CTO Wires Trends in Guidewire Selection in Refractory Cases Craig A. Thompson, M.D., MMSc. Director, Invasive Cardiology and Vascular Medicine Yale University School of Medicine/Yale New Haven Hospital Consultant (Hon) Heart Hospital, London and London Chest Hospital

Craig A. Thompson, MD Consulting Fees: Abbott Vascular Terumo Cardiovascular Systems Group Ownership Interest (Stocks, Stock Options, or other Ownership Interest): Bridgepoint

Antegrade and Retrograde CTO PCI The basic gear 4 Wire Platform Tapered or nontapered soft (~1gram) hydrophilic guidewire Antegrade microchannel/soft plaque probing Knuckle wire technique Non tapered, plastic jacketed low gram force wire Retrograde collateral workhorse wire Non tapered, high gram force plastic jacketed wire Lesion crossing Facilitation of wiring in complex and/or dissection High gram force (12g+), tapered penetration wire Crossing and reentry devices Crossboss Stingray Support microcatheters Finecross Corsair

ANTEGRADE RETROGRADE Wire Escalation Wire Escalation Antegrade Soft Polymer Jacket Probe Soft Polymer Jacket Probe No Proximal Cap Ambiguity Lesion <20mm Good target + Proximal Cap Ambiguity Lesion <20mm Poor target Clear Path and Target High Gram Force Penetration WIre Unclear Path and Target, +Tortuosity High Force Polyner Wire Clear Path and Target High Gram Force Penetration WIre Unclear Path and Target, +Tortuosity High Force Polymer Wire ANTEGRADE RETROGRADE Antegrade Dissection ReEntry Retrograde Dissection ReEntry Dissection Method CROSSBOSS Dissection Method KNUCKLE WIRE (polymer) No Proximal Cap Ambiguity Lesion >20mm +/- Good target Refractory + Proximal Cap Ambiguity Lesion >20mm Poor target Refractory ReEntry Method STINGRAY ReEntry REVERSE CART Polymer Jacket Refractory

Art of the Knuckle Wire

Knuckle wire IVUS

Conclusions In refractory cases need to dramatically change strategies away from wire based approach! Crossboss/stingray reentry in antegrade direction Reverse CART in retrograde direction Major trend is to declare wire failure early and convert to one of these dedicated reentry strategies Looped polymer jacketed wires may facilitate Limited antegrade subadventitial tracking (LaST) and/or IVUS guided wiring can be considered as final bailout