Crossing CTOs via Planned Dissection: LaST (Limited Antegrade Subintimal Tracking): from knuckle wire to Bridgepoint Craig A. Thompson, M.D., MMSc. Director, Invasive Cardiology and Vascular Medicine Yale University School of Medicine/Yale New Haven Hospital Executive Director, Yale-University College London Cardiovascular Device Development Program Consultant (Hon) Heart Hospital, London and London Chest Hospital

Craig A. Thompson, MD Consulting Fees Abbott Vascular Bridgepoint Terumo Volcano I intend to reference off label or unapproved uses of drugs or devices in my presentation. I intend to discuss DES, guidewires, PTCA balloons/catheters in CTO

The Continuum of CTO PCI Dissection Reentry Antegrade Retrograde Adoption of only 1 or 2 of these limbs will limit the patients that can be treated on the basis of coronary anatomy

Antegrade Dissection Reentry Techniques Lumen CTO Distal cap random STAR reentry CTO Distal cap Lumen LAST redirection CTO Distal cap Lumen Bridgepoint reentry

Why Develop Limited Subadventitial Tracking (LaST)? Bailout for complex cases Of cases viewed by highly experienced operators as suitable for retrograde, ~10-20% of time collaterals cannot be crossed Bailout for failed connection after successful retrograde collateral crossing Treatment option for patients not suitable for retrograde at all and refractory to conventional approach Preceded availability of dedicated reentry tools

Art of the Knuckle Wire

Concept of LAST technique dissection and redirection within CTO segment

RCA CTO Refractory from Conventional Strategies

RCA CTO Refractory from Conventional Strategies

RCA CTO Refractory from Conventional Strategies

RCA CTO Refractory from Conventional Strategies

LCx CTO

Bridgepoint Crossing and Reentry

RCA CTO complex 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) 14

RCA CTO complex 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) 15

RCA CTO complex 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) 16

RCA CTO complex 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) 17

RCA CTO complex 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) 18

RCA CTO Primary Dissection Reentry Strategy for Efficiency

RCA CTO Primary Dissection Reentry Strategy for Efficiency

Overall Strategy Initial planning Lesion Length>20mm Poor Distal Target, Good Collaterals Or Ambiguous Proximal cap Retrograde Antegrade Wire Escalation Reentry Lesion Length<20mm Poor distal Target Poor Collaterals Dissection-Reentry LaST Lesion Length <20mm, Good Distal Target Good Collaterals Antegrade Wire Escalation Dissection Reentry Retrograde LaST Lesion Length > 20mm Dissection-Reentry Antegrade wire escalation/LaST

Initial and Final Antegrade Devices Facilitating Devices

Initial and Final Antegrade Devices Enabling Crossing Devices

Conclusions Limited Antegrade Subadventital Tracking (LaST) facilitated with the knuckle wire technique: Can serve as bailout strategy for failing antegrade and retrograde CTO PCI cases Can serve as a platform for therapy for refractory antegrade procedures with no retrograde options Bridgepoint crossing and reentry systems Can safely and efficiently provide crossing for CTO lesions Can serve as initial strategy for many CTO procedures Can provide a bailout option for failing antegrade and retrograde procedures