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The Spectrum of Guidewires Available to Recanalize CTO and How to Choose the Wire/Device Hybrid CTO PCI 2011 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
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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
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Conventional CTO PCI Strategies
Antegrade CTO PCI procedure ExcessiveTime, Contrast, Radiation Limited Retrograde Bailout Retrograde CTO PCI procedure ExcessiveTime, Contrast, Radiation Limited Antegrade Bailout
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The Continuum of CTO PCI
Dissection Reentry Antegrade Retrograde Adoption of only 1 or 2 of these limbs will limit the patients that can be treated on the basis of coronary anatomy
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Guiding Principles for CTO PCI success and time efficiency
Anatomy dictates strategy Antegrade Retrograde Reentry Complimentary strategies With multiple options, choose time effective strategies Intend to set “base of operations” as quickly as possible Distal cap for antegrade Proximal cap for retrograde Have sequential, adaptable strategic plan mapped out Change from failing strategy early Antegrade Crossing Retrograde Crossing HYBRID Antegrade Dissection and Reentry Retrograde Dissection and Reentry
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Hybrid CTO PCI Strategy
Hybrid Strategy Simple retrograde Complex Antegrade Complex Retrograde Simple Antegrade Interchange freely between approaches Optimize best applications from antegrade, retrograde, and reentry “Toggle” back and forth between strategies as needed and opportunity permits
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Hybrid CTO PCI basic principles
Procedural efficiency, contrast, radiation with greater priority Maintain safety, improve efficacy Always make progress…don’t let case stall Preplanned multistep procedural strategy Setup for seamless transition between antegrade wire escalation, dissection reentry, and retrograde Quick transition to alternate plans when failure mode occurs Opportunity for contigency plan success Can return to more focused attempt to earlier strategies if needed
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The “base of operations”
Antegrade Goal Move gear safely and quickly to distal cap to focus on true lumen entry or… Move gear beyond distal cap to focus on reentry Retrograde Goal Move gear safely and quickly to proximal cap for true lumen entry or reverse CART (dissection connection)
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The basic gear Crossing and reentry devices Crossboss Stingray
4 Wire Platform Tapered 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
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Overall Strategy Initial planning Lesion Length>20mm
Poor Distal Target, Good Collaterals Or Ambiguous Proximal cap Retrograde Antegrade Wire Escalation Reentry Lesion Length<20mm Poor distal Target Poor Collaterals Dissection-Reentry LaST Lesion Length <20mm, Good Distal Target Good Collaterals Antegrade Wire Escalation Dissection Reentry Retrograde LaST Lesion Length > 20mm Dissection-Reentry Antegrade wire escalation/LaST
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Antegrade wire escalation
RCA CTO Hybrid Retro S2 Retro S3 Retro S4 Retro S1 Antegrade wire escalation Antegrade Dissection Retro LCx epicardial
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LCx CTO Hybrid Antegrade Wire 1 Antegrade Wire 2 Retro D2 Retro D3
Antegrade LaST
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Bellingham CTO Workshop Jan 2011
17 patients from 6 states 13 physicians 5 CTO operators working in pairs C Thompson, B Lombardi, A Grantham, T DeMartini, M Wyman Strategy determined by group blinded to operator assignment Hybrid approach Initial strategy/device Time and progress parameters to switch strategies Operator unblinding immediately prior to case Primary and secondary operator Execute assigned strategy
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Baseline Demographics Bellingham CTO Workshop Jan 2011
17 Mean age (yrs) 63.7 Gender (M) 94% Prior CABG 35% CTO location LAD 47% RCA 29% LCx 24% Reattempt 53% ISR 6% Lesion Length (bilateral injection) 23.5mm Proximal Reference Diameter 2.89mm Distal Reference Diameter 2.60mm Planned Procedure (vs Ad Hoc) CTO Summit 2011, New York, NY
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Procedure Outcomes Bellingham CTO Workshop Jan 2011
Efficiency Case time (mean) 89.9 min Cases < 2hrs 82% Contrast 273.5 cc Fluro Time 39.6 min DAP 308,599 mGycm2 Effectiveness Technical Success 100% Safety MACE 5.8% (perforation) Death/MI 0%
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Procedure Characteristics and Outcomes Bellingham CTO Workshop Jan 2011
Initial Technique Antegrade Wire Escalation 64.7% Dissection Reentry 29.4% Retrograde First 5.8% Retrograde (initial+crossover) Retro Wiring 40% XCART CART 20%
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Initial and Final Antegrade Devices
Facilitating Devices
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Initial and Final Antegrade Devices
Enabling Crossing Devices
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Conclusions Antegrade wire escalation, antegrade dissection reentry, and retrograde wire escalation and dissection reentry techniques are complimentary and necessary for full spectrum CTO PCI Hybrid strategy optimizes opportunity for success by conditionally exploring sequential options Ease of education Potentially improve adoption of CTO PCI Hybrid strategy can potentially shorten procedure times, reduce radiation exposure with quality and safety equal or superior to conventional approaches
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