14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany AGIK Parallel Session - Session 2: Essential tools for CTO-PCI Other dedicated devices Youssef Abdelwahed, Berlin, Germany Room: West Foyer - Friday 12:00 Chairmen: Alexander Ghanem, Hamburg, Germany; Luca Grancini, Milan, Italy; Florian Krötz, Starnberg, Germany

1. Other Dedicated
Devices
Youssef Abdelwahed
Charité – Campus Benjamin Franklin

2. Guide Extension and
Snaring

3. Guide Extension
• Different sizes 5F to 8F

4. Guide Extension
• Different sizes 5F to 8F
• Increase the backup Support

5. Guide Extension
• Different sizes 5F to 8F
• Increase the backup Support
• They Add Length to the Antegrade GC

6. Guide Extension
• Different sizes 5F to 8F
• Increase the backup Support
• They Add Length to the Antegrade GC
• To Facilitate:
• Device Delivery
• Device Retrieval

7. Guide Extension
• Different sizes 5F to 8F
• Increase the backup Support
• They Add Length to the Antegrade GC
• To Facilitate:
• Device Delivery
• Device Retrieval
• Homemade Snare

8. Guide Extension
• Different sizes 5F to 8F
• Increase the backup Support
• They Add Length to the Antegrade GC
• To Facilitate:
• Device Delivery
• Device Retrieval
• Homemade Snare
• Reverse CART

9. Guide Extension
• Different sizes 5F to 8F
• Increase the backup Support
• They Add Length to the Antegrade GC
• To Facilitate:
• Device Delivery
• Device Retrieval
• Homemade Snare
• Reverse CART
• In Managing Complications
• Ping Pong to Deliver Covered Stents
• Reduce Haematoma in ADR

10. Guide Extension
• Different sizes 5F to 8F
• Increase the backup Support
• They Add Length to the Antegrade GC
• To Facilitate:
• Device Delivery
• Device Retrieval
• Homemade Snare
• Reverse CART
• In Managing Complications
• Ping Pong to Deliver Covered Stents
• Reduce Haematoma in ADR

11. Device Delivery

12. EuroIntervention 2012;8:299-301
Guide catheter extensions: where are they taking us?

13. Device Retrieval

14. Case 1:
Unable to retrieve Stent Balloon after deployment

15. Case 1:
Successfully retrieving the Stent Balloon using GCE

16. Homemade Snare

17. CTO lesion
In a case of retrograde PCI for CTO, it is sometimes
quite difficult to advance the retrograde wire into the
antegrade GC.

18. CTO lesion
In such cases, use of a snare catheter has been reported
to be useful for catching the retrograde wire in the aorta.
J Invasive Cardiol. 2009;21:e137–E140
J Am Coll Cardiol Intv 2012;5:1–11

19. CTO lesion
J Invasive Cardiol. 2009;21:e137–E140
J Am Coll Cardiol Intv 2012;5:1–11
In such cases, use of a snare catheter has been reported
to be useful for catching the retrograde wire in the aorta.

23. Kinked Catheter
Trans-femoral approach
Kinked 4Fr JL40

24. Kinked Catheter
Trans-femoral approach
Kinked 4Fr JL40

25. Fang, Hsiu-Yu. et al. Oct. 2016.

26. • Commercially available snares have some issues.
• additional costs
• size limitations
• availability
• risks of vessel injury
31
We needed a homemade snare
consisting of PCI devices
which are already available on the table.

27. Case 2:
Loosing a Coronary wire

28. Case 2:
Retrieving the lost Coronary wire using Tangling Wires

29. • It consists of:
– A conventional .014 inch guidewire
– A PCI balloon
– A guiding catheter
– A child catheter
6Fr GC Child catheter
Balloon
GW
Homemade snare with M & C
sumi2gSnare
snare with M&C

30. using 300cm wire
Initial Homemade Snare

31. Push out only one side of wire
using 300cm wire
Initial Homemade Snare

32. Push out only one side of wire
using 300cm wire
Initial Homemade Snare

33. Big snare loop with wire shaft
Wire shaft = stiff and dangerous
using 300cm wire
Initial Homemade Snare

34. How can we make big snare loop
with soft wire tip???
using 300cm wire
Initial Homemade Snare

35. How can we make big snare loop
with soft wire tip???
using 300cm wire
Initial Homemade Snare

36. Initial Homemade Snare
• A .014 inch guide wire is shaped into a hairpin bend at a point of
15 to 20 mm from the wire tip.
• Mounted by a balloon, the wire is advanced into the GC,
keeping the wire tip placed side by side with the balloon.
Yokoi K, Sumitsuji S, et al. Eurointervention 2014)
41

37. • A .014 inch guide wire is shaped into a hairpin bend at a point of
15 to 20 mm from the wire tip.
• Mounted by a balloon, the wire is advanced into the GC,
keeping the wire tip placed side by side with the balloon.
The balloon is inflated at adequate pressure
to fix the wire tip.
42
Initial Homemade Snare

