10 Commandments for antegrade CTO

Didier Tchétché,

Clinique Pasteur, Toulouse, France.

Potential conflicts of interest

• None

-Appropriate hydration

-Information about predicted procedure length

-Adequate timeslot in your planning

-Empty bladders

1- Prepared your patient and yourself must be

2- A bilateral injection will get

-Features of the CTO -J CTO score -Choice of the initial strategy -Evaluate distal location of the gw

EBU or XB

3.5 LAD

4.0 LCx

Amplatz

Left 2 or 3

for LCx

Judkins

right/Amplatz

for RCA

3- An adequate guiding-catheter you will select

-Support -Coaxiality -Enable multiple options -6F-7F-8F

4- Microcatheters you will systematically use

-Support for guide-wires -Guide-wires exchange -CTO crossing -Distal tip injection (contralatreal) -Prohibit antegrade tip injection

Non CTO lesion single angulation 2 mm at 45°

Microcatheter: double angulation

CTO: distal 1 mm angulation 45°+ second bend 15

-Know the tip load -Double curve

5- Adequated selected and shaped your wire will be

6- Antegrade wiring techniques you will learn

“Controlled drilling technique” Guide wire advancement with

gentle forward movements

“Penetrating technique” small movements pushing the

wire through the occlusion aiming at the distal lumen.

Paralell Wire technique

• Parallel wire (contact wire) technique involves 2 antegrade wires in which the first wire ends up in the false lumen.

• 2nd wire with same tip load or stronger

• The shaft of second wire remains in contact with the first wire and the tip is deflected to gain entry into the true lumen.

See Saw technique

From Mitsudo

-Two full sets of microcatheters

-and their respective wires are used

STAR technique (subintimal tracking and reentry)

• Create a sub-intimal dissection plane

• with hydrophilic wire (Pilot, Fielder XT or whisper)

• Re-enter distally with wire, usually at bifurcation

• Similar technique to peripheral CTO

Colombo A,. Catheter Cardiovasc Interv 2005;64:407-411.

Antegrade dissection-reentry

Crossboss™ Stingray™

IVUS guided wiring

• Localize the entry point

• Find the true lumen if guidewire into false lumen.

-Trapping balloon ++

-Wire extension

-Flushing technique (Nanto)

-GC≥ 7F

7- How to exchange wires/devices you will learn

-Anchoring techniques

-wire

-balloon

-Centercross

-Guide catheter extension

8- How to improve guide catheter support you must know

-Small OPN balloons

-Open mouth technique

-Rotablator

-Dedicated microcatheters:

-Tornus

-Turnpike Gold

9- What to do if balloon does not cross you must learn

10- Flexible you must remain

-No dogma

-Switch techniques

-Master retrograde techniques

-Continuous learning