1. CTO Wires Trends in Guidewire Selection in Refractory Cases
Craig A. Thompson, M.D., MMSc.
Director, Invasive Cardiology and Vascular Medicine
Yale University School of Medicine/Yale New Haven Hospital
Consultant (Hon) Heart Hospital, London and London Chest Hospital

2. Craig A. Thompson, MD Consulting Fees: Abbott Vascular
Terumo Cardiovascular Systems Group
Ownership Interest (Stocks, Stock Options, or other Ownership Interest):
Bridgepoint

3. Antegrade and Retrograde CTO PCI The basic gear
4 Wire Platform
Tapered or nontapered 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

4. ANTEGRADE RETROGRADE Wire Escalation Wire Escalation Antegrade
Soft Polymer Jacket Probe
Soft Polymer Jacket Probe
No Proximal Cap Ambiguity
Lesion <20mm
Good target
+ Proximal Cap Ambiguity
Lesion <20mm
Poor target
Clear Path and Target
High Gram Force Penetration WIre
Unclear Path and Target, +Tortuosity
High Force Polyner Wire
Clear Path and Target
High Gram Force Penetration WIre
Unclear Path
and Target, +Tortuosity
High Force Polymer Wire
ANTEGRADE
RETROGRADE
Antegrade
Dissection ReEntry
Retrograde
Dissection ReEntry
Dissection Method
CROSSBOSS
Dissection Method
KNUCKLE WIRE
(polymer)
No Proximal Cap Ambiguity
Lesion >20mm
+/- Good target
Refractory
+ Proximal Cap Ambiguity
Lesion >20mm
Poor target
Refractory
ReEntry Method
STINGRAY
ReEntry
REVERSE CART
Polymer Jacket
Refractory

5. Art of the Knuckle Wire

6. Knuckle wire IVUS

11. Conclusions
In refractory cases need to dramatically change strategies away from wire based approach!
Crossboss/stingray reentry in antegrade direction
Reverse CART in retrograde direction
Major trend is to declare wire failure early and convert to one of these dedicated reentry strategies
Looped polymer jacketed wires may facilitate
Limited antegrade subadventitial tracking (LaST) and/or IVUS guided wiring can be considered as final bailout