38. • During the balloon inflation, snare loop is made by pushing
the wire.
43
Initial Homemade Snare

39. • During the balloon inflation, snare loop is made by pushing
the wire.
Push
44
Initial Homemade Snare

40. • Adjusting the snare loop
by pushing the wire back and forth.
Push
45
Initial Homemade Snare

41. Pull
• Adjusting the snare loop
by pushing the wire back and forth.
46
Initial Homemade Snare

42. Pull
• Adjusting the snare loop
by pushing the wire back and forth.
47
Initial Homemade Snare

43. • This snare can catch and bring
the retrograde wire into the antegrade GC.
48
Initial Homemade Snare

44. • This snare can catch and bring
the retrograde wire into the antegrade GC.
49
Initial Homemade Snare

45. • This snare can catch and bring
the retrograde wire into the antegrade GC.
50
Initial Homemade Snare

46. • However it was still difficult to achieve the retrograde wire
externalization.
To resolve this issue, a mother and child system
(M&C) was added.
51
Initial Homemade Snare

47. 1. Advance a child catheter in the GC.
The homemade snare with M & C

48. 2. A .014 inch guidewire is shaped into a hairpin at a point of
15 to 20 mm from the wire tip.
The homemade snare with M & C

49. 2. A .014 inch guidewire is shaped into a hairpin at a point of
15 to 20 mm from the wire tip.
The homemade snare with M & C

50. 3. Mounted by a balloon, the wire is advanced into the child
catheter in the GC, almost up to the tip of the GC,
keeping the wire tip placed side by side with the balloon.
The homemade snare with M & C

51. 4. Inflate the balloon to trap the folded wire tip.
The homemade snare with M & C

52. 4. Inflate the balloon to trap the folded wire tip.
※ During inflation,
the tip is trapped, but the inside part can be freely moved.
The homemade snare with M & C

53. 5. Pushing the wire makes the snare loop larger.
※ During inflation,
the tip is trapped, but the inside part can be freely moved.
The homemade snare with M & C

54. 5. Pushing the wire makes the snare loop larger.
※ During inflation,
the tip is trapped, but the inside part can be freely moved.
The homemade snare with M & C

55. 5. Pushing the wire makes the snare loop larger.
※ During inflation,
the tip is trapped, but the inside part can be freely moved.
The homemade snare with M & C

56. 6. After snaring the target wire, pull back the wire
with keeping the balloon inflated.
The homemade snare with M & C

57. 6. After snaring the target wire, pull back the wire
with keeping the balloon inflated.
The homemade snare with M & C

58. 6. After snaring the target wire, pull back the wire
with keeping the balloon inflated.
The homemade snare with M & C

59. 7. With snaring the target wire,
just pull back the child system and out.
The homemade snare with M & C

60. 7. With snaring the target wire,
just pull back the child system and out.
The homemade snare with M & C

61. 7. With snaring the target wire,
just pull back the child system and out.
The homemade snare with M & C

62. 7. With snaring the target wire,
just pull back the child system and out.
The homemade snare with M & C

63. LCA CRA
RCA LAO
• RCA was occluded at the ostium.
• RCA blood flow was supplied through collateral channels from the LCA.
Case 3:
Ostial RCA CTO Case

64. • Sion wire was advanced through the septal channel.
• Conquest Pro successfully crossed the lesion to the aorta.
• The retrograde wire couldn’t be advanced into the antegrade GC, because RCA was
difficult to be engaged with GC.
Case 3:
Ostial RCA CTO Case

65. • Homemade snare was then used to catch the retrograde wire in the aorta.
• The Conquest Pro wire was changed to 300 cm wire(RG3).
Case 3:
Ostial RCA CTO Case

66. • Complete revascularization of the RCA was achieved without any complications.
Case 3:
Ostial RCA CTO Case

67. Case 4:
RCA CTO Case

68. Case 4:
RCA CTO Case

69. Case 4:
RCA CTO Case

70. Characteristics of our homemade snare
• Low-cost
– Homemade snare consists of
• A conventional .014 inch wire
• A PCI balloon
• A child catheter
– Can be used in most cases of the retrograde approach
PCI.

71. • Safety
• Because only the soft part of the wire enters the vessel, the
risk of vascular injury is negligible.
• Size-adjustable
• To adjust the size of the snare loop, the shaped wire is just
pulled backwards and pushed forwards.
• Easy use
• Once the retrograde wire is caught, it can be easily pulled
out with the whole snare system (the child catheter and
the balloon).
Characteristics of our homemade snare

72. CBF
KARDIOLOGIE
Thank You!
youssef.abdelwahed@charite.de

73. CBF
KARDIOLOGIE
Thank You!
youssef.abdelwahed@charite.de