1. The language of CTO interventions – what it all means
Dr Angela Hoye
Senior Lecturer in Cardiology
Hull & East Yorkshire Hospitals

2. MY CONFLICTS OF INTEREST ARE:
Clinical Events Committee member for SPIRIT II, SPIRIT V and SPIRIT Woman, fees paid by Abbott Vascular Inc
and a CTO enthusiast

3. Improved exercise capacity (Improved survival (?))
Why do we open CTOs?
Improved symptoms
Improved LV function
Improved exercise capacity
Reduced need for CABG
(Improved survival (?))
Quality of life

4. Explosion of interest!
CTO`s!

6. Try to explain/simplify some of the language used during CTO angioplasty
Discuss the design and use of some of the specialised devices
Focus on the techniques
antegrade
retrograde

9. Know when (and how) to use the right device in what circumstance
Specialist wires
Hydrophilic eg Whisper, Fielder FC
Stiff tip eg Miracle family
Tapered tip eg Fielder XT, Confianza
Tip load

10. Tip load: Weight needed to be applied to bend / buckle the tip of the guide wire
Floppy: <1g
Intermediate: ~3g
Stiff: ≥4.5g
Support
Flexibility
More
Less 3g
4.5g 6g
12g
Fielder FC tip load 1.6g
Fielder XT tip load 1.2g 0.009”
Confianza 9 tip load 8.6g, tip 0.009” hydrophobic coating
Confianza Pro 9 tip load 9.3g, tip 0.009”
Confianza Pro 12 tip load 12.4g, tip 0.009”
Stiff wires especially when combined with a tapered tip increase penetration power but also increase the risk of perforation

11. Examples: Wire Tip load (g) Size of tip Fielder FC 1.6 0.014”
Fielder XT
1.2
0.009
Miracle 6 ≈6
Confianza 9
8.6
Confianza Pro 9
9.3
Confianza Pro 12
12.4

12. TORNUS (Abbott Vascular)
Braided stainless steel flexible catheter able to enlarge the vessel by “screwing” through it
Tapered tip
Rotate counter-clockwise to advance
Clockwise to withdraw
No more than rotations in the same direction

13. Corsair (Vascular Perspectives)
Tapered soft tip
Hydrophilic coating
ASAHI brand braiding pattern, consisting of 8 thinner wires wound with 2 larger ones
Advancement:
hold a torque device at all times to avoid ASAHI Corsair and the guide wire to be rotated together
Image the Corsair tip under fluoroscopy to make sure that the tip is not trapped by the lesion
avoid torque accumulation - limit the rotation to 10 times in one direction. To continue advancing ASAHI Corsair, rotate the opposite direction
Rotate the Corsair during removal into the guide

14. Wiring techniques (antegrade approach) → Parallel wires / seesaw

15. Mitsudo et al J Inv Cardiol 2008

17. Eg. Balloon support, parallel wire technique, use of simultaneous coronary injection
Acts as a marker

19. Anchor balloon
Used when need more “penetration power” and the guide catheter is backing out
Fujita et al Catheterization and Cardiovascular Interventions 59:482–488 (2003)

20. Fujita et al Catheterization and Cardiovascular Interventions 59:482–488 (2003)

21. STAR: “subintimal tracking and re-entry”

22. STAR:
Create a (long) dissection plane with a hydrophilic wire eg Whisper or Pilot with an “umbrella” handle tip
Advance the wire whilst maintaining the loop
1.5mm OTW balloon for support
Best suited to the RCA with few proximal branches
Colombo et al CCI 2005;64:407-11

24. Case example

25. STAR: results of 68 patients
Procedural success in 62%
Dissection limiting procedure in 6%
Perforation in 7% (limited the procedure in 4%)
Pericardial effusion in 7% though no pericardiocentesis
At follow-up: restenosis in 45%
TLR: 29% after DES
TLR: 50% after BMS
“Last resort”
Carlino et al Catheterization and Cardiovascular Interventions 72:790–796 (2008)

26. What about “backwards”?
Kissing wires
CART
Reverse CART
Knuckle wire technique
“rendezvous”
etc etc
Introduced in the 1980`s by Geoff Hartzler for non-occlusive lesions
Katoh used it for CTOs in the 1990s

27. Principle of the retrograde technique
Antegrade wire
Epicardial channel use (P0.01), CC0, corkscrew channel (P0.0001), angle with recipient vessel 90° (P0.0007),
and nonvisibility of connection with recipient vessel were found to be significant predictors of procedural failure.
Retrograde wire

28. Principles of the retrograde technique:
Short (80-85cm guide), typically 7F
Hydrophilic wire through the collateral
Septal collaterals are preferable to epicardial ones
Choose collaterals that are straight
Good filling of the distal vessel from a selective injection into the collateral is ideal though not essential
Collateral dilatation: low pressure (1-2atm) dilation with a very small balloon (<1.5mm) or use the Corsair

34. Kissing wires

37. “controlled antegrade and retrograde subintimal tracking”
What about the CART technique?
“controlled antegrade and retrograde subintimal tracking”
Surmely et al J Invasive Cardiology 2006

38. CART: Simultaneous antegrade and retrograde approach
Create a (localised) subintimal dissection by inflating a small ( mm balloon) over the retrograde wire
Surmely et al J Invasive Cardiology 2006
Surmely et al J Invasive Card 2006;18:334–338

39. The balloon is kept in place to keep the subintimal space open
The antegrade wire is advanced further along the deflated retrograde balloon that lies from the subintimal space to the distal true lumen
Dilatation and stent implantation in the usual manner
Surmely et al J Invasive Card 2006;18:334–338

40. “localised” dissection
CART
“localised” dissection
STAR
“long” dissection

41. Reverse CART:

42. Surmely et al J Invasive Cardiology 2006
Rathore et al J Am Coll Cardiol Intv 2010;3:155– 64

44. Antegrade 3mm balloon

45. Knuckle wire:
Galassi et al Clin Res Cardiol (2010) 99:587–590

46. “Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010

47. “Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010

48. “Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010

49. “Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010

50. “Reverse anchoring technique”
Matsumi et al Catheterization and Cardiovascular Interventions 71:810–814 (2008)

51. IVUS All these techniques can be facilitated with adjunctive IVUS
Help identify the entry point into the occlusion
Help direct a stiff wire to penetrate from the sub-intima back into the true lumen
Guide and optimise the result of stenting

52. Summary & Conclusions
Recent advances in CTO angioplasty have increased the rate of successful recanalization
In contemporary practice CTO PCI involves a range of specialised devices
Specialist techniques may involve both an antegrade and retrograde approach with the aim of passing the wire from the proximal to the distal true vessel lumen
In “expert” hands, these techniques have a good success rate (and low complication rate)

53. Thankyou!