Advanced CTO Techniques: Case Review VI AR Galassi, MD, FACC, FESC, FSCAI Head of Cardiac Catheterization and Interventional Cardiology Unit, Division of Cardiology, Ferrarotto Hospital Associate Professor of Cardiology University of Catania, ITALY

Disclosure Statement of Financial Interest I, Alfredo R Galassi DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation 2

CTO Wire Escalation Techniques CTO Wire Escalation Techniques Old Trends CTO Wire Escalation Techniques Recent Trends “Hybrid” Sliding-Drilling/Penetration-Sliding “Hybrid” Sliding-Drilling/Penetration Soft Polymeric-hydrophilic GW Fielder XT or FC Not cross Severe Stiff Miracle 4.5-6, Confianza Pro 9-12 Moderate Stiff GW 0.014” Miracle 3, Medium, Crossit 200 Not cross Soft Polymeric-hydrophilic GW Fielder XT or FC Severe Stiff Miracle 4.5-6, Confianza Pro 9-12

Entering a microchannel with a soft polymeric wire Fielder XT-FC supported by a microcatheter

Entering the lesion by a moderate-stiff wire supported by a microcatheter

Advancing the microcatheter and exchanging the stiff wire by a soft polymeric wire Fielder XT-TC

A) The Fielder XT-FC enters the true lumen The Mini-STAR technique

B) The Fielder XT-FC enters a false lumen The Mini-STAR technique

B) The Fielder XT-FC reenters from The Mini-STAR technique the false lumen The Mini-STAR technique

LAD CTO with ipsilateral collateral circulation 75 yrs, male, CCS class III LAD CTO with ipsilateral collateral circulation Belgrade live 10

Approach with Fielder XT and Finecross microcatheter but failed (Asahi-Abbott) Finecross (Terumo) Belgrade live 11

Approach with Fielder FC and Finecross microcatheter but failed (Asahi-Abbott) Finecross (Terumo) Belgrade live 12

Subsequent approach with Confianza Pro 9 Stiff guidewire penetrated only proximal part of CTO 13

Subsequent advancement of microcatheter onto Confianza Pro 9 14

Exchanging Confianza Pro 9 with Fielder FC into microcatheter and its advancement into CTO body 15

Subsequent advancement of small profile OTW balloon Falcon CTO 1.0/14 mm (Invatec) Belgrade live 16

Sequential attempt to dilate the lesion without success 17

Due to the presence of heavy calcification balloon was not able to cross the CTO body Belgrade live 18

An attempt was performed with a small RX balloon entry profile without success Sprinter 1.5/15 mm (Medtronic) Belgrade live 19

A Tornus 2.6 was hardly advancing into the CTO body reentering the true lumen Tornus 2.6 Fr (Asahi) Belgrade live 20

Finally the Tornus 2.6 was able to advance into the CTO body Belgrade live 21

The Fielder FC guidewire was exchanged within Tornus with Prowater Flex Prowater Flex (Asahi-Abbott) Belgrade live 22

Distal Tornus position was checked with ipsilateral collateral flow injection Prowater Flex (Asahi-Abbott) Belgrade live 23

Final result after 4 DES implantation 24

7 FR JR 4 67 yrs, male 1994: CABG LIMA on LAD, SVG on OM1 January 2010: Subocclusion of SVG on OM1, occlusion of native Cx 7 FR JR 4 Live case Cairo February 24-25, 2010 25

January 2010: Subocclusion of SVG on OM1, Occlusion of native Cx Live case Cairo February 24-25, 2010 26

January 2010: LCX CTO with collateral circulation from suboccluded bypass 27

February 2010: LCX CTO with ipsilateral collateral circulation Live case Cairo February 24-25, 2010 28

February 2010: LCX CTO with ipsilateral collateral circulation Fielder XT (Asahi-Abbott) Finecross (Terumo) Live case Cairo February 24-25, 2010 29

Stiff guidewire penetrated Failed approach with Fielder XT and subsequent approach with Confianza Pro 9 Stiff guidewire penetrated into subintima 30

Successfull mini-STAR in OM1 31

Successfull mini-STAR in OM1 The auto J-wire shape configuration 32

Successful mini-STAR in LCX and OM2 with Fielder FC wires 33

Final result after 3 DES implantation on LCX-OM1-OM2 trifurcation Live case Cairo February 24-25, 2010 34

Proximal LAD CTO with ipsilateral and retrograde collateral fillings 58 yrs, male, CCS class 3 Proximal LAD CTO with ipsilateral and retrograde collateral fillings 7 FR AL 1 7 FR XB 3.5

Proximal LAD CTO with ipsilateral and retrograde collateral fillings 7 FR AL 1 7 FR XB 3.5

Antegrade approach by Fielder FC and Corsair (Asahi-Abbott) Corsair (Asahi) 1.35 min

Antegrade approach by Confianza Pro 9 and Corsair (Asahi-Abbott) Corsair (Asahi) 0.57 min

Reentering into true lumen by Fielder FC (Asahi-Abbott) Corsair (Asahi) 1.47 min

Advancement of Corsair across CTO onto Fielder FC (Asahi-Abbott) Corsair (Asahi) 0.30 min

Mini-STAR technique on D1 Fielder FC (Asahi-Abbott) Finecross (Terumo) 0.20 min

Mini-STAR technique on D1 Fielder FC (Asahi-Abbott) Finecross (Terumo) 0.13 min

Final result after SES implantation Cypher 2.25/18 mm D1 (Cordis) Cypher 2.75/33 mm LAD (Cordis)

PCI Success Rate in CTOs, and Percentage Use of Stiff Wires vs Plastic Wires by AR Galassi % This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 84/109 lesions 123/137 lesions 154/164 lesions 154/163 lesions 44 44

Conclusions The mini-STAR technique, using Fielder wires family (Abbott/Asahi), is feasible and safe The mini-STAR technique is generally used when: - a soft polymeric wire pass into a microchannel and stop into the body of the occlusion - a dissection is previously created by a stiff wire with a standard antegrade approach