chronic total occlusions - livemedia.gr · jacc cardiovasc imaging. 2015 jul;8(7):804-13....
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Chronic Total Occlusions Essential Toolbox
Α-Δ. ΜΑΥΡΟΓΙΑΝΝΗΚΑΡΔΙΟΛΟΓΟΣ
AIMOΔΥΝΑΜIΚΟ ΕΡΓΑΣΤΗΡΙΟΓ.Ν.Θ. «Γ.ΠΑΠΑΝΙΚΟΛΑΟΥ»
ΘΕΣΣΑΛΟΝΙΚΗ
Disclosure Statement of Financial Interest
none whatsoever…
The Late Open Artery Hypothesis: Rationale and Dilemmas of CTO PCI
• Reduction in ischemic burden
• Enable completeness of revascularization
• Improvement of symptoms
• Improvement in LV function
• Reduced predisposition to arrhythmic
events and ischemic events
• Avoidance of procedures and reduced
medications
• Survival benefit
• Technical and procedural challenges
• Misperceptions regarding viability,
collateral flow
• Uncertainty regarding which patients may
benefit balanced by
• Concern for complications in patients who
may not derive clinical benefit
Disclaimer: Capability to perform CTO PCI imparts clinical wisdom to decide when it is and is not indicated
CTO Revascularization Evidence Considerations from a Patient Perspective
What is the Procedural Success and Safety Following Contemporary CTO PCI?
Event Estimate Context
Death 0.2-0.9%
Source: OPENCTO¹, PERSPECTIVE²,
RECHARGE³
1.5%
ACC NCDR SVG PCI
Procedural MI 1.8% to2.8%
Source: OPENCTO¹, PERSPECTIVE²,
RECHARGE³ EXPERT CTO4
3.6%
LM PCI EXCEL Trial 6
Technical Success86% to90%
Source: OPENCTO1, PERSPECTIVE2,
RECHARGE3, EXPERT CTO4, PROGRESS5
74%
Mayo Clinic 2003-20057
Clinical Success 86% to 96%
Source: PERSPECTIVE2, EXPERT CTO4 85,9%
ACC NCDR
1Sapontis. JACC Intv2017; 2 Kandzari. TCT 2017; 3 Maeremans. JACC 2016; 4 Kandzari. JACC Intv2015; 5 Karmpaliotis. CCI 2016; 6 Stone. NEJM 2016; 7 Prasad JACC 2007; 8 Brilakis JACC Interventions 2015
Stone GW. et al.
Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I.
Circulation . 2005 Oct 11;112(15):2364-72
CTO PCI: at the Intersection of Evidence and Experience in Clinical Practice
The Basics
• CLINICAL INDICATION
• DUAL ACCESS AND DUAL INJECTIONS
• STUDYING THE LESION
• GUIDE SUPPORT
• EQUIPMENT KNOWLEDGE AND USE
• COMPLICATION MANAGEMENT KNOWLEDGE
Final Strategy per J CTO Score
AWE antegrade wire escalation ADR antegrade dissection reentry RW retrograde wiring RDR retrograde dissection reentry
Luo C. et al.
Predictors of Interventional Success of Antegrade PCI for CTO.
JACC Cardiovasc Imaging. 2015 Jul;8(7):804-13
Revascularization
Advanced Strategies and Technique
Angiographic Assessment for CTO-PCI
Procedure Planning
Dual Catheter Angiography
Antegrade Retrograde
1. Ambiguous proximal cap
2. Poor distal target
3. Interventional collaterals
Wire
Escalation
Dissection Reentry
( Cross Boss Stingray )
Wire
Escalation
Dissection Reentry
( Reverse CART )
Yes
Yes Yes
No
No No
fail fail fail fail
fail fail
Brilakis ES. et al.
A percutaneous treatment algorithm for crossing coronary chronic total occlusions.
JACC Cardiovasc Interv. 2012 Apr;5(4):367-79
4. Length < 20mm
Δῶς μοι πᾶ στῶ καὶ τὰν γᾶν κινάσωAρχιμήδης ο Συρακούσιος (περ. 287 π.Χ- περ. 212 π.Χ.)
✓ sheaths
✓ catheters
✓ wires
✓ balloons
✓ microcatheters
✓ dedicated devices
✓ IVUS
✓ other…
…from scratch: sheaths and catheters
PRO CONall TRA cannot always trap Corsair
less bleeding all ADR over long wires
less support
Corsair and trap no Stingray and trap
Stingray and trap
Corsair+branch anchor+trap usually TFA
Stingray and trap uncomfortable
real time IVUS guidance bleeding
7 FR
6 FR
8 FR
When There' s a Will There' s a WayThe BUSHI DO (Bipoint Unilateral Sheathless catheter Insertion via Distal & prOximal radial artery)
Technique
Yoshimachi F., Takagava Y., Sakai K., Ikari Y.
EuroPCR 2018
Support: Guide Catheter Extension
E.Brilakis
Manual of Coronary Chronic Total Occlusion Interventions. A Step-by-Step Approach.
