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

1. Kambis Mashayekhi
Parallel Wiring vs. ADR: Any difference?
University Heartcenter Freiburg - Bad Krozingen

2. 2
X X X X
X X X X

3. CTO Techniques
James C. Spratt, Optima Education
G. Sianos, EuroIntervention 2018;14:31-33

4. Parallel Wire Technique
Parallel wire:
The subinitimal wire shows
you where you should not go
Direct wiring:
Check in 2 plans before
puncturing the cap
Controlled wire reenty
infront of the distal CAP

5. Introduction of the Parallel Wire Technique
O. Katoh and Claus Reifart
1995 - Frankfurt/ Germany - PCI Live course
First description and demonstration
Ochiai M et al.
The latest wire technique for chronic
total occlusion. Ital Heart J.
2005;6:489-93.

6. Asia Pacific Algorithm
Harding SA er al. JACC Cardiovasc Interv. 2017 Nov.

7. Consensus Document of the Euro CTO Club
Galassi et al., EuroIntervention 2019

8. How to perform parallel wire technique?
J-CTO 5
with
Faint landing zone

9. Ostial LAD - Occlusion
Dual lumen MC for puncturing: Increases penetration force

10. Ostial LAD - Occlusion
High tip load wire
12g

11. Ostial LAD - Occlusion
Corsair to penetrate the
antegrade cap
Subintimal wire position

12. Ostial LAD - Occlusion
Dual lumen assisted
parallel wire
with Gaia 3rd

13. Ostial LAD - Occlusion
Gaia 3rd – true lumen

14. Final result
Ostial LAD - Occlusion

15. Antegrade Dissection Reentry
Reentry with a stiff
puncture wire:
Stingray or dual
lumen MC:
Check position before
puncturing the cap
Controlled wire reenty distal of the distal CAP
into the non occluded part of the vessel

16. Hybrid Algorithm for CTO-PCI
Brilakis ES, et.al., JACC Cardiovasc Interv 2012 Apr, 5(4): 357-79

17. Ambiguous Cap Narrow landing zone
How to perform ADR?

18. How to perform ADR?

19. How to perform ADR?

20. IVUS for puncturing the cap Loosing the landing zone
How to perform ADR?

21. Lesson
Always try to control your wire tip at the
reentry zone and try to reduce your subintimal
pathway length

22. superselectiv injection for visualization
hematoma aspiration through the
Stingray LP
How to perform ADR?

23. Lesson
Always try to avoid big subintimal hematoma
compression your landing zone
• Stop the subintimal inflow (Guideliner or Balloon)
• Do not overmanipulate the wire at the distal cap
• If ipsilateral collaterals: do an superselective Injection to visualize the landing zone
• Blood aspiration from subintimal space gives you a higher chance for the reentry

24. Puncture with CP 12 Confirm wire position
How to perform ADR?

25. How to perform ADR?

26. Lesson
Even after correct puncture you should change
your wire to a polymer jacket wire with lower tip
load to avoid distal wire perforation

27. How to perform ADR?

28. How to perform ADR?

29. How did our strategy changed over time?

30. Parallel wire technique in the ERCTO Registry:
n=17,626 procedures
Years
2008-2009
(N=3,027)
Years
2010-2011
(N=4,812)
Years
2012-2013
(N=5,473)
Years
2014-2015(1/2)
(N=4,314)
p value
(for trend)
Intravascular ultrasound 2.1% 3.2% 10.8% 12.8% <0.001
Wire escalation approach 89.2% 83.5% 69.2% 64.6% <0.001
Parallel wire technique 20.5% 16.3% 8.7% 8.0% <0.001
Retrograde approach 10.1% 14.6% 25.5% 29.9% <0.001
Retrograde approach
(previously failed CTOs) 25.4% 29.1% 39.2% 42.9% <0.001
Externalization of
retrograde wire 0.3% 2.9% 12.2% 16.5% <0.001
Corsair microcatheter 2.6% 16.4% 34.2% 39.2% <0.001
Konstantinidis et al, Circ Cardiovasc Interv. 2018;11:e006229

