How to Control the Wire to Cross the CTO Lesion ? Yuejin Yang MD, PhD, FACC Cardiovascular Institute and Fu-Wai Hopital, CAMS & PUMC CIT 2010, Mar.31-April.3,2010, Beijing, China

PCI: Primary Steps Punctuating & canulating to get entrance into peripheral artery (femoral or radial) Guiding catheter to bridge a tunnel from outside body into diseased CA Guidewiring to establish a rail into the CA beyond the blockage lesion Balloon dilating the blockage lesion over the wire rail Stenting the stenotic lesion over the rail to keep CA open

PCI: Key Steps for CTO Lesion Strong guiding catheter backup support No Judkin’s guiding Special guiding catheter usually needed Different guidewire to get through CTO lesion into distal true lumen (the most important and difficult step) Lower profile balloon cross the CTO blockage lesion to dilate Stent deployment at the lesion site

Pathology of CTO Lesions Hard plaque Soft plaque Proximal & distal fibrous caps and central organizing thrombus Other Features: Inflammation Neovascularization More soft plaque in DM（36%）than Non-DM（11%）

Most CTOs are not totally occluded with stenosis of 90-99%（78%）and 100%（22%） No relation between stenosis and age, stenosis and plaque type Recanalization: small（41%），large（59%） and capillaries（100%）of all CTO MDCTA: Show: microvessels, calcification and internal anatomy

CTO angiogram TIMI flow -0 with - an ante-grade channel - a bridge collateral (not 99% stenosis) - a mid-island without AMI / RMI Tapered type Abrupt type (the most tough)

Ante-grade channel Flow competition

Bridge collateral Flow competition Some micochannels

Tapered type CTO

Abrupt type CTO

Ante-grade channel or Bridge collateral ?

A “breakthrough” in CTO Therapy New CTO guidewires Advanced techniques DES on restenosis Improve outmodes after therapy

CTO: Three Key Elements Guiding catheter: strong back-up support (Essential) Wire: Get pass through lesion (Pivotal role) Balloon: Cross the lesion Also important Sometimes be problematic ?

PCI: Strategy for CTO Antegrade approach the majority routine use in daily practice Retrograde approach the minority the alterative for special CTO lesion morphology essential prerequisite needed

Drilling Technique and Wire Short tip curve (-2mm) with a proximal secondary bend Rapid rotational tip motion with gentle forward probing Start with moderate stiffness tips and stepwise↑ Wires Guidant CROSS-IT (100. 200. 300) Asahi-Abbott MIRACLE (3, 4.5, 6, &12) Medtronic PERSUADER (3,6,9) “Workhorse” technique with discrete entry point

Cancel a secondary curve Support to wire manipulation Microcatheter Cancel a secondary curve Support to wire manipulation

Penetration Technique and Wires Minimal tip rotation with aggressive forward Probing Tip stiffness should penetrate even heavily calcified entry cap (9-12gs) Wires Asahi –Abbott CONFIENZA (Regular & Pro) Miracle ( 6-12gs) Guidant CROSS-IT 400 Blunt entry point, heavily calcified or resistant lesions

Sliding Technique and Wires Longer and shallower tip shapes No secondary bend Simultaneous tip rotation and probing Hydrophilic wire prefered Wires Guidant PILOT (50,150,200) BSC PT (LS, MS, choice) For the lesions with microchannels or subtotal, ISR total occlusions, calcified and angulated even STAR technique (subintimal reentry)

Three Keys for Successful Wiring The shaping of the wire tip double-bend The manipulation of the wire from feather touch to strenuous pushing The penetration power of the wire The second wire tip must stiffer than the Ca++ in CTO when the softer one enter the sub-intimal space Warning against the medium stiff wires

“Zen Philosophy” in PCI for CTO We should overcome the temptation to rotate actively or to advance rapidly the dedicated stiff wires for CTO Zen philosophy: To maintain the directional control when wire advanced

CTO: Key Techniques Specialized wires（above） Dual（contralateral）injection Parallel wire and see-saw technique Lumen reentry（STAR, CART） IVUS guidance Tornus catheter Retrograde（collateral）approach Novel devices: Safe Cross, Frontrunner Crosser

Parallel wire technique Cross a lesion by using two wires

Parallel wire technique Stretching the vessel

Parallel wire technique Sharper curve than the first wire Crossing the first wire

Retro-grade dilatation of false lumen and Retro-grade puncture (CART) Penetrate to the proximal from the distal vessel or As a landmark for ante-grade penetration

How to Deal with Dissection of CTO Re-steer Parallel wire: a standard routine technique STAR: wire from false to true lumen, Stenting false lumen Last resort, primarily reserved for the RCA CART: Controlled Antegrade and Retrograde subintimal Tracking From true via false to true lumen & stenting Similar to STAR

Wire Manipulation Tricks for CTO Hydrophilic wire + microcatheter leading to CTO lesion and change stiff wire to penetrate the CTO lesion Routine dual injection as long as no ante grade lumen seen Not try passage hydrophilic wire through true CTO lesion except for recent AMI “false CTO” due to easy subintimal false lumen passage. No pushing too much while wire forwarding

