wire crossing technique in antegrade approach · wire crossing technique in antegrade approach 5th...

Toyohashi Heart Center

Takahiko Suzuki MD

Wire Crossing Technique in Wire Crossing Technique in Antegrade approachAntegrade approach

55thth CTO Live 2011CTO Live 2011

Development of CTO wires and CCT activities

Conquest

SHOOTING

1995 1999 2003

Magic

Miracle

2005 2006

FielderFCX-tream

Mid Japan CCIC CCT

CTO club

Live course(Osaka, Toyohashi, Shiga)

ACS Standard

USCI Steerable

CTO-PCI in Antegrade approach Current Choice of CTO wires

Fielder FC

X-treme

Miracle

Conquest

11stst

22ndnd

FinalFinal

Wizard

Development of CTO wire techniques and our activities

Single wire

IVUS guided

2000 2001 2005

Retrograde (CART)

Parallel wire

2010

Mid Japan CCIC CCT

19991994 1995

CTO Club

Principle of wire crossing technique strategy

Single wire technique with Plastic Jacket WiresSingle wire technique with Plastic Jacket Wires

Retrograde wire techniqueCART or reverse CART

Parallel wire technique

IVUS guided wiringIVUS guided wiring

Antegrade approachAntegrade approach

Are there any good collateral channels from retrograde?

YesNo

IVUS Guide Technique is Final option

Single wire technique Single wire technique with plastic jacket wireswith plastic jacket wires

Retrograde / CART Retrograde / CART

Parallel wiringParallel wiring×××

IVUS Guide Wiring TechniqueIVUS Guide Wiring Technique○

Tactics of the Parallel wire technique

• A first wire should be advanced to the mid or distal segment of CTO lesion in the subintima.

• Miracle 12g or 6g is preferred as a second wire.• A second wire should be turned to the opposite or

different direction of a first wire which already entered in the subintimal space.

• A first wire is more likely to enter in the subintimal space at the CTO entry, but it is sometime to enter in mid or distal CTO. Hence, the operator should prudently handle the first wire and check the entry point of the subintima by feeling of the guide wire.

Limitations of the Parallel Wire Technique

• The second wire should be advanced into a different direction which the first wire was assumed entering in the subintimal space. However, the wire is often prevented to advance in the true lumen due to wire bias.• Continuing this wire manipulation tends to enlarge the false lumen causing difficulty in the IVUS-guided technique.

Tactics of the IVUS-guided technique

• Initially, a first wire is advanced into the distal of a totally occluded lesion. Then, a false lumen is dilated with a 1.25mm or 1.5mm balloon catheter to insert an IVUS catheter .

• IVUS imaging is used to identify a CTO entry thereby detecting the position of a second wire tip. The drilling or penetration technique is used to advance into the true lumen of the total occlusion.


IVUS Guide Technique Overview

A B

C D

E

How to advance the guidewire under the IVUS-guidance

Guide wire rarely advances through the center of the true lumen of a totally occluded lesion despite it successfully enters to the CTO entry.In most cases, the wire is easily advanced along the

edge of the vessel and then into false lumen.Under this circumstance, the guide wire should not be

pushed . Instead, the guide wire is gently advanced to the center of the occlusion with torque control.


Even under the IVUS-guidance, it’s difficult to enter a second wire with strong bending distal tip . If the presence of the following conditions is met.

1) large dissection2) wire bias 3) vessel bending4) hard plaque

Limitations of the IVUS-guided technique

Toyohashi ExperienceToyohashi Experience

CTO-PCI

～～～～2010

Lesion Characteristics(’99-’10, n=1724)

Target vesselRCA 673 (39.0%)LAD 517 (30.0%)LCX 368 (21.3%)LMT 8 (0.5%)Branch 138 (8.0%)

Bypass graft 2 (0.12%)Prior PCI 476 (27.6%)In-stent occlusion 193 (11.2%)Bending>45°°°° 261 (15.2%)Calcified lesion 627 (36.4%)Significant side branch 254 (14.7%)

Number of CTO-PCI (’02~’10 n=1271)

(n)

Initial Success Rate

73.5%(83/113)

79.0%(94/119)

84.2%(117/139)

(%)

86.3%(145/168)

92.4%(157/170)

87.6% (1113/1271)

92.2%(142/154)

91.6%(142/155)

91.5%(108/118)

92.6%(125/135)

Successful guide wire technique by year (’02~’10)

Crossing Techniques(2010, n=135)

Crossing Guide Wire(2010, n=135)

Success rate of guide wire crossing

86.3%(120/139)

95.6%(129/135)

Toyohashi experienceCTO-PCI (’04 vs. ’10)

