14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany Main Session - Session 7: Avoid complications and optimize CTO PCI outcome Is there space for a minimalistic CTO PCI? Pier Francesco Agostoni, Antwerp, Belgium Room: Guteberg Hall (Auditorium) - Saturday 16:40 Chairmen: Kambis Mashayekhi, Lahr, Germany; Gerald S. Werner, Darmstadt, Germany; Masahisa Yamane, Sayama City, Japan

1. Is there space for a
minimalistic CTO PCI?

2. Is there space for a
MINIMALISTIC HYBRID
ALGORITHM in CTO PCI?

3. What the Minimalistic Hybrid Algorithm
is NOT:
- It is NOT only CTO PCI via radial
- It is NOT only CTO PCI without
contralateral injection
- It is definitely NOT AWE with stiff wires
without distal target visualization

4. The Minimalistic Hybrid Algorithm is
a FULL algorithm integrating all
possibilities offered by the classic
hybrid approach with specific and
dedicated access site-related “care”

5. Simultaneous

6. Less invasive CTO set-up nowadays
Double forearm
(radial, ulnar, distal radial)
7F Antegrade
6F Retrograde

7. Minimalistic Hybrid Approach
“Downsize” the bi-forearm 7F ante/6F retro
set-up even further with the goal to maintain
the effectiveness of the hybrid algorithm and
to reduce the invasiveness for the patient

8. Stepwise dual angiography
Good interpretation of the angiogram
with long films and proper visualisation
of collaterals remains crucial

9. 2 main CTO characteristics to decide approach
in the Minimalistic Hybrid Algorithm:
1. Presence of contralateral or ipsilateral
collaterals as MAIN collaterals for retrograde
intervention or for distal vessel visualization
2. Choice of the hybrid strategy (AWE, ADR or
retro) with the HIGHEST “A PRIORI” chance
of success:
1. AWE -> Retro -> ADR
2. AWE -> ADR -> Retro
3. ADR -> Retro
4. Retro -> (AWE) -> ADR

10. Specific point of the Minimalistic Hybrid Approach:
When speaking of Antegrade Wire Escalation…
• “Blind antegrade wiring” (done with microcatheter
support, ONLY soft tip wires and WITHOUT distal vessel
visualization)
• This can be done with 6F ante guiding and no distal
visualization
• “Advanced AWE” (done with microcatheter support, stiffer
wires and WITH distal vessel visualization)
• This needs to be done preferably with 7F antegrade
guiding and ABSOLUTELY with distal visualization
• Advanced AWE is similar to ADR in terms of set-up
1. Blind wiring -> Retro -> Advanced AWE/ADR
2. Blind wiring -> Advanced AWE/ADR -> Retro
3. Advanced AWE/ADR -> Retro
4. Retro -> Advanced AWE/ADR

11. Main CTO
collaterals:
CONTRALATERAL
AWE
Retro
ADR
AWE
ADR
(Retro)
Retro
(AWE)
ADR
ADR
Retro

12. Main CTO collaterals:
IPSILATERAL

13. Specific points of the Minimalistic Hybrid Approach:
• Minimize simultaneous dual access, keeping it only for
selected cases from the beginning, and adding a second guiding
catheter half way during the procedure according
to the way the procedure is going
• The set-up will be adapted along the way according to how the
procedure is going: dynamic set-up
• Be ready to change, not only hybrid strategy but also set-up:
major difference versus the classic hybrid

14. Summarizing…
• Blind antegrade wiring:
• Single 6F antegrade guiding
• Retrograde procedure:
• Double 6F ante/retro guiding
• Advanced AWE (IVUS, DLMC, stiff wires) or ADR:
• Antegrade 7F guiding and 6F retro guiding
• CTO with ipsilateral collaterals:
• Single 7F guiding

15. Minimalistic hybrid
approach: for whom?
It is not a patient-related issue…
It is an operator-related issue!
MHA is not for CTO beginners
Operators willing to try MHA need to be skilled with all
4 major hybrid techniques (AWE, ADR, RWE, RDR) and
need to be confident with forearm approach

16. Catheter Cardiovasc Interv. 2020;95:97-104
Retrospective registry
100 CTO

17. Catheter Cardiovasc Interv. 2021;98:617-625
Prospective registry
56 CTO

18. Catheter Cardiovasc Interv. 2022 Jul 28: in press
Extended prospective registry
143 CTO

19. 2 “EXPLANATORY” PAPERS
Int J Cardiol. 2019;283:84-87
Minerva Cardiol Angiol. 2021;69:764-772

20. “2-CENTER” REGISTRY DEDICATED TO
“BLIND WIRING”
Minerva Cardiol Angiol. 2022 Feb 25: in press

21. Conclusions
MHA: definitely not a new standard, however a
possibility, if one wants to minimize “access site
damage” (intended as avoiding superfluous extra
catheters and minimizing French size)
– Definitely an interesting possibility in patients with
limited access site options
In MHA, conversely to the new global CTO algorithm,
more space given to retro techniques than to ADR
– ADR in MHA remains somewhat the last resort
– Reducing ADR to the minimum means reducing the need
for 7F guidings
– Simple antegrade CTO and retrograde CTO are feasible
with single/dual 6F set-up