Subintimal Tracking and Reentry for CTO STAR Method

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Subintimal Tracking and Reentry for CTO STAR Method 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

Subintimal Tracking and Reentry (STAR) rationale and historical perspective Alternative technique for distal true lumen access Adaptation of technique in peripheral CTO intervention Devascularized vessel in CTO = devitalized tissue at media Natural dissection plane Used by surgeons for endarterectomy Reentry ?Path of least resistance in distal “normal” vessel toward lumen Smaller distal vessel less likely to propagate dissection

Antegrade Dissection and Reentry STAR method

Art of the Knuckle Wire

Knuckle wire IVUS

Subintimal Tracking and Reentry (STAR) Patient Selection Failure with conventional wire strategies No retrograde opportunity Relatively healthy distal vessel beyond CTO Minimal important branches in shear/dissection zone (RCA, OM) Strong clinical indication This is final measure, not first measure Better methods have been developed!

Subintimal Tracking and Reentry (STAR) technique Supportive 8Fr guide Create or use existing dissection in proximal CTO (Miracle, Confianza, etc.) 1.5mm balloon into track Fielder XT/Whisper/Pilot 50 with tight “J” tip/”umbrella tip” Advance with balloon support, avoid spinning wire if possible May need pilot 150, 200 for proximal Use softest wire possible for distal (whisper) Reentry

Antegrade Dissection and Reentry Minimal subadventitial space Enlarged subadventitial space Occlusion Occlusion

Subintimal Tracking and Reentry (STAR) Side branch rescue Runoff is key to durability Miracle/Confianza – parallel wire Mini-STAR Wire in SB ostium 1.5 balloon to ostium Exchange for Whisper “J” tip

Subintimal Tracking and Reentry (STAR) Tips Stiffer polymer wire (“J”) proximally if needed but always softer distally “J-bend” ~ < media-to-media diameter Runoff vessels are key Don’t lose true lumen distal branch, multiple wires if necessary PTCA pre-stent conservative size, pressures <12 ATM Bifurcation stenting only if absolutely necessary SB dissections may be OK DES Consider angiographic follow-up

Subintimal Tracking and Reentry (STAR)

Subintimal Tracking and Reentry (STAR)

Subintimal Tracking and Reentry (STAR) Complications Perforation Side branch loss Runoff Vessel Loss Unpredictable dissection Relatively high restenosis Failure

STAR Technique baseline demographics 112 patients, 119 lesions CTO Length Criterion for STAR Courtesy M Carlino, A Colombo

STAR Technique acute outcome and complications (112 pt./119 lesion) Recanalization with Angiographic success in 103/119 lesions (86.6%) 4 (3.4%) Dissection limiting procedure 1 acute thrombosis 5 (4.2%) wire perforation limiting procedure 3 (2.5%) vessel rupture [3 PTFE stent] Courtesy M Carlino, A Colombo

STAR Technique MACE In Hospital Death 0 CABG 0 Non Q MI 16/112 (14%) 6 Month Follow-up Death 1/112 (noncardiac) CABG 1/112 AMI 0 Courtesy M Carlino, A Colombo

STAR Technique Angiographic Follow-up 77/112 (69% eligible pt., 6.2+4.1 months) Restenosis 38/77 (49.4%) TLR 36/119 (30.2%) % P<0.008 P<0.01 Courtesy M Carlino, A Colombo

STAR guided by contrast injection Carlino M, et al. CCI 2008

Subintimal Tracking and Reentry STAR coronary technique Conclusions Relatively safe and effective alternative method to cross coronary CTO Conventional antegrade failure, poor retrograde option Learning curve Most appropriate for “conduit” vessels (RCA/OM) DES and runoff vessels appear to be important determinants of durability Better methods and technologies have been developed for dissection/redirection and reentry