Post on 16-Feb-2017
Antegrade Approach Step by Step
Gerald S. Werner, MD, FESC, FACC, FSCAI
Medizinische Klinik I
Klinikum Darmstadt GmbH
Darmstadt, Germany
Conflict of interest
• I, Gerald S. Werner, MD, have no conflict of interest to declare with regard to the following presentation
The goal of CTO-PCI
• Ideally: Restore the original anatomy of an occluded artery
• Open an occluded artery
– with the least damage to the coronary anatomy
– with the least investment of time and material, reducing procedural risks
• There is no retrograde vs antegrade approach, there is only the choice of the best strategy for the specific lesion and patient
Strategic options for CTOs in Europe
Bilateral
Maximal Guide backup
AntegradeFielder XT -> Ultimate
or -> Progress 200T/Conf.Pro 9
Penetration, then step down
Distal good target Parallel with stiff
wire
ReentrysystemBridgePoint
Antegradeno Stump
IVUS for guided Penetration ?
Retrograde
With feasible collateral pathways
Ostial CTO
Long CTO
Re-Attempt
Ideal access
Strategic options for CTOs in EuropeThe antegrade spectrum of technical options
Bilateral
Maximal Guide backup
AntegradeFielder XT -> Ultimate
or -> Progress 200T/Conf.Pro 9
Penetration, then step down
Distal good target Parallel with stiff
wire
ReentrysystemBridgePoint
Antegradeno Stump
IVUS for guided Penetration ?
Retrograde
With feasible collateral pathways
J-CTO Score Sheet: Predicting complexity
Morino Y et al. JACC Interv, 2011; 4: 213
Examples not likely to work antegrade
Likely targets for the antegrade approach
Antegrade: Step by Step
• Lesion specific analysis
– Identify the proximal cap
– How long is the lesion
– What is the presumed course of the occluded segment
– Identify the distal target
• Patient specific considerations
– Previous attempts (which wires, why failed)
– Renal function (limits on contrast use)
Basic Setup
• Two catheters (radial and/or femoral route)
• Guide backup: 7F provides all options, in ostial locations and with IVUS guidance 8F preferred
• Microcatheter selection:
– Finecross: sleek profile, passes deep into lesions
– Corsair: provides additional support for the guide
– Caravelle: sleek profile with tapered tip
– Others to mention: Nhancer, Vascular Solutions
UB3UB3
Hard plaque
Severe calcification
Stiffer tip
XT-(A)XT-(A)
ASAHI Gaia FirstASAHI Gaia First
ASAHI Gaia SecondASAHI Gaia Second
ASAHI Gaia ThirdASAHI Gaia Third
Miracle12Miracle12
Confianza Pro 12
Hornet 14;
Progress 200T
Confianza Pro 12
Hornet 14;
Progress 200T
XT-RXT-R
2016: Which wire to use when?
The wire selection
• Explore the lesion– Fielder XT, atraumatic, provides feedback on lesion
rigidity, tracks loose tissue and may even penetrate noncalcified caps; “you follow the wire”
• Pass the lesion– Gaia 1-3 to penetrate the cap and steer through the
occluded segment; “the wire follows you”
• Conquer the calcified lesions – Confianza Pro 12 for penetration
– Others: Hornet 14, Progress 200T
– Pilot 200 to find the soft spots within severe calcium
Advance with in the vessel: work horse
Penetrate the cap
Wire tip shape: adapt to the purpose
Remember always: tip shape is lost rapidly
So reshape, whenever you get stuck
Remember always: tip shape is lost rapidly
So reshape, whenever you get stuck
Pass within the occlusion
Pass a collateral
Which wire to start with ?Examples from the Live Cases
Case #4Tapered lesion
My approach:
Fielder XT(-A) on microcatheterIf stuck -> Gaia 1
If distal target missed ->Proceed to parallel wire
Gaia 1st controlled wire passage
Gaia 1st controlled wire passage
Which wire to start with ?Examples from the Live Cases
Case #8Faint notch at side branch
My approach:Fielder XT(-A) to deliver the microcatheter to the proximal cap, exploring, but penetration unlikelyGaia 2 as starter
If distal target missed ->Proceed to parallel wire
The parrallel wiretechnique is classic
Crossit
200-400 or
Conquest
3g-6g
N.Reifart/O.Katoh 1996
Why parallel wiring works well in the RCA:the wire straightens the vessel architecture
Why parallel wiring works well in the RCA:the wire straightens the vessel architecture
When and why parallel wire works
• If the 1st wire is close to the target, the 1st wire straightens the vessel course, and allows passage of the 2nd (stiffer) wire
• If the 1st wire is far from the target, the 2nd
wire needs to find a new course, especially in bent segments
• Often the entry point into the proximal cap needs to be changed
• Parallel wire is not a reentry technique
When and why parallel wire may fail
• The distal target is diffusely diseased and narrow
• The distal target is severely calcified and prevents entry even with a stiff wire tip
• Failure of the operator to check orthogonal views frequently: biplane systems are helpful
Which wire to start with ?Examples from the Live Cases
Case #5Blunt occlusion at side branch
Possible approach:Pass wire in side branch, dilate proximal and advance IVUS
IVUS guided penetration with Gaia 2
Bailout: retrograde
RCA CTO: Strategic options
Torino. 16.4.15
Retrograde approach in mind as
most likely strategy
Chair of session: “antegrade
approach nonsense”
Agreed, but still we need an
antegrade wire for a successful
retrograde approach
The further the antegrade wire
reaches, the shorter the
retrograde wire needs to
travel….
RCA CTO: Strategic options
Torino. 16.4.15
Puncture of the cap with Gaia 2
Torino. 16.4.15
Then via Finecross wire downgraded to Sion Black
Torino. 16.4.15
Complex long RCA CTO
Torino. 16.4.15
20 years Post CABG: Ostial RCA CTOAdditional information from MSCT
Retrograde options are challenging
Moderate calcification -> medium-strength wire
If parallel wiring fails: StingRay reentry device
H.B. 30.1.15
Parallel fails, then StingRay
H.B. 30.1.15
Strategic options for CTOs in Europe
Bilateral
Maximal Guide backup
AntegradeFielder XT -> Ultimate
or -> Progress 200T/Conf.Pro 9
Penetration, then step down
Distal good target Parallel with stiff
wire
ReentrysystemBridgePoint
Antegradeno Stump
IVUS for guided Penetration ?
Retrograde
With feasible collateral pathways
Ostial CTO
Long CTO
Re-Attempt
Ideal access
Parallel fails, then StingRay
H.B. 30.1.15
Parallel fails, then StingRay
H.B. 30.1.15
StingRay wire passed before the stent
H.B. 30.1.15
Antegrade: Step by Step
• Lesion specific approach
– Start with the softest possible wire
– Step up if necessary
– Use parallel wire as an early and easy bailout
– If retrograde is difficult, early decision for guided reentry technique (StingRay)
• Patient specific approach
– Select the most likely strategy to solve the lesion
– Do not attempt complex lesions without the option for retrograde conversion
Antegrade: Step by Step
• Lesion specific approach
– Start with the softest possible wire
– Step up if necessary
– Use parallel wire as an early and easy bailout
– If retrograde is difficult, early decision for guided reentry technique (StingRay)
• Patient specific approach
– Select the most likely strategy to solve the lesion
– Do not attempt complex lesions without the option for retrograde conversion