The language of CTO interventions – what it all means Dr Angela Hoye Senior Lecturer in Cardiology Hull & East Yorkshire Hospitals

MY CONFLICTS OF INTEREST ARE: Clinical Events Committee member for SPIRIT II, SPIRIT V and SPIRIT Woman, fees paid by Abbott Vascular Inc and a CTO enthusiast..............

Improved exercise capacity (Improved survival (?)) Why do we open CTOs? Improved symptoms Improved LV function Improved exercise capacity Reduced need for CABG (Improved survival (?)) Quality of life

Explosion of interest! CTO`s!

Try to explain/simplify some of the language used during CTO angioplasty Discuss the design and use of some of the specialised devices Focus on the techniques antegrade retrograde

Know when (and how) to use the right device in what circumstance Specialist wires Hydrophilic eg Whisper, Fielder FC Stiff tip eg Miracle family Tapered tip eg Fielder XT, Confianza Tip load

Tip load: Weight needed to be applied to bend / buckle the tip of the guide wire Floppy: <1g Intermediate: ~3g Stiff: ≥4.5g Support Flexibility More Less 3g 4.5g 6g 12g Fielder FC tip load 1.6g Fielder XT tip load 1.2g 0.009” Confianza 9 tip load 8.6g, tip 0.009” hydrophobic coating Confianza Pro 9 tip load 9.3g, tip 0.009” Confianza Pro 12 tip load 12.4g, tip 0.009” Stiff wires especially when combined with a tapered tip increase penetration power but also increase the risk of perforation

Examples: Wire Tip load (g) Size of tip Fielder FC 1.6 0.014” Fielder XT 1.2 0.009 Miracle 6 ≈6 Confianza 9 8.6 Confianza Pro 9 9.3 Confianza Pro 12 12.4

TORNUS (Abbott Vascular) Braided stainless steel flexible catheter able to enlarge the vessel by “screwing” through it Tapered tip Rotate counter-clockwise to advance Clockwise to withdraw No more than 10-20 rotations in the same direction

Corsair (Vascular Perspectives) Tapered soft tip Hydrophilic coating ASAHI brand braiding pattern, consisting of 8 thinner wires wound with 2 larger ones Advancement: hold a torque device at all times to avoid ASAHI Corsair and the guide wire to be rotated together Image the Corsair tip under fluoroscopy to make sure that the tip is not trapped by the lesion avoid torque accumulation - limit the rotation to 10 times in one direction. To continue advancing ASAHI Corsair, rotate the opposite direction Rotate the Corsair during removal into the guide

Wiring techniques (antegrade approach) → Parallel wires / seesaw

Mitsudo et al J Inv Cardiol 2008

Eg. Balloon support, parallel wire technique, use of simultaneous coronary injection Acts as a marker

Anchor balloon Used when need more “penetration power” and the guide catheter is backing out Fujita et al Catheterization and Cardiovascular Interventions 59:482–488 (2003)

Fujita et al Catheterization and Cardiovascular Interventions 59:482–488 (2003)

STAR: “subintimal tracking and re-entry”

STAR: Create a (long) dissection plane with a hydrophilic wire eg Whisper or Pilot with an “umbrella” handle tip Advance the wire whilst maintaining the loop 1.5mm OTW balloon for support Best suited to the RCA with few proximal branches Colombo et al CCI 2005;64:407-11

Case example

STAR: results of 68 patients Procedural success in 62% Dissection limiting procedure in 6% Perforation in 7% (limited the procedure in 4%) Pericardial effusion in 7% though no pericardiocentesis At follow-up: restenosis in 45% TLR: 29% after DES TLR: 50% after BMS “Last resort” Carlino et al Catheterization and Cardiovascular Interventions 72:790–796 (2008)

What about “backwards”? Kissing wires CART Reverse CART Knuckle wire technique “rendezvous” etc etc................. Introduced in the 1980`s by Geoff Hartzler for non-occlusive lesions Katoh used it for CTOs in the 1990s

Principle of the retrograde technique Antegrade wire Epicardial channel use (P0.01), CC0, corkscrew channel (P0.0001), angle with recipient vessel 90° (P0.0007), and nonvisibility of connection with recipient vessel were found to be significant predictors of procedural failure. Retrograde wire

Principles of the retrograde technique: Short (80-85cm guide), typically 7F Hydrophilic wire through the collateral Septal collaterals are preferable to epicardial ones Choose collaterals that are straight Good filling of the distal vessel from a selective injection into the collateral is ideal though not essential Collateral dilatation: low pressure (1-2atm) dilation with a very small balloon (<1.5mm) or use the Corsair

Kissing wires

“controlled antegrade and retrograde subintimal tracking” What about the CART technique? “controlled antegrade and retrograde subintimal tracking” Surmely et al J Invasive Cardiology 2006

CART: Simultaneous antegrade and retrograde approach Create a (localised) subintimal dissection by inflating a small (1.5-2.0mm balloon) over the retrograde wire Surmely et al J Invasive Cardiology 2006 Surmely et al J Invasive Card 2006;18:334–338

The balloon is kept in place to keep the subintimal space open The antegrade wire is advanced further along the deflated retrograde balloon that lies from the subintimal space to the distal true lumen Dilatation and stent implantation in the usual manner Surmely et al J Invasive Card 2006;18:334–338

“localised” dissection CART “localised” dissection STAR “long” dissection

Reverse CART:

Surmely et al J Invasive Cardiology 2006 Rathore et al J Am Coll Cardiol Intv 2010;3:155– 64

Antegrade 3mm balloon

Knuckle wire: Galassi et al Clin Res Cardiol (2010) 99:587–590

“Rendezvous in coronary” technique Muramatsu et al J Invas Cardiol 2010

“Rendezvous in coronary” technique Muramatsu et al J Invas Cardiol 2010

“Rendezvous in coronary” technique Muramatsu et al J Invas Cardiol 2010

“Rendezvous in coronary” technique Muramatsu et al J Invas Cardiol 2010

“Reverse anchoring technique” Matsumi et al Catheterization and Cardiovascular Interventions 71:810–814 (2008)

IVUS All these techniques can be facilitated with adjunctive IVUS Help identify the entry point into the occlusion Help direct a stiff wire to penetrate from the sub-intima back into the true lumen Guide and optimise the result of stenting

Summary & Conclusions Recent advances in CTO angioplasty have increased the rate of successful recanalization In contemporary practice CTO PCI involves a range of specialised devices Specialist techniques may involve both an antegrade and retrograde approach with the aim of passing the wire from the proximal to the distal true vessel lumen In “expert” hands, these techniques have a good success rate (and low complication rate)

Thankyou!