New developments in antegrade dissection/re-entry approach Stéphane Rinfret, Canada The Experts “Live” Workshop 2017 Friday, September 15th, 2017

1. New developments in antegrade
dissection-reentry approach
Stéphane Rinfret, MD, SM
Chief of Interventional Cardiology
Complex PCI and CTO program

2. Disclosure Statement of Financial Interest
•Boston Scientific: Proctorship
•Abbott Vascular: Proctorship, Research grants
•Terumo: Proctorship, symposiums
•Medtronic Canada: Proctorship, Research grants
•SounBite Medical: Consultant
•Abiomed: Consultant
All modest

3. Antegrade dissection-reentry: when?
1. Long CTO without retrograde option, and good landing zone
•No other options
2. AWE attempt but sub-adventitial tracking (with any wire)
• Usually not the initial intention of the operator
• Alternative: parallel wires, retrograde

4. 1. Wire-based: Variation on a same theme
• LAST (Limited Antegrade Sub-Intimal tracking)
• STAR (Sub-intimal Tracking and Reentry)
• Mini-STAR
• Contrast-guided STAR
All involve less predictable reentry site with wires (either knuckled or straight)
2. Device-based (with StingRay)
Allows for more predictable and controlled reentry points
Wire-based ADR vs. Device-based

5. What’s is new?
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-aventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space

6. What’s is new?
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-aventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space

7. Longterm outcomes ADR
L Azzalini et al, Int J Cardiology 2016

8. L Azzalini et al, Int J Cardiology 2016

9. Long-term outcomes: all techniques
Azzalini L et al, Eurointervention 2017, in press
True-to-true: either antegrade or retro
Modern DR: StingRay, Reverse CART
Old DR: CART, LAST, STAR, Contrast-guided STAR

10. What’s is new
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-adventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space

11. Sub-adventitial trauma and hematoma
risk factors
• Less trauma and hematoma is associated with more effective reentry
In order:
1. Contrast-guided dissection
2. Knuckle-wire
3. CrossBoss dissection
4. Straight-wire next to the true lumen
• Large inflow (from balloon dilation, injections)
Rinfret S. Percutaneous Intervention for Coronary Chronic Total Occlusion: the Hybrid
approach. 1st ed. Switserland: Springer International Publishing, 2016.

12. What’s is new
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-adventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space

13. • Guide extension catheter with an integrated trapping
balloon for maintaining GW position during catheter
exchanges
• Same GuideLiner V3 functionality for:
• Coaxial alignment & backup support
• Distal device delivery
• Selective delivery of contrast
• Offered in 6F, 7F & 8F

14. Advantages
• You can trap all devices even in 6F
• Makes ADR possible and easier through 6F
• Can serve as an inflow occluder during ADR
• Readily available to increase support,
including power anchoring
• Can be used retrograde to improve support
and ease exchange of microcatheters
• Can be used to perform TrapLiner-X CART

15. What’s is new
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-aventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space

16. Long CTO, non-ambiguous but blunt cap
post CABG

17. No interventional collaterals

18. Antegrade with Fighter then Pilot 200

19. In vessel structure- then Gaia

20. Vessel structure?

21. Start over with a knuckle

22. For sure in vessel structure

23. At distal cap (not beyond)

24. Switch for straight XT at this point

25. TP Spiral advanced to the re-entry spot

26. Miracle 12 placed for exchange

27. TrapLiner to occlude to inflow

28. Stingray+TrapLiner in place

29. Stick with Stingray wire

30. Swap with Pilot 200: Still sub-intimal

31. Bobsleigh

32. Stick and drive with Hornet 14

33. Into the true lumen

34. Stingray removed

35. Final

36. 20mm RCA CTO, ambiguous course of
vessel, good landing zone

37. No easy interventional collateral

38. Corsair at proximal cap

39. Stick with CP12

40. Corsair advanced

41. XT knuckled

42. Into the vessel structure

43. Corsair a bit far from true lumen

44. Corsair pulled into CTO segment

45. Gaia closer to the intimal border

46. Corsair re-advanced to create a channel
for StingRay balloon

47. StingRay in place: wrong and right views

48. Very favorable position

49. Stick

50. Post swap with Pilot 200

51. Post stenting

52. What’s is new
• Newer techniques better than older techniques
• Better longterm outcomes
• Better understanding of sub-adventitial vessel trauma
• Better techniques to prevent sub-aventitial hematoma
• More AWE ± ADR than ADR right away
• More TurnPike, more Gaia, less CrossBoss with StingRay
• Better wires to re-enter into the true lumen
• Better understanding of mechanisms to penetrate the SI space

53. Access to SI plane with ambiguous cap
• ‘Move the cap’ or ‘create your own cap’
• Scratch and go vs. BASE (balloon-assisted SI entry)
?
?

54. OM1 CTO, ambiguous proximal cap

55. Branch at proximal cap

56. Need to move the cap more proximal

57. BASE (Balloon-Assisted Subintimal Entry)

58. TurnPike in SI plane

59. Straight Pilot 200 then MC advanced

60. Fielder XT knuckled

61. In the vessel structure

62. TurnPike at the distal cap (with a
bifurcation)

63. Wire-based re-entry with Gaia 3rd

64. Stenting proximal

65. TwinPass and Pilot 200 to get anterior
branch

66. PCI

67. Both branches preserved

68. Available: TCT 2017
www.ctomanual.orgAvailable on
Springer.com!