcified caps; “you follow the wire” • Pass the lesion – Gaia 1-3 to penetrate the cap and steer through the occluded segment; “the wire follows you” • Conquer the calcified lesions – Confianza Pro 12 for penetration – Others: Hornet 14, Progress 200T – Pilot 200 to find the soft spots within severe calcium
- 13. Advance with inthe vessel: work horse Penetrate the cap Wire tip shape: adapt to the purpose Remember always: tip shape is lost rapidly So reshape, whenever you get stuck Remember always: tip shape is lost rapidly So reshape, whenever you get stuck Pass within the occlusion Pass a collateral
- 14. Which wire tostart with ? Examples from the Live Cases Case #4 Tapered lesion My approach: Fielder XT(-A) on microcatheter If stuck -> Gaia 1 If distal target missed -> Proceed to parallel wire
- 15. Gaia 1st controlledwire passage
- 16. Gaia 1st controlledwire passage
- 17. Which wire tostart with ? Examples from the Live Cases Case #8 Faint notch at side branch My approach: Fielder XT(-A) to deliver the microcatheter to the proximal cap, exploring, but penetration unlikely Gaia 2 as starter If distal target missed -> Proceed to parallel wire
- 18. The parrallel wire techniqueis classic Crossit 200-400 or Conquest 3g-6g N.Reifart/O.Katoh 1996
- 19. Why parallel wiringworks well in the RCA: the wire straightens the vessel architecture
- 20. Why parallel wiringworks well in the RCA: the wire straightens the vessel architecture
- 21. When and whyparallel wire works • If the 1st wire is close to the target, the 1st wire straightens the vessel course, and allows passage of the 2nd (stiffer) wire • If the 1st wire is far from the target, the 2nd wire needs to find a new course, especially in bent segments • Often the entry point into the proximal cap needs to be changed • Parallel wire is not a reentry technique
- 22. When and whyparallel wire may fail • The distal target is diffusely diseased and narrow • The distal target is severely calcified and prevents entry even with a stiff wire tip • Failure of the operator to check orthogonal views frequently: biplane systems are helpful
- 23. Which wire tostart with ? Examples from the Live Cases Case #5 Blunt occlusion at side branch Possible approach: Pass wire in side branch, dilate proximal and advance IVUS IVUS guided penetration with Gaia 2 Bailout: retrograde
- 24. RCA CTO: Strategicoptions Torino. 16.4.15 Retrograde approach in mind as most likely strategy Chair of session: “antegrade approach nonsense” Agreed, but still we need an antegrade wire for a successful retrograde approach The further the antegrade wire reaches, the shorter the retrograde wire needs to travel….
- 25. RCA CTO: Strategicoptions Torino. 16.4.15
- 26. Puncture of thecap with Gaia 2 Torino. 16.4.15
- 27. Then via Finecrosswire downgraded to Sion Black Torino. 16.4.15
- 28. Complex long RCACTO Torino. 16.4.15
- 29. 20 years PostCABG: Ostial RCA CTO Additional information from MSCT Retrograde options are challenging
- 30. Moderate calcification ->medium-strength wire
- 31. If parallel wiringfails: StingRay reentry device H.B. 30.1.15
- 32. Parallel fails, thenStingRay H.B. 30.1.15
- 33. Strategic options forCTOs in Europe Bilateral Maximal Guide backup Antegrade Fielder XT -> Ultimate or -> Progress 200T/Conf.Pro 9 Penetration, then step down Distal good target Parallel with stiff wire Reentrysystem BridgePoint Antegrade no Stump IVUS for guided Penetration ? Retrograde With feasible collateral pathways Ostial CTO Long CTO Re-Attempt Ideal access
- 34. Parallel fails, thenStingRay H.B. 30.1.15
- 35. Parallel fails, thenStingRay H.B. 30.1.15
- 36. StingRay wire passedbefore the stent H.B. 30.1.15
- 37. Antegrade: Step byStep • Lesion specific approach – Start with the softest possible wire – Step up if necessary – Use parallel wire as an early and easy bailout – If retrograde is difficult, early decision for guided reentry technique (StingRay) • Patient specific approach – Select the most likely strategy to solve the lesion – Do not attempt complex lesions without the option for retrograde conversion
- 38. Antegrade: Step byStep • Lesion specific approach – Start with the softest possible wire – Step up if necessary – Use parallel wire as an early and easy bailout – If retrograde is difficult, early decision for guided reentry technique (StingRay) • Patient specific approach – Select the most likely strategy to solve the lesion – Do not attempt complex lesions without the option for retrograde conversion