1. How to Control the Wire to Cross the CTO Lesion ?
Yuejin Yang MD, PhD, FACC
Cardiovascular Institute and Fu-Wai Hopital, CAMS & PUMC
CIT 2010, Mar.31-April.3,2010, Beijing, China

2. PCI: Primary Steps
Punctuating & canulating to get entrance into peripheral artery (femoral or radial)
Guiding catheter to bridge a tunnel from outside body into diseased CA
Guidewiring to establish a rail into the CA beyond the blockage lesion
Balloon dilating the blockage lesion over the wire rail
Stenting the stenotic lesion over the rail to keep CA open

3. PCI: Key Steps for CTO Lesion
Strong guiding catheter backup support
No Judkin’s guiding
Special guiding catheter usually needed
Different guidewire to get through CTO lesion into distal true lumen (the most important and difficult step)
Lower profile balloon cross the CTO blockage lesion to dilate
Stent deployment at the lesion site

4. Pathology of CTO Lesions
Hard plaque
Soft plaque
Proximal & distal fibrous caps and central organizing thrombus
Other Features: Inflammation
Neovascularization
More soft plaque in DM（36%）than Non-DM（11%）

5. Most CTOs are not totally occluded with stenosis of 90-99%（78%）and 100%（22%）
No relation between stenosis and age,
stenosis and plaque type
Recanalization: small（41%），large（59%） and capillaries（100%）of all CTO
MDCTA: Show: microvessels, calcification
and internal anatomy

10. CTO angiogram
TIMI flow -0 with an ante-grade channel a bridge collateral (not 99% stenosis) a mid-island without AMI / RMI
Tapered type
Abrupt type (the most tough)

11. Ante-grade channel
Flow competition

12. Bridge collateral
Flow competition
Some micochannels

13. Tapered type CTO

14. Abrupt type CTO

15. Ante-grade channel or Bridge collateral ?

16. A “breakthrough” in CTO Therapy
New CTO guidewires
Advanced techniques
DES on restenosis
Improve outmodes after therapy

17. CTO: Three Key Elements
Guiding catheter: strong back-up
support
(Essential)
Wire: Get pass through lesion
(Pivotal role)
Balloon: Cross the lesion
Also important
Sometimes be problematic ?

18. PCI: Strategy for CTO Antegrade approach the majority
routine use in daily practice
Retrograde approach
the minority
the alterative
for special CTO lesion morphology
essential prerequisite needed

20. Drilling Technique and Wire
Short tip curve (-2mm) with a proximal
secondary bend
Rapid rotational tip motion with gentle
forward probing
Start with moderate stiffness tips and
stepwise↑
Wires
Guidant CROSS-IT ( )
Asahi-Abbott MIRACLE (3, 4.5, 6, &12)
Medtronic PERSUADER (3,6,9)
“Workhorse” technique with discrete entry point

21. Cancel a secondary curve Support to wire manipulation
Microcatheter
Cancel a secondary curve
Support to wire manipulation

22. Penetration Technique and Wires
Minimal tip rotation with aggressive
forward Probing
Tip stiffness should penetrate even
heavily calcified entry cap (9-12gs)
Wires
Asahi –Abbott CONFIENZA
(Regular & Pro)
Miracle ( 6-12gs)
Guidant CROSS-IT 400
Blunt entry point, heavily calcified or
resistant lesions

23. Sliding Technique and Wires
Longer and shallower tip shapes
No secondary bend
Simultaneous tip rotation and probing
Hydrophilic wire prefered
Wires
Guidant PILOT (50,150,200)
BSC PT (LS, MS, choice)
For the lesions with microchannels or
subtotal, ISR total occlusions, calcified
and angulated even STAR technique
(subintimal reentry)

24. Three Keys for Successful Wiring
The shaping of the wire tip
double-bend
The manipulation of the wire
from feather touch to strenuous pushing
The penetration power of the wire
The second wire tip must stiffer than the
Ca++ in CTO when the softer one enter the
sub-intimal space
Warning against the medium stiff wires

25. “Zen Philosophy” in PCI for CTO
We should overcome the temptation
to rotate actively or
to advance rapidly the dedicated
stiff wires for CTO
Zen philosophy:
To maintain the directional
control when wire advanced

26. CTO: Key Techniques Specialized wires（above）
Dual（contralateral）injection
Parallel wire and see-saw technique
Lumen reentry（STAR, CART）
IVUS guidance
Tornus catheter
Retrograde（collateral）approach
Novel devices: Safe Cross, Frontrunner
Crosser

27. Parallel wire technique
Cross a lesion by using two wires

28. Parallel wire technique
Stretching the vessel

29. Parallel wire technique
Sharper curve than the first wire
Crossing the first wire

30. Retro-grade dilatation of false lumen and Retro-grade puncture (CART)
Penetrate to the proximal
from the distal vessel or
As a landmark for ante-grade penetration

31. How to Deal with Dissection of CTO
Re-steer
Parallel wire: a standard routine technique
STAR: wire from false to true lumen,
Stenting false lumen
Last resort, primarily reserved for the RCA
CART: Controlled Antegrade and Retrograde
subintimal Tracking
From true via false to true lumen & stenting
Similar to STAR

32. Wire Manipulation Tricks for CTO
Hydrophilic wire + microcatheter leading to
CTO lesion and change stiff wire to penetrate
the CTO lesion
Routine dual injection as long as no ante grade lumen seen
Not try passage hydrophilic wire through true
CTO lesion except for recent AMI “false CTO”
due to easy subintimal false lumen passage.
No pushing too much while wire forwarding