Academic Press 2014, 1st Edition
Support: Microcatheter & OTW Balloon
Microcatheters & OTW Balloons:
• enhance the wire-penetrating
capacity
• improve wire torque response
• allow wire tip reshaping without losing
wire position
• facilitate wire exchanges
Microcatheter vs OTW Balloon:
• more flexible and track better
• less kinking upon wire removal
• less likely to cause proximal vessel
injury
• better assessment of the tip location
• better penetration of the CTO once a
wire is through
• ↑↑↑ cost
Support: Microcatheter
Ron Waksman, Shigeru Saito.Chronic Total Occlusions: A Guide to Recanalization.
2nd Edition, Apr 2013 Wiley-Blackwell
Dual-Wire Antegrade CTO Techniques: Dual Lumen Catheter
guidewire in subintimal space
microcatheterDual lumen microcatheter
second guidewire
second wire into
distal true lumenE. Brilakis
Manual of Chronic Total Occlusion Interventions: A Step-by-Step Approach
2nd Edition, Academic Press 2017
Wired…
Guide Wire Clinical Segmentation
During the course of CTO therapy, a variety of diverse
guidewires are needed to manage both CTO crossing and
subsequent lesion treatment
Guidewire Anatomy: the essentials
Tip styles
Core tapers &
materials
Core diameter
Coils & covers Coatings
CTO Guide Wire Milestones
1999
GUIDANT HT CROSS-IT XT
Tapered Tip Design
2008
1995
ASAHI Fielder XT
Polymer Covered Tapered
Guide Wire
SCIMEDChoice PT
1st Polymer Covered GW
ASAHI Miracle
1st Dedicated CTO spring
coil GW
TERUMOCrosswire
1st Nitinol
Hydrophilic
CTO Guide
Wire
2009
ABBOTT PROGRESS
Polymer Sleeve CTO GWi
incorporating Penetration
Power
1996
ASAHIConfianza/Pro
Tappered hydrophilic
wires
2010/11
ASAHI SION
Fielder XT-A/R
TipDouble Coil GW
CTO Toolbox-Wires
❖ Tapered, soft (~1) plastic jacketed GW (XT/XT-A/XTR)
➢ Antegrade/Retrograde microchannel/soft plaque probing
➢ Facilitation of quick wiring Dissection Re-entry in abmbigous vessel anatomy/soft plaque (Knuckle wire technique)
➢ Very small and tortuous collateral chanel crossing epicardial and septal(retrograde access)
❖ Non-tapered, soft plastic jacketed GW (Fielder FC/Pilot 50/Whisper)
➢ Multi-tasking (Mainly work in the body of the occlusion-getting less fashionable)
❖ Non tapered, medium gram force plastic jacketed wire (Pilot 150/200)
➢ Body of the occlusion
➢ Facilitation of quick wiring in complex lesions and/or dissection-reentry in ambiguous vessel anatomy
❖ Non-tapered, soft, composite core, hydrophilic coated GW (SION)
➢ Multitasking
➢ Access to difficult take-off collaterals
➢ Crossing of non challenging collaterals channels
➢ Subintinal spaces connection and GC engagment in retrograde technigues (CART/XCART)
❖ Non-tapered, medium gram force (<6g), non coated, sliding wires (Miracle 3/4.5/6)
➢ Used to be workhorse wires for lesion crossing-tend to be abandoned
❖ Non-tapered, medium gram force (<6g), hydrophilic coated, sliding wires (Miracle Ultimate)
➢ For lesion crossing (body of the occlusion) in hard but not severely calcified plaques and non tortuous anatomy
❖ Tapered, medium gram (<6g), composite core, hydrophilic coated GW (GAIA family)
➢ Are becoming the workhorse wires for lesion crossing (body of the occlusion) in hard but not severely calcified plaques even in tourtous anatomy
➢ Subintima space connection in Retrograde techniques
❖ Tapered and not tapered w-w/o hydrophilic coating, high gram(>9) GW penetration wires (Confianza fm, PROGRESS 200T)
➢ Crossing of severely calcified spots, exchanged to other categories afterwards
Composite Core technology
• Anti kinking structure
• Higher torque performance with W core
Tip load
XT-A = 1.0g XT-R = 0.6gW-Coil structure
SLIP-COAT® Coating 170mm0.36mm
(0.014”)30mm20mm
straight taper
“Composite core”0.26mm
(0.010”) PTFE Coating
Compatible for retrograde approach ; Length 190cm
Soft Polymeric Tappering Jacket Guide Wires
FIELDER XT-R, FIELDER XT-A
Introduced in 2012-Fusion of Technology
Fielder XT: Precise Tip Shaping due to its Short Soldering Tip
before shaping after shaping
Spinning out of control: Torque Whip
Description of the Deflection
In compliant lesions, stress is applied to the shaped portion of the wire;
thus, the direction in which the tip advances changes.
Sianos G.