Wire Manipulation Tricks for CTO No wire stuck when backward pulling Protect side branch when wiring No ballooning without confirming the true lumen Stop if severe dissection occurred with wiring Protamine given against heparin if failed and routine Echo examination needed Plaque crack technique works if balloon uncross

Determination of True Lumen Wire going side branches freely Wire going forward easily Wire tip rotating freely when manipulation No resistance in wire forwarding No tip bending even twisting in wire forwarding No resistance in balloon forwarding Ante grade flow restored after ballooning (even very low profile balloon i.e. rujin 1.25mm)

Case 6: RCA CTO with SVG occluded after 3 years of CABG CHD 4年 CABG 2年 症状再发 1年 TFI：5Fr导管 SVG-LAD 引导 TRI：AL1-RCA CAA：SVG-RCA 100% SVG-LAD OK LM OK LAD 100% LCX 100% RCA 100% IVUS：Perfect

CAA: 2008-4-28

EUROPCR 2008 Life DEMO case (2008-5-16)

Case 3. LAD ostium CTO with 3 years

Case 5: Triple-CTO, Refuse to do CABG 王波 M 42 yrs 630746 No chance to retrograde approach Staged PCI successful 07-7-9 baseline CAA: LM: OK, LAD: 100%, RCA-mid: 100% RCA-CTO PCI guiding×2 07-7-16: LCX PCI guiding×2 08-2-28 Follow-up CAA: RCA, LCX OK 08-2-22 CIT: No time to do 08-3-24 LAD ostium PCI: successful

LAD100％ LEX99％ RCA100％

Ruijin1.25、2.5球囊扩张

植入Excell2.5×28mm、3.0×28mm支架

Ruijin1.25、2.5球囊扩张，提供LAD充分侧支循环

支架通畅，LEX100%，LAD100%

钢丝 Pilot150进真腔，用1.25、2.5的球囊扩张

植入Excell2.5×28mm、2.5×14mm、 2.5×24mm支架

08-2-28 Follow-up CAA Follow-up CAA: baseline, LM: OK, LCX stents: OK, Prox LCX: 80% LAD: CTO RCA Stents: open No chance to retrograde approach

Case 5: 08-3-24 LAD Ostium-CTO TRI-improssible done to occluded RA TRI: Guiding: 6Fr EBU 3.5 Wire: Conquest×2 Miracle 6×1 Miracle 12×1 Universal×1 Pilot 50×1 Balloon: 1.25mm

Wiring Universal wire to LCX Conquest not to ostium of LAD Refind ostium of LAD Wire to LAD Wire to LAD-Dia

Wiring true lumen check Contralateral injeetion: seemed to be OK Looked OK Wire to true lumen of distal LAD Balloon to distal LAD

Ballooning Ballooning Opened

Reallooning

Stenting: Excel 2.5×28mm, Excel 2.7×28mm,

Pro-LCX ballooning LCX stenting: Excel 3.0×15mm Results & LCX stenting Pro-LCX ballooning LCX stenting: Excel 3.0×15mm

Final results

Balloon Uncross? Guiding catheter backup support ? bigger, special one, and 5 in 6 or 7 Lower profile balloon? rujin, sprinter 1.25mm Buddy wire technique? Anchor balloon technique? Rotablator ? Plaque cracking technique? Tornus?

How to Deal with Balloon Uncross Maximize guiding support 8Fr, A-L1-2, Deep engagement Buddy wire technique Anchor balloon Child-mother catheter system Rotational atherectomy Tornus crossing catheter（2.1Fr 2.6Fr） Laser

TRI－CTO（X12yrs） Anker balloon budy wire Miracle 60gr

TRI－CTO（X12yrs） Anker balloon budy wire Miracle 60gr

TRI－CTO（X12yrs） Anker balloon budy wire Miracle 60gr

TRI－CTO（X12yrs） Anker balloon budy wire Miracle 60gr

TRI－CTO（X12yrs） Anker balloon budy wire Miracle 60gr

TRI－CTO（X12yrs） Anker balloon budy wire Miracle 60gr

LCX—OM CTO lesion

Guiding: 6Fr-AL1 Wire : PT Graphics intermediate Balloon : marverick 1 Guiding: 6Fr-AL1 Wire : PT Graphics intermediate Balloon : marverick 1.5-20mm No pass of the balloon

Still NO Pass of the balloon

After changing 7 Fr guiding to get stronger backup support , balloon pass throught the lesion.

Final result after stenting with 2.5-16mm

Tornus Crossing Catheter Counterclockwise rotation (driving) (＜20times) to cross CTO Other roles Guiding backup support↑ Wiring force imcrease and exchange Remove the barrier between a side and a main branch Limitations: cannot cross severe Ca++ lesion

Welcome Chaired by Yue-Jin Yang MD. PhD. FACC Co-Chaired by Dr. Saito Attend China Heart Conference (IHF2010)： 2nd international TR Coronary Therapeutics (TRCT) Chaired by Yue-Jin Yang MD. PhD. FACC Co-Chaired by Dr. Saito Dr. kiemeneiji NCC, 2010/08/13-15, Beijing, China

Thank you very much !