33. Wire Manipulation Tricks for CTO
No wire stuck when backward pulling
Protect side branch when wiring
No ballooning without confirming the true lumen
Stop if severe dissection occurred with wiring
Protamine given against heparin if failed
and routine Echo examination needed
Plaque crack technique works if balloon uncross

34. Determination of True Lumen
Wire going side branches freely
Wire going forward easily
Wire tip rotating freely when manipulation
No resistance in wire forwarding
No tip bending even twisting in wire forwarding
No resistance in balloon forwarding
Ante grade flow restored after ballooning
(even very low profile balloon i.e. rujin
1.25mm)

35. Case 6: RCA CTO with SVG occluded after 3 years of CABG
CHD 4年 CABG 2年 症状再发 1年
TFI：5Fr导管 SVG-LAD 引导
TRI：AL1-RCA
CAA：SVG-RCA 100%
SVG-LAD OK
LM OK LAD 100%
LCX 100% RCA 100%
IVUS：Perfect

36. CAA:

38. EUROPCR 2008 Life DEMO case (2008-5-16)

46. Case 3. LAD ostium CTO with 3 years

53. Case 5: Triple-CTO, Refuse to do CABG
王波 M yrs
No chance to retrograde approach
Staged PCI successful
baseline CAA: LM: OK, LAD: 100%,
RCA-mid: 100% RCA-CTO PCI guiding×2
: LCX PCI guiding×2
Follow-up CAA: RCA, LCX OK
CIT: No time to do
LAD ostium PCI: successful

54. LAD100％ LEX99％ RCA100％

55. Ruijin1.25、2.5球囊扩张

56. 植入Excell2.5×28mm、3.0×28mm支架

57. Ruijin1.25、2.5球囊扩张，提供LAD充分侧支循环

59. 支架通畅，LEX100%，LAD100%

60. 钢丝 Pilot150进真腔，用1.25、2.5的球囊扩张

61. 植入Excell2.5×28mm、2.5×14mm、 2.5×24mm支架

63. Follow-up CAA
Follow-up CAA: baseline, LM: OK, LCX stents: OK, Prox LCX: 80%
LAD: CTO RCA Stents: open No chance to retrograde approach

64. Case 5: 08-3-24 LAD Ostium-CTO
TRI-improssible done to occluded RA
TRI: Guiding: 6Fr EBU 3.5
Wire: Conquest×2
Miracle 6×1
Miracle 12×1
Universal×1
Pilot 50×1
Balloon: 1.25mm

65. Wiring Universal wire to LCX Conquest not to ostium of LAD
Refind ostium of LAD Wire to LAD Wire to LAD-Dia

66. Wiring true lumen check
Contralateral injeetion: seemed to be OK Looked OK
Wire to true lumen of distal LAD Balloon to distal LAD

67. Ballooning
Ballooning Opened

68. Reallooning

69. Stenting: Excel 2.5×28mm, Excel 2.7×28mm,

70. Pro-LCX ballooning LCX stenting: Excel 3.0×15mm
Results & LCX stenting
Pro-LCX ballooning LCX stenting: Excel 3.0×15mm

71. Final results

72. Balloon Uncross? Guiding catheter backup support ?
bigger, special one,
and 5 in 6 or 7
Lower profile balloon?
rujin, sprinter 1.25mm
Buddy wire technique?
Anchor balloon technique?
Rotablator ?
Plaque cracking technique?
Tornus?

73. How to Deal with Balloon Uncross
Maximize guiding support
8Fr, A-L1-2, Deep engagement
Buddy wire technique
Anchor balloon
Child-mother catheter system
Rotational atherectomy
Tornus crossing catheter（2.1Fr 2.6Fr）
Laser

74. TRI－CTO（X12yrs）
Anker balloon budy wire Miracle 60gr

75. TRI－CTO（X12yrs）
Anker balloon budy wire Miracle 60gr

76. TRI－CTO（X12yrs）
Anker balloon budy wire Miracle 60gr

77. TRI－CTO（X12yrs）
Anker balloon budy wire Miracle 60gr

78. TRI－CTO（X12yrs）
Anker balloon budy wire Miracle 60gr

79. TRI－CTO（X12yrs）
Anker balloon budy wire Miracle 60gr

80. LCX—OM CTO lesion

81. Guiding: 6Fr-AL1 Wire : PT Graphics intermediate Balloon : marverick 1
Guiding: 6Fr-AL1 Wire : PT Graphics intermediate Balloon : marverick mm
No pass of the balloon

82. Still NO Pass of the balloon

83. After changing 7 Fr guiding to get stronger backup support , balloon pass throught the lesion.

84. Final result
after stenting
with mm

90. Tornus Crossing Catheter
Counterclockwise rotation (driving) (＜20times)
to cross CTO
Other roles
Guiding backup support↑
Wiring force imcrease and exchange
Remove the barrier between a side and a
main
branch
Limitations: cannot cross severe Ca++ lesion

94. Welcome Chaired by Yue-Jin Yang MD. PhD. FACC Co-Chaired by Dr. Saito
Attend China Heart Conference (IHF2010)：
2nd international TR Coronary Therapeutics (TRCT)
Chaired by
Yue-Jin Yang MD. PhD. FACC
Co-Chaired by
Dr. Saito
Dr. kiemeneiji
NCC, 2010/08/13-15, Beijing, China

95. Thank you very much !