The language of CTO interventions – what it

all means

Dr Angela Hoye

Senior Lecturer in Cardiology

Hull & East Yorkshire Hospitals

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..............

Improved symptoms

Improved LV function

Improved exercise capacity

Reduced need for CABG

(Improved survival (?))

Why do we open CTOs?Why do we open CTOs?

• Explosion of interest!

CTO`s!

• Try to explain/simplify some of the language used during CTO angioplasty

1.Discuss the design and use of some of the specialised devices

2.Focus on the techniques• antegrade• retrograde

• 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

Support

Fle

xibility

MoreLess

Mor

eLess

3g

4.5g

6g

12g

Tip load: Weight needed to be applied to bend / buckle the tip of the guide wire

Floppy: <1g

Intermediate: ~3g

Stiff: ≥4.5g

Stiff wires especially when combined with a tapered tip increase penetration power but also

increase the risk of perforation

• Examples:Wire Tip load (g) Size of tip

Fielder FC 1.6 0.014”

Fielder XT 1.2 0.009

Miracle 6 ≈6 0.014”

Confianza 9 8.6 0.009

Confianza Pro 9 9.3 0.009

Confianza Pro 12 12.4 0.009

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 10-20 rotations in the

same direction

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

Wiring techniques (antegrade approach)

→ Parallel wires / seesaw

Mitsudo et al J Inv Cardiol 2008

• Eg. Balloon support, parallel wire technique, use of simultaneous coronary injection

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)

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

STAR: “subintimal tracking and re-entry”

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

Case example

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)

• What about “backwards”?– Kissing wires– CART– Reverse CART– Knuckle wire technique– “rendezvous”

etc etc.................

• Principle of the retrograde technique

Retrograde wire

Antegrade wire

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

• Kissing wires

• What about the CART technique?

“controlled antegrade and retrograde

subintimal tracking”

Surmely et al J Invasive Cardiology 2006

• CART:

• Simultaneous antegrade and retrograde approach• Create a (localised) subintimal dissection by inflating a

small (1.5-2.0mm balloon) over the retrograde wire

Surmely et al J Invasive Card 2006;18:334–338Surmely et al J Invasive Cardiology 2006

• 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

CART“localised”

dissection

STAR“long”

dissection

Reverse CART:

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

• Knuckle wire:

Galassi et al Clin Res Cardiol (2010) 99:587–590

“Rendezvous in coronary” technique

Muramatsu et al J Invas Cardiol 2010

“Rendezvous in coronary” technique

Muramatsu et al J Invas Cardiol 2010

“Rendezvous in coronary” technique

Muramatsu et al J Invas Cardiol 2010

“Rendezvous in coronary” technique

Muramatsu et al J Invas Cardiol 2010

• “Reverse anchoring technique”

Matsumi et al Catheterization and Cardiovascular Interventions 71:810–814 (2008)

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

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)

Thankyou!