14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany Main Session - Session 6: The Calcified CTO – The ultimate challenge Impenetrable calcified cap Jo Dens, Genk, Belgium Room: Guteberg Hall (Auditorium) - Saturday 13:10 Chairmen: Nicolas Boudou, Bordeaux, France; Roberto Garbo, Turin, Italy; Sudhir Rathore, Guildford, UK

1. “Impenetrable calcified cap“
Jo Dens
Zienkenhuis Oost Limburg, Genk, Belgium
EuroCTO 2022

2. If possible, be prepared…
• Identify calcium distribution with CT scan upfront
• “donut” like: try to remain intraplaque
• “pancake” like: go around
• Collaboration with RX/own expertise

3. 4 ways to success…

4. Maximize support
Modify the cap entry
Move base of operations
Retrograde modification

5. Part I
Maximum support, most robust devices…

6. Did you maximize penetration force?
• Co-axial guiding 7F/8F
• Deep intubation
• Robust microcatheter (post ostial CTO lesion)
• “screw in device” like turnpike spiral, turnpike gold
• Guide-extension – wire and balloon anchoring techniques
• Balloon jailed MC (power knuckle) – 5 F GE + MC (telescopic
approach)

7. Long CTO of RAC, post ostial
Step 1: AL 0.75, 7 F Step 2: turnpike spiral

8. Step 3: adding a guide extension

9. Step 4: balloon modification with wire entry
followed by a readvancement of turnpike over
the knuckle

10. Confirmed position

11. Re-entry
Stingray delivery Hornet 14

12. Re-entry
Confirmed position

13. Final result

14. Part 2
“Modify the cap entry (antegradely)”

15. Cap entry modification:
• Robust (screw- in) MC (Tornus, TP spiral, TP gold)
• Small profile balloon, if it tips in, balloon rupture (grenado-
angioplasty)
• If the MC tips in, consider Carlino (contrast injection induced
dissection)

16. MC/Balloon do not enter/cross
wire true to true
knuckle goes beyond the cap
• If wire is intraplaque, balloon and MC do not cross:
• Side branch at the cap: IVL (sesame facilitated opening technique)
• No side branch at the the cap: laser the cap entrance (0.9 mm)
• If wire is extraplaque, MC do not cross:
• consider knuckling of an extra support wire, repeat steps (MC/balloon)
• consider knuckling of a rota-wire, use 1.25 mm burr
• consider external cap modification with a balloon/IVL

17. Cap entry modification
one wire is true to true and MC/B does not cross
second wire is extra-plaque
Balloon
IVL
Rota
External plaque crush/modification Distal subintimal anchor

18. Subtotal calcified lesion in distal RAC

19. Subtotal calcified lesion in distal RAC
Crossed with sion wire

20. Guide-extension + Ryurei 1.2 mm
Corsair did not cross

21. First run with laser 0.9 mm (low energy)

22. Fourth run, complete crossing (high energy 80/80)

23. Final result

24. Part 3
Move the cap: Balloon Assited Subintimal Entry (BASE)
Guiding and contrast induced dissection of the ostium (RAC) (R. Garbo)

25. All “cap attacks” fail…move the base of
operations, with dissection
BASE Retro knuckle or Carlino
If SB at cap entry, S-BASE

26. CTO RAC
• Blunt cap
• at the bifurcation with the RV branch
• Lenght: short
• No bend
• No clear calcium
• Second attempt
• Antegrade attempt
• Ipsicollaterals
• J-CTO 2

27. Wrong wire
position (wire
perforation)
Terumo MC in
RV branch for
tip injections

28. BASE knuckle entry at proximal shoulder of
balloon
• Multiple inflations with a
properly (or even oversized)
sized balloon are needed to
create dissection planes
• Tip of MC can be at the middle
or at the shoulder of the balloon
• A knuckle is pushed from the tip
of the MC, with the balloon
inflated

29. Confirmation of ”cap crossed”
• Confirm the knuckle crosses the
bifurcation in the direction of
the distal RAC

30. Re-entry needed after BASE @ S-BASE
Puncture with Hornet 14, down (dot/wire separation)

31. End result

32. Part 4
Modify the cap from retro

33. Do you have a retrograde option?
• Any intervention from retro can modify the prox cap:
• Knuckle retro beyond the prox cap
• Retrograde microcatheter
• Balloon from retro (if collateral allows)
• Retrograde Carlino

34. Retrograde techniques
• Retro wire
• Kissing wires to create (wire) space
• Tip-in & Rendez-vous with wire in ante or retro MC to change where you
come from (ante vs retro)
• Retrograde OTW balloon (to create space for your antegrade material)
• Reverse CART
• Rota over an externalised RG3 wire

35. Calcified CTO of LAD

36. Failed AW, retro tip injection

37. Suoh goes retro

38. Caravel stuck, retro Gaia II in ante GE + corsair

39. Ante corsair crosses…

40. Open LAD.

41. Algoritm
Ante: maximize support
Ante: cap modification
Ante: BASE – go around
Retro: modification

42. Algoritm
Ante: maximize support
Ante: cap modification
Ante: BASE – go around
Retro: modification