Crossed guide wires

67.5%

15.0%

17.5%

33.5%

65%

1.5%

(n=120) (n=129)


(n=120) (n=129)

Successful guide wire technique by year


55.7%

9.3%

20.0%

1.4%

61.5%

4.4%

10.4%

16.3%

3.0%

Complications (’99~’10)Major complications

– Death in hospital 9 (0.5%)– Emergency CABG 7 (0.3%)– Q-MI 5 (0.3%)

Minor complications– Cardiac tamponade 16 (0.9%)– Aortic dissection 5 (0.3%)– Acute occlusion 12 (0.7%)– Subacute occlusion 4 (0.2%)– Side branch compromise 53(3.1%)– Coronary perforation

• Type-I 160 (9.3%)• Type-II 16 (0.9%)

Angiographic Follow UpBMS era DES era

(Jan.’03-Sep.’04) (Jan.’08-Dec.’9)

No. of CTOs 227 276Initial success 183 (80.6%) 249(90.2%)

No. of CAG F/U 139 (76.0%) 158 (63.0%)

No. of restenosis 54 (38.8%) 41(29.5%)No. of reocclusion 23 (16.5%) 19 (12.0%)

77 (55.3%) 60 (30.1%)No. of TLR 60 (43.1%) 46(29.1%)

Clinical restenosis 29.5% 24.1%Clinical TLR 32.8% 18.5%

Mean F/U period 7.1±±±±4.4(mos.) 9.3±±±±4.9(mos.)

Summary

・・・・From Toyohashi Heart Center experience in 2010, antegrade approach was 80% of recanalized CTO.

・・・・Comparing 2004 with 2010 , plastic jacket wire was used more frequently (from 15% to 65%) in successful CTO -PCI. On the other hand , the usage of spring coil wire was decreased from 68% to 34%.

Conclusion

• Antegrade approach is a basic technique in CTO-PCI.

• Antegrade wiring should be a first strategy for all CTO cases even though in case with suitable collateral channels for retrograde approach from donor artery .

• IVUS guide wiring is final option in CTO-PCI . Operator should perform procedure with this point in mind .

1313thth CTO Club CTO Club

June 17-18, 2011, Toyohashi, Japan

www.cct.gr.jp/ctoclubwww.cct.gr.jp/ctoclub

See you in Kobe!

Thank you for your attention. Thank you for your attention.

Baseline DemographicsVariablesVariables CTO SuccessCTO Success

N=791N=791

CTO FailureCTO Failure

N=113N=113

P valueP value

Age, yrs, mean+/Age, yrs, mean+/--SDSD 65.42+/65.42+/--10.710.7 66.01+/66.01+/--11.211.2 0.5870.587

MaleMale 654(82.2%)654(82.2%) 94(83.2%)94(83.2%) 0.8370.837

Diabetes MellitusDiabetes Mellitus 318(40.2%)318(40.2%) 42(37.4%)42(37.4%) 0.4730.473

HypertensionHypertension 312(61.7%)312(61.7%) 74(65.5%)74(65.5%) 0.3340.334

HyperlipedemiaHyperlipedemia 312(39.5%)312(39.5%) 45(39.9%)45(39.9%) 0.9360.936

Previous MIPrevious MI 679(85.8%)679(85.8%) 99(87.6%)99(87.6%) 0.5710.571

Previous CABGPrevious CABG 94(11.1%)94(11.1%) 20(17.7%)20(17.7%) 0.0360.036

Previous PCIPrevious PCI 220(27.9%)220(27.9%) 27(24.1%)27(24.1%) 0.2930.293

Unstable AnginaUnstable Angina 60(7.7%)60(7.7%) 15(12.8%)15(12.8%) 0.0260.026

CCS Class 3/4CCS Class 3/4 52(6.6%)52(6.6%) 11(9.3%)11(9.3%) 0.1870.187

Vessel desVessel des-- Single Vs DsSingle Vs Ds

Two Vs DsTwo Vs Ds

Three Vs DsThree Vs Ds

102(12.9%)102(12.9%)

258(32.6%)258(32.6%)

431(54.5%)431(54.5%)

7(6.4%7(6.4%

35(31.03%)35(31.03%)

70(62.5%)70(62.5%)

0.0050.005

J.Am.Coll Cordeiol.Intv.2009:2:489-497

Angiographic VariablesVariablesVariables CTO SuccessCTO Success

N=791N=791

CTO FailureCTO Failure

N=113N=113

P valueP value

Target vesselTarget vessel-- LADLAD

RCARCA

LCXLCX

LMTLMT

BranchBranch

RITA/SVGRITA/SVG

239(30.2%)239(30.2%)

312(39.3%)312(39.3%)

182(23.1%)182(23.1%)

