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

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

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

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% ）

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)

Ante-grade channel

Flow competition

Bridge collateral

Some micochannelsFlow competition

Tapered type CTO

Abrupt type CTO

Ante-grade channel or Bridge collateral ?

A “breakthrough” in A “breakthrough” in CTO TherapyCTO Therapy

• New CTO guidewires

• Advanced techniques

• DES on restenosis

• Improve outmodes after therapy

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 ?

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

Drilling Technique and Wire• Technique 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 (100. 200. 300) Asahi-Abbott MIRACLE (3, 4.5, 6, &12) Medtronic PERSUADER (3,6,9) “Workhorse” technique with discrete entry point

Microcatheter

Support to wire manipulationCancel a secondary curve

Penetration Technique and Wires• Technique

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

Sliding Technique and Wires • Technique 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)

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

“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

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

Parallel wire technique

Cross a lesion by using two wires

Parallel wire technique

Stretching the vessel

Parallel wire technique

Sharper curve than the first wire

Crossing the first wire

Retro-grade dilatation of false lumen and Retro-grade puncture (CART)

Penetrate to the proximal from the distal vessel

orAs a landmark for ante-grade penetration

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

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

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

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)

Case 6: RCA CTO with SVG occluded after 3 years of CABG

彭世英 F 61 岁 病案号： 606891

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

CAA: 2008-4-28

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

Case 3. LAD ostium CTO with 3 yearsCase 3. LAD ostium CTO with 3 years

Case 5: Triple-CTO, Refuse to do CABG

王波 M 42 yrs 630746

No chance to retrograde approach

Staged PCI successful

07-7-9 baseline CAA: LM: OK, LAD: 100%,

RCA-mid: 100% RCA-CTO PCI guiding×2

07-7-16: LCX PCI guiding×2

08-2-28 Follow-up CAA: RCA, LCX OK

08-2-22 CIT: No time to do

08-3-24 LAD ostium PCI: successful

LAD100 ％ LEX99 ％ RCA100 ％

Ruijin1.25 、 2.5 球囊扩张

植入 Excell2.5×28mm 、 3.0×28mm 支架

Ruijin1.25 、 2.5 球囊扩张，提供 LAD 充分侧支循环

支架通畅， LEX100% ， LAD100%

钢丝 Pilot150 进真腔，用 1.25 、 2.5 的球囊扩张

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

08-2-28 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

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

Wiring

Universal wire to LCX Conquest not to ostium of LAD

Refind ostium of LAD Wire to LAD Wire to LAD-Dia

Contralateral injeetion: seemed to be OK Looked OK

Wire to true lumen of distal LAD Balloon to distal LAD

Wiring true lumen check

Ballooning

Ballooning Opened

Reallooning

Stenting

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

Excel 3.0×24mm, Excel 2.5×18mm

Results & LCX stenting

Pro-LCX ballooning LCX stenting: Excel 3.0×15mm

Final results

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?

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

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

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

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

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

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

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

LCX—OM CTO lesion

Guiding: 6Fr-AL1 Wire : PT Graphics intermediate Balloon : marverick 1.5-20mm

No pass of the balloon

Still NO Pass of the balloon

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

Final result after stenting with 2.5-16mm

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

Welcome Attend China Heart Conference (IHF2010) ：

2nd international TR Coronary Therapeutics (TRCT)

Chaired byYue-Jin Yang MD. PhD. FACC

Co-Chaired byDr. Saito

Dr. kiemeneijiNCC, 2010/08/13-15, Beijing, China

Thank you very much !