1. Crossing CTOs via Planned Dissection: LaST (Limited Antegrade Subintimal Tracking): from knuckle wire to Bridgepoint
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

2. 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

3. 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

4. Antegrade Dissection Reentry Techniques
Lumen
CTO
Distal cap
random
STAR reentry
CTO
Distal cap
Lumen
LAST redirection
CTO
Distal cap
Lumen
Bridgepoint reentry

5. Why Develop Limited Subadventitial Tracking (LaST)?
Bailout for complex cases
Of cases viewed by highly experienced operators as suitable for retrograde, ~10-20% of time collaterals cannot be crossed
Bailout for failed connection after successful retrograde collateral crossing
Treatment option for patients not suitable for retrograde at all and refractory to conventional approach
Preceded availability of dedicated reentry tools

6. Art of the Knuckle Wire

7. Concept of LAST technique dissection and redirection within CTO segment

8. RCA CTO Refractory from Conventional Strategies

9. RCA CTO Refractory from Conventional Strategies

10. RCA CTO Refractory from Conventional Strategies

11. RCA CTO Refractory from Conventional Strategies

12. LCx CTO

13. Bridgepoint Crossing and Reentry

14. RCA CTO complex This is the Bulleted List slide.
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15. RCA CTO complex This is the Bulleted List slide.
To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left)
The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide.
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Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows:
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Select the text at the bottom of the slide and type in a short version of your presentation title.
Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 15

16. RCA CTO complex This is the Bulleted List slide.
To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left)
The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide.
If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page.
Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows:
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Select the text at the bottom of the slide and type in a short version of your presentation title.
Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 16

17. RCA CTO complex This is the Bulleted List slide.
To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left)
The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide.
If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page.
Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows:
Choose View / Master / Slide Master from your menu.
Select the text at the bottom of the slide and type in a short version of your presentation title.
Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 17

18. RCA CTO complex This is the Bulleted List slide.
To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left)
The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide.
If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page.
Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows:
Choose View / Master / Slide Master from your menu.
Select the text at the bottom of the slide and type in a short version of your presentation title.
Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 18

19. RCA CTO Primary Dissection Reentry Strategy for Efficiency

20. RCA CTO Primary Dissection Reentry Strategy for Efficiency

21. 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

22. Initial and Final Antegrade Devices
Facilitating Devices

23. Initial and Final Antegrade Devices
Enabling Crossing Devices

24. Conclusions
Limited Antegrade Subadventital Tracking (LaST) facilitated with the knuckle wire technique:
Can serve as bailout strategy for failing antegrade and retrograde CTO PCI cases
Can serve as a platform for therapy for refractory antegrade procedures with no retrograde options
Bridgepoint crossing and reentry systems
Can safely and efficiently provide crossing for CTO lesions
Can serve as initial strategy for many CTO procedures
Can provide a bailout option for failing antegrade and retrograde procedures