31. ADR in ERCTO Registry :
n=17,626 procedures
Years
2008-2009
(N=3,027)
Years
2010-2011
(N=4,812)
Years
2012-2013
(N=5,473)
Years
2014-2015(1/2)
(N=4,314)
p value
(for trend)
Wire escalation approach 89.2% 83.5% 69.2% 64.6% <0.001
Parallel wire technique 20.5% 16.3% 8.7% 8.0% <0.001
Antegrade Dissection
Reentry approach (ADR) 0.7% 1.9% 5.4% 5.5% <0.001
Crossboss crossing
catheter 0.4% 0.7% 1.8% 1.8% <0.001
Stingray re-entry system 0.4% 1.5% 3.2% 3.4% <0.001
Retrograde approach 10.1% 14.6% 25.5% 29.9% <0.001
Konstantinidis et al, Circ Cardiovasc Interv. 2018;11:e006229

32. The Hybrid Approach to Chronic Total Occlusion
Percutaneous Coronary Intervention: Update From the PROGRESS CTO Registry
Tajti P. et al, JACC Cardiovasc Interv. 2018

33. The Hybrid Approach to Chronic Total Occlusion
Percutaneous Coronary Intervention: Update From the PROGRESS CTO Registry
Tajti P. et al, JACC Cardiovasc Interv. 2018
AWE: J-CTO 2.28 ADR: J-CTO 2.86 Retrograde: J-CTO 3.12

34. Variable
Univariate Multivariate
Odds ratio 95% confidence
interval
p Odds ratio 95% confidence
interval
p
Age (per 10 years) 1.45 1.18-1.79 0.001 1.53 1.18-1.97 0.001
Male sex 1.37 0.68-2.76 0.38
Prior coronary artery bypass graft 2.02 1.27-3.23 0.003
Blunt stump 1.61 1.07-2.44 0.02
Moderate-to-severe calcification 1.62 1.06-2.47 0.03
>45º bending 2.51 1.65-3.82 <0.001
Length >20 mm 2.40 1.49-3.86 <0.001 2.76 1.45-5.25 0.002
Rotational atherectomy 2.60 0.79-8.54 0.11
Use of antegrade dissection/re-entry 2.42 1.26-4.62 0.008 3.30 1.59-6.86 0.001
Use of retrograde approach 2.16 1.33-3.49 0.002 2.16 1.23-3.78 0.007
Independ predictors for perforations
Azallini L.,……,Mashayekhi K., accepted for EuroIntervention 2019

35. Are there differences in long term clinical outcomes of
intentional subinitimal versus luminal wiring?

36. Midterm outcome of intimal vs. subintimal tracking with antegrade
and retrograde approach in CTOs: J<PROCTOR2 study
TVR after 12 months
Hasegawa K et al., EuroIntervention 2017 Feb

37. Midterm outcome of intimal vs. subintimal tracking with
antegrade and retrograde approach in CTOs: J<PROCTOR2 study
Predictor for subintimal tracking in the retrograde group
Hasegawa K et al., EuroIntervention 2017 Feb

38. FFR ≤ 0.80 more frequent with
subintimal vs. luminal wiring
Karamasis GV et al. Circ Cardiovasc. Interv. 2018 Nov;11(11)

39. Discordance Between Presumed and Core Laboratory
IVUS-Confirmed Recanalization Path
Simon J. Walsh et al., Jacc Int. 2020

40. Summarized findings from the CONSISTENT CTO Study
Simon J. Walsh et al., Jacc Int. 2020
multivariate adjustment, crossing strategy was not
an independent predictor of TVF (p= 0.893)

41. • Goal for the parallel wire technique is a controlled wire reentry in front of the
distal cap
• Goal for an ADR is to get a wire in subintimal position beyond the distal cap
• Both techniques are useful and important
• ADR is almost used in more complex scenarios
• The complication rates in more complex cases (J-CTO score) are generally
higher
• Based on clinical outcome data there is a trend towards higher TVR in ADR
• The Consistent Study showed no significant difference in MACE for dissection
reentry techniques in CTO PCI
Conclusion

42. When to start with ADR?
Thanks to Bill Lombardi 2017

43. When to start with ADR?
Thanks to Bill Lombardi 2017