1. Advanced CTO Techniques:
Case Review VI
AR Galassi, MD, FACC, FESC, FSCAI
Head of Cardiac Catheterization and
Interventional Cardiology Unit,
Division of Cardiology, Ferrarotto Hospital
Associate Professor of Cardiology
University of Catania, ITALY

2. Disclosure Statement of Financial Interest
I, Alfredo R Galassi DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation 2

3. CTO Wire Escalation Techniques CTO Wire Escalation Techniques
Old Trends
CTO Wire Escalation Techniques
Recent Trends
“Hybrid” Sliding-Drilling/Penetration-Sliding
“Hybrid” Sliding-Drilling/Penetration
Soft Polymeric-hydrophilic GW
Fielder XT or FC
Not cross
Severe Stiff
Miracle 4.5-6, Confianza Pro 9-12
Moderate Stiff GW 0.014”
Miracle 3, Medium, Crossit 200
Not cross
Soft Polymeric-hydrophilic GW
Fielder XT or FC
Severe Stiff
Miracle 4.5-6, Confianza Pro 9-12

4. Entering a microchannel with a soft polymeric wire Fielder XT-FC supported by a microcatheter

5. Entering the lesion by a moderate-stiff wire
supported by a microcatheter

6. Advancing the microcatheter and
exchanging the stiff wire by a soft polymeric wire Fielder XT-TC

7. A) The Fielder XT-FC enters the true lumen The Mini-STAR technique

8. B) The Fielder XT-FC enters a false lumen The Mini-STAR technique

9. B) The Fielder XT-FC reenters from The Mini-STAR technique
the false lumen
The Mini-STAR technique

10. LAD CTO with ipsilateral collateral circulation
75 yrs, male, CCS class III
LAD CTO with ipsilateral collateral circulation
Belgrade live 10

11. Approach with Fielder XT and Finecross microcatheter but failed
(Asahi-Abbott)
Finecross
(Terumo)
Belgrade live 11

12. Approach with Fielder FC and Finecross microcatheter but failed
(Asahi-Abbott)
Finecross
(Terumo)
Belgrade live 12

13. Subsequent approach with Confianza Pro 9
Stiff guidewire penetrated
only proximal part of CTO 13

14. Subsequent advancement of microcatheter onto Confianza Pro 914

15. Exchanging Confianza Pro 9 with Fielder FC into microcatheter and its advancement into CTO body15

16. Subsequent advancement of small profile OTW balloon
Falcon CTO
1.0/14 mm
(Invatec)
Belgrade live 16

17. Sequential attempt to dilate the lesion
without success 17

18. Due to the presence of heavy calcification
balloon was not able to cross the CTO body
Belgrade live 18

19. An attempt was performed with a small RX balloon entry profile without success
Sprinter
1.5/15 mm
(Medtronic)
Belgrade live 19

20. A Tornus 2.6 was hardly advancing
into the CTO body reentering the true lumen
Tornus 2.6 Fr
(Asahi)
Belgrade live 20

21. Finally the Tornus 2.6 was able to advance into the CTO body
Belgrade live 21

22. The Fielder FC guidewire was exchanged
within Tornus with Prowater Flex
Prowater Flex
(Asahi-Abbott)
Belgrade live 22

23. Distal Tornus position was checked with ipsilateral collateral flow injection
Prowater Flex
(Asahi-Abbott)
Belgrade live 23

24. Final result after 4 DES implantation24

25. 7 FR JR 4 67 yrs, male 1994: CABG LIMA on LAD, SVG on OM1
January 2010: Subocclusion of SVG on OM1, occlusion of native Cx
7 FR JR 4
Live case Cairo
February 24-25, 2010 25

26. January 2010: Subocclusion of SVG on OM1,
Occlusion of native Cx
Live case Cairo
February 24-25, 2010 26

27. January 2010: LCX CTO with collateral circulation from suboccluded bypass27

28. February 2010: LCX CTO with ipsilateral collateral circulation
Live case Cairo
February 24-25, 2010 28

29. February 2010: LCX CTO with ipsilateral collateral circulation
Fielder XT
(Asahi-Abbott)
Finecross
(Terumo)
Live case Cairo
February 24-25, 2010 29

30. Stiff guidewire penetrated
Failed approach with Fielder XT and subsequent approach with Confianza Pro 9
Stiff guidewire penetrated
into subintima 30

31. Successfull mini-STAR in OM131

32. Successfull mini-STAR in OM1
The auto J-wire shape
configuration 32

33. Successful mini-STAR in LCX and OM2 with Fielder FC wires33

34. Final result after 3 DES implantation on LCX-OM1-OM2 trifurcation
Live case Cairo
February 24-25, 2010 34

35. Proximal LAD CTO with ipsilateral and retrograde collateral fillings
58 yrs, male, CCS class 3
Proximal LAD CTO with ipsilateral
and retrograde collateral fillings
7 FR AL 1
7 FR XB 3.5

36. Proximal LAD CTO with ipsilateral and retrograde collateral fillings
7 FR AL 1
7 FR XB 3.5

37. Antegrade approach by Fielder FC and Corsair
(Asahi-Abbott)
Corsair
(Asahi)
1.35 min

38. Antegrade approach by Confianza Pro 9 and Corsair
(Asahi-Abbott)
Corsair
(Asahi)
0.57 min

39. Reentering into true lumen by Fielder FC
(Asahi-Abbott)
Corsair
(Asahi)
1.47 min

40. Advancement of Corsair across CTO onto Fielder FC
(Asahi-Abbott)
Corsair
(Asahi)
0.30 min

41. Mini-STAR technique on D1
Fielder FC
(Asahi-Abbott)
Finecross
(Terumo)
0.20 min

42. Mini-STAR technique on D1
Fielder FC
(Asahi-Abbott)
Finecross
(Terumo)
0.13 min

43. Final result after SES implantation
Cypher 2.25/18 mm D1
(Cordis)
Cypher 2.75/33 mm LAD
(Cordis)

44. PCI Success Rate in CTOs, and Percentage Use of
Stiff Wires vs Plastic Wires by AR Galassi %
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84/109
lesions
123/137
lesions
154/164
lesions
154/163
lesions 44 44

45. Conclusions
The mini-STAR technique, using Fielder wires family (Abbott/Asahi), is feasible and safe
The mini-STAR technique is generally used when:
- a soft polymeric wire pass into a microchannel and stop into the body of the occlusion
- a dissection is previously created by a stiff wire with a standard antegrade approach