How to Control the Wire to Cross the CTO Lesion ?

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%）

9. CTO angiogram • TIMI flow -0 with - an ante-grade channel- a bridge collateral (not 99% stenosis)- a mid-islandwithout AMI / RMI • Tapered type • Abrupt type(the most tough)

10. Flow competition Ante-grade channel

11. Flow competition Bridge collateral Some micochannels

12. Tapered type CTO

13. Abrupt type