gerald werner - antegradeapproach step by step
TRANSCRIPT
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Antegrade Approach Step by Step
Gerald S. Werner, MD, FESC, FACC, FSCAI
Medizinische Klinik I
Klinikum Darmstadt GmbH
Darmstadt, Germany
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Conflict of interest
• I, Gerald S. Werner, MD, have no conflict of interest to declare with regard to the following presentation
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The goal of CTO-PCI
• Ideally: Restore the original anatomy of an occluded artery
• Open an occluded artery
– with the least damage to the coronary anatomy
– with the least investment of time and material, reducing procedural risks
• There is no retrograde vs antegrade approach, there is only the choice of the best strategy for the specific lesion and patient
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Strategic options for CTOs in Europe
Bilateral
Maximal Guide backup
AntegradeFielder XT -> Ultimate
or -> Progress 200T/Conf.Pro 9
Penetration, then step down
Distal good target Parallel with stiff
wire
ReentrysystemBridgePoint
Antegradeno Stump
IVUS for guided Penetration ?
Retrograde
With feasible collateral pathways
Ostial CTO
Long CTO
Re-Attempt
Ideal access
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Strategic options for CTOs in EuropeThe antegrade spectrum of technical options
Bilateral
Maximal Guide backup
AntegradeFielder XT -> Ultimate
or -> Progress 200T/Conf.Pro 9
Penetration, then step down
Distal good target Parallel with stiff
wire
ReentrysystemBridgePoint
Antegradeno Stump
IVUS for guided Penetration ?
Retrograde
With feasible collateral pathways
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J-CTO Score Sheet: Predicting complexity
Morino Y et al. JACC Interv, 2011; 4: 213
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Examples not likely to work antegrade
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Likely targets for the antegrade approach
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Antegrade: Step by Step
• Lesion specific analysis
– Identify the proximal cap
– How long is the lesion
– What is the presumed course of the occluded segment
– Identify the distal target
• Patient specific considerations
– Previous attempts (which wires, why failed)
– Renal function (limits on contrast use)
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Basic Setup
• Two catheters (radial and/or femoral route)
• Guide backup: 7F provides all options, in ostial locations and with IVUS guidance 8F preferred
• Microcatheter selection:
– Finecross: sleek profile, passes deep into lesions
– Corsair: provides additional support for the guide
– Caravelle: sleek profile with tapered tip
– Others to mention: Nhancer, Vascular Solutions
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UB3UB3
Hard plaque
Severe calcification
Stiffer tip
XT-(A)XT-(A)
ASAHI Gaia FirstASAHI Gaia First
ASAHI Gaia SecondASAHI Gaia Second
ASAHI Gaia ThirdASAHI Gaia Third
Miracle12Miracle12
Confianza Pro 12
Hornet 14;
Progress 200T
Confianza Pro 12
Hornet 14;
Progress 200T
XT-RXT-R
2016: Which wire to use when?
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The wire selection
• Explore the lesion– Fielder XT, atraumatic, provides feedback on lesion
rigidity, tracks loose tissue and may even penetrate noncalcified caps; “you follow the wire”
• Pass the lesion– Gaia 1-3 to penetrate the cap and steer through the
occluded segment; “the wire follows you”
• Conquer the calcified lesions – Confianza Pro 12 for penetration
– Others: Hornet 14, Progress 200T
– Pilot 200 to find the soft spots within severe calcium
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Advance with in the vessel: work horse
Penetrate the cap
Wire tip shape: adapt to the purpose
Remember always: tip shape is lost rapidly
So reshape, whenever you get stuck
Remember always: tip shape is lost rapidly
So reshape, whenever you get stuck
Pass within the occlusion
Pass a collateral
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Which wire to start with ?Examples from the Live Cases
Case #4Tapered lesion
My approach:
Fielder XT(-A) on microcatheterIf stuck -> Gaia 1
If distal target missed ->Proceed to parallel wire
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Gaia 1st controlled wire passage
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Gaia 1st controlled wire passage
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Which wire to start with ?Examples from the Live Cases
Case #8Faint notch at side branch
My approach:Fielder XT(-A) to deliver the microcatheter to the proximal cap, exploring, but penetration unlikelyGaia 2 as starter
If distal target missed ->Proceed to parallel wire
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The parrallel wiretechnique is classic
Crossit
200-400 or
Conquest
3g-6g
N.Reifart/O.Katoh 1996
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Why parallel wiring works well in the RCA:the wire straightens the vessel architecture
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Why parallel wiring works well in the RCA:the wire straightens the vessel architecture
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When and why parallel wire works
• If the 1st wire is close to the target, the 1st wire straightens the vessel course, and allows passage of the 2nd (stiffer) wire
• If the 1st wire is far from the target, the 2nd
wire needs to find a new course, especially in bent segments
• Often the entry point into the proximal cap needs to be changed
• Parallel wire is not a reentry technique
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When and why parallel wire may fail
• The distal target is diffusely diseased and narrow
• The distal target is severely calcified and prevents entry even with a stiff wire tip
• Failure of the operator to check orthogonal views frequently: biplane systems are helpful
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Which wire to start with ?Examples from the Live Cases
Case #5Blunt occlusion at side branch
Possible approach:Pass wire in side branch, dilate proximal and advance IVUS
IVUS guided penetration with Gaia 2
Bailout: retrograde
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RCA CTO: Strategic options
Torino. 16.4.15
Retrograde approach in mind as
most likely strategy
Chair of session: “antegrade
approach nonsense”
Agreed, but still we need an
antegrade wire for a successful
retrograde approach
The further the antegrade wire
reaches, the shorter the
retrograde wire needs to
travel….
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RCA CTO: Strategic options
Torino. 16.4.15
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Puncture of the cap with Gaia 2
Torino. 16.4.15
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Then via Finecross wire downgraded to Sion Black
Torino. 16.4.15
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Complex long RCA CTO
Torino. 16.4.15
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20 years Post CABG: Ostial RCA CTOAdditional information from MSCT
Retrograde options are challenging
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Moderate calcification -> medium-strength wire
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If parallel wiring fails: StingRay reentry device
H.B. 30.1.15
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Parallel fails, then StingRay
H.B. 30.1.15
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Strategic options for CTOs in Europe
Bilateral
Maximal Guide backup
AntegradeFielder XT -> Ultimate
or -> Progress 200T/Conf.Pro 9
Penetration, then step down
Distal good target Parallel with stiff
wire
ReentrysystemBridgePoint
Antegradeno Stump
IVUS for guided Penetration ?
Retrograde
With feasible collateral pathways
Ostial CTO
Long CTO
Re-Attempt
Ideal access
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Parallel fails, then StingRay
H.B. 30.1.15
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Parallel fails, then StingRay
H.B. 30.1.15
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StingRay wire passed before the stent
H.B. 30.1.15
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Antegrade: Step by Step
• Lesion specific approach
– Start with the softest possible wire
– Step up if necessary
– Use parallel wire as an early and easy bailout
– If retrograde is difficult, early decision for guided reentry technique (StingRay)
• Patient specific approach
– Select the most likely strategy to solve the lesion
– Do not attempt complex lesions without the option for retrograde conversion
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Antegrade: Step by Step
• Lesion specific approach
– Start with the softest possible wire
– Step up if necessary
– Use parallel wire as an early and easy bailout
– If retrograde is difficult, early decision for guided reentry technique (StingRay)
• Patient specific approach
– Select the most likely strategy to solve the lesion
– Do not attempt complex lesions without the option for retrograde conversion