New Wires; What we have, What is essential, What is in the horizon.
EUROCTO CLUB
The Experts Live Workshop, 2017
• Softer guide wire tends to have more deflection.
• Much easier to use deflection in order to cross the lesion.
Softer tip guide wire
Parameters Influencing the Deflection
Sianos G.
New Wires; What we have, What is essential, What is in the horizon.
EUROCTO CLUB
The Experts Live Workshop, 2017
Parameters Influencing the Deflection
• Stiffer guide wire possess a lot of straight direction force
→ less deflection.
Stiffer tip guide wire
Sianos G.
New Wires; What we have, What is essential, What is in the horizon.
EUROCTO CLUB
The Experts Live Workshop, 2017
The Gaia Series: Anti Trapping Technology
1,7
2
3,5
4
4,5
6
0 2 4 6 8
ASAHI Gaia First
ASAHI Gaia Next 1
ASAHI Gaia Second
ASAHI Gaia Next 2
ASAHI Gaia Third
ASAHI Gaia Next 3
Tip Load Line Up
ACT ONE High torque performance while ensuring tip flexibility
Gaia micro-cone tip High penetration ability
XTRAND coil Anti trapping feature to avoid coil damage
Gaia Concept
Deflection And Rotational (Directional-torque) Control
Deflection
Rotation
Intentional control through deflection to stay true lumen
Sianos G.
New Wires; What we have, What is essential, What is in the horizon.
EUROCTO CLUB
The Experts Live Workshop, 2017
Asahi Gaia Third? Or Confianza Pro?
Plaque=intima
Lumen
Tough tissue…
Asahi Gaia ⇒ Pass by GW control <Deflection & Rotation>Confianza Pro ⇒ Pass by penetration force
Ca++
Confianza Pro
Gaia
Sianos G.
New Wires; What we have, What is essential, What is in the horizon.
EUROCTO CLUB
The Experts Live Workshop, 2017
Sion Blue/ Sion
Guide Wire for Epicardial Channel Tracking
UB3/Pilot 150-200
Hard plaque Severe calcification
Stiffer tip
XT-A
ASAHI Gaia First
ASAHI Gaia Second
Miracle6-9
ASAHI Gaia Third
Confianza Pro12
Progress 200T
Confianza Pro
XT-R
Current Algorithm: What to Use When?
Complex Antegrade CTO Techniques: ADR
Dissection & re-entry strategies:
▪ dissection:
• Knuckle wire
• CrossBoss catheter
▪ re-entry:
• wire-based re-entry:
- STAR technique
- contrast enhanced
- mini-STAR & LAST technique
• device-based re-entry:
- Stingray balloon and guidewire
- IVUS guided
well defined proximal cap
>20 mm long CTO
good distal vessel with no side branches
at distal cap (visible via contralateral)
E.Brilakis
Manual of Coronary Chronic Total Occlusion Interventions. A Step-by-Step Approach.
Academic Press 2014, 1st Edition
How To Use The Cross Boss Catheter
Step1. deliver Cross Boss to th proximal cap
Step 2. Cross Boss torque attachment
Step 3. Fast spin
Step 4. Assess
Cross Boss in
side branch
Cross Boss
partially crosses
occlusion but does
not reach distal cap
Cross Boss crosses
CTO into distal
subintimal
space
Cross Boss
partially crosses
CTO into distal true
lumem
Modify proximal cap
Increase support Redirect Advance guidewire Stingray reentryInsert workhorse
guidewire
Cross Boss does
not advance
Contemporary ADR vs Classic ADR
Classic ADR 2011 Contemporary ADR 2018
Set Up 8Fr. Femoral with supportive guides
AL 0.75 EBU 3.5
8 Fr. Femoral with Trapliner or 6 Fr.
Radial without guide extension
Initial Microcatheter CrossBoss Corsair/ Turnpike family 135 cm but
still end with CrossBoss to limit
dissection
Re entry Catheter Stingray Stingray
Re entry Wire Stingray wire More flexible approach: Stingray
wire/ CP12/ Hornet 14/ Gaia 3/ Astato
Re entry Technique Stick and Go Stick and Swap with Pilot 200
Hematoma Management STRAW if loss of visualization of
distal vessel
Active management with Trapliner
upfront and preemptive STRAW
Pershad A.
Chronic Total Occlusion Summit 2018
Use CrossBoss to Prepare Re-entry Zone
Following knuckle Wire Following CrossBoss
Remember: Its Not (Only) the Size of the Stick, but the Skill of the Magician…
Αγία Τριάδα Θεσσαλονίκης 07/ 09/ 2019
Septal Crossing and Support Catheter: Corsair
tapered soft polyurethane tip
20 cm screw head structure
hydrophilic polymer coating
PTFE inner layer
Small O.D/ OTW microcatheters: Finnecross stainless steel braid structure
hydrophilic coating
PTFE inner layer
tapered diameter
catheter length 130 cm / 150 cm
optimal guidewire support