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The language of CTO interventions – what it
all means
Dr Angela Hoye
Senior Lecturer in Cardiology
Hull & East Yorkshire Hospitals
MY CONFLICTS OF INTEREST ARE:
Clinical Events Committee member for SPIRIT II, SPIRIT V and SPIRIT Woman, fees paid by Abbott Vascular Inc
and a CTO enthusiast..............
Improved symptoms
Improved LV function
Improved exercise capacity
Reduced need for CABG
(Improved survival (?))
Why do we open CTOs?Why do we open CTOs?
• Explosion of interest!
CTO`s!
• Try to explain/simplify some of the language used during CTO angioplasty
1.Discuss the design and use of some of the specialised devices
2.Focus on the techniques• antegrade• retrograde
• Know when (and how) to use the right device in what circumstance
• Specialist wires– Hydrophilic eg Whisper, Fielder FC– Stiff tip eg Miracle family– Tapered tip eg Fielder XT, Confianza
• Tip load
Support
Fle
xibility
MoreLess
Mor
eLess
3g
4.5g
6g
12g
Tip load: Weight needed to be applied to bend / buckle the tip of the guide wire
Floppy: <1g
Intermediate: ~3g
Stiff: ≥4.5g
Stiff wires especially when combined with a tapered tip increase penetration power but also
increase the risk of perforation
• Examples:Wire Tip load (g) Size of tip
Fielder FC 1.6 0.014”
Fielder XT 1.2 0.009
Miracle 6 ≈6 0.014”
Confianza 9 8.6 0.009
Confianza Pro 9 9.3 0.009
Confianza Pro 12 12.4 0.009
TORNUS (Abbott Vascular)• Braided stainless steel flexible
catheter able to enlarge the vessel by “screwing” through it
• Tapered tip• Rotate counter-clockwise to
advance• Clockwise to withdraw• No more than 10-20 rotations in the
same direction
Corsair (Vascular Perspectives)
• Tapered soft tip• Hydrophilic coating• ASAHI brand braiding pattern, consisting of 8 thinner wires
wound with 2 larger ones• Advancement:
– hold a torque device at all times to avoid ASAHI Corsair and the guide wire to be rotated together
– Image the Corsair tip under fluoroscopy to make sure that the tip is not trapped by the lesion
– avoid torque accumulation - limit the rotation to 10 times in one direction. To continue advancing ASAHI Corsair, rotate the opposite direction
• Rotate the Corsair during removal into the guide
Wiring techniques (antegrade approach)
→ Parallel wires / seesaw
Mitsudo et al J Inv Cardiol 2008
• Eg. Balloon support, parallel wire technique, use of simultaneous coronary injection
Anchor balloon
• Used when need more “penetration power” and the guide catheter is backing out
Fujita et al Catheterization and Cardiovascular Interventions 59:482–488 (2003)
Fujita et al Catheterization and Cardiovascular Interventions 59:482–488 (2003)
STAR: “subintimal tracking and re-entry”
STAR:• Create a (long) dissection plane with a
hydrophilic wire eg Whisper or Pilot with an “umbrella” handle tip
• Advance the wire whilst maintaining the loop
• 1.5mm OTW balloon for support
• Best suited to the RCA with few proximal branches
Colombo et al CCI 2005;64:407-11
Case example
STAR: results of 68 patients• Procedural success in 62%
– Dissection limiting procedure in 6%– Perforation in 7% (limited the procedure in 4%)– Pericardial effusion in 7% though no
pericardiocentesis
• At follow-up: restenosis in 45%– TLR: 29% after DES– TLR: 50% after BMS
• “Last resort”
Carlino et al Catheterization and Cardiovascular Interventions 72:790–796 (2008)
• What about “backwards”?– Kissing wires– CART– Reverse CART– Knuckle wire technique– “rendezvous”
etc etc.................
• Principle of the retrograde technique
Retrograde wire
Antegrade wire
Principles of the retrograde technique: • Short (80-85cm guide), typically 7F• Hydrophilic wire through the collateral
• Septal collaterals are preferable to epicardial ones• Choose collaterals that are straight• Good filling of the distal vessel from a selective
injection into the collateral is ideal though not essential
• Collateral dilatation: low pressure (1-2atm) dilation with a very small balloon (<1.5mm) or use the Corsair
• Kissing wires
• What about the CART technique?
“controlled antegrade and retrograde
subintimal tracking”
Surmely et al J Invasive Cardiology 2006
• CART:
• Simultaneous antegrade and retrograde approach• Create a (localised) subintimal dissection by inflating a
small (1.5-2.0mm balloon) over the retrograde wire
Surmely et al J Invasive Card 2006;18:334–338Surmely et al J Invasive Cardiology 2006
• The balloon is kept in place to keep the subintimal space open
• The antegrade wire is advanced further along the deflated retrograde balloon that lies from the subintimal space to the distal true lumen
• Dilatation and stent implantation in the usual manner
Surmely et al J Invasive Card 2006;18:334–338
CART“localised”
dissection
STAR“long”
dissection
Reverse CART:
Surmely et al J Invasive Cardiology 2006Rathore et al J Am Coll Cardiol Intv 2010;3:155– 64
• Knuckle wire:
Galassi et al Clin Res Cardiol (2010) 99:587–590
“Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010
“Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010
“Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010
“Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010
• “Reverse anchoring technique”
Matsumi et al Catheterization and Cardiovascular Interventions 71:810–814 (2008)
IVUS• All these techniques can be facilitated with
adjunctive IVUS– Help identify the entry point into the occlusion– Help direct a stiff wire to penetrate from the
sub-intima back into the true lumen– Guide and optimise the result of stenting
Summary & Conclusions• Recent advances in CTO angioplasty have increased
the rate of successful recanalization• In contemporary practice CTO PCI involves a range of
specialised devices • Specialist techniques may involve both an antegrade
and retrograde approach with the aim of passing the wire from the proximal to the distal true vessel lumen
• In “expert” hands, these techniques have a good success rate (and low complication rate)
Thankyou!