4(0.4%)4(0.4%)

52(6.6%)52(6.6%)

2(0.2%)2(0.2%)

28(24.6%)28(24.6%)

43(37.9%)43(37.9%)

19(17.2%)19(17.2%)

1(0.4%)1(0.4%)

22(19.7%)22(19.7%)

0(0%)0(0%)

<0.0001<0.0001

Side branch at CTO siteSide branch at CTO site 144(18.2%)144(18.2%) 11(9.8%)11(9.8%) 0.030.03

CalcificationCalcification--ModerateModerate

SevereSevere

214(26.9%)214(26.9%)

79(9.9%)79(9.9%)

22(19.2%)22(19.2%)

22(19.2%)22(19.2%) 0.0010.001

Non Aortic ostialNon Aortic ostial 86(10.9%)86(10.9%) 17(14.7%)17(14.7%) 0.2940.294

In Stent RestenosisIn Stent Restenosis 95(12.1%)95(12.1%) 9(8.3%)9(8.3%) 0.1740.174

TortuousityTortuousity-- ModerateModerate

SevereSevere

81(10.5%)81(10.5%)

35(4.4%)35(4.4%)

16(14.3%)16(14.3%)

12(10.3%)12(10.3%)

0.0010.001


In-Hospital ComplicationsVariableVariable CTO Success=791CTO Success=791 CTO Failure=113CTO Failure=113 P ValueP Value

DeathDeath 2(0.25%)2(0.25%) 3(2.6%)3(2.6%)

Q wave MIQ wave MI 4(0.50%)4(0.50%) 1(0.88%)1(0.88%)

Non Q MINon Q MI 20(2.5%)20(2.5%) 2(1.76%)2(1.76%)

Acute Repeat PCIAcute Repeat PCI 5(0.6%)5(0.6%) 0(0%)0(0%)

Urgent CABGUrgent CABG 1(0.10%)1(0.10%) 1(0.88%)1(0.88%)

MACEMACE 12(1.5%)12(1.5%) 5(4.4%)5(4.4%) 0.0270.027

Aortic DissectionAortic Dissection 1(0.10%)1(0.10%) 1(0.88%)1(0.88%) nsns

Delayed tamponadeDelayed tamponade 5(0.6%)5(0.6%) 1(0.88%)1(0.88%) nsns

Distal EmbolisationDistal Embolisation 24(3.0%)24(3.0%) 0(0%)0(0%) 0.0080.008

SpasmSpasm 2(0.23%)2(0.23%) 0(0%)0(0%) 1.001.00

Any DissectionAny Dissection 110(13.9%)110(13.9%) 25(22%)25(22%) 0.0060.006

Side branch compromiseSide branch compromise 35(4.4%)35(4.4%) 1(0.88%)1(0.88%) 0.0080.008

Sub acute occlusionSub acute occlusion 2(0.23%)2(0.23%) 0(0%)0(0%) 1.001.00


Logistic regression for procedural failure

VariablesVariables Hazard ratioHazard ratio 95% C.I95% C.I P ValueP Value

Female sexFemale sex 0.930.93 .57.57--1.521.52 0.7870.787

AgeAge 0.980.98 0.970.97--1.01.0 0.1640.164

Diabetes MellitusDiabetes Mellitus 1.081.08 0.780.78--1.511.51 0.6280.628

Previous MIPrevious MI 0.810.81 0.500.50--1.341.34 0.4270.427

Previous CABGPrevious CABG 0.740.74 0.430.43--1.051.05 0.1950.195

Unstable anginaUnstable angina 0.610.61 0.360.36--1.061.06 0.0840.084

InIn--stent restent re--stenosisstenosis 1.271.27 0.650.65--2.492.49 0.4780.478

Absence of side branchAbsence of side branch 1.961.96 1.181.18--3.263.26 0.0090.009

Severe TortuousitySevere Tortuousity 2.302.30 1.261.26--4.184.18 0.0060.006

Moderate CalcificationModerate Calcification 1.951.95 1.191.19--3.213.21 0.0080.008

Severe CalcificationSevere Calcification 1.601.60 0.970.97--2.652.65 0.0640.064

Ostial locationOstial location 0.700.70 0.440.44--1.111.11 0.1320.132

Multi vessel diseaseMulti vessel disease 1.201.20 0.850.85--1.691.69 0.2830.283


Baseline Demographics

Retro

Success vs. Failure

p=ns

Circ Cardiovasc Intervent 2009:2:124-132

Angiographic Variables

Retro

Success vs. Failure

p=ns


Collateral Channels

CC00or01

CC<90°P<0.0001


wire crossing technique in antegrade approach · wire crossing technique in antegrade approach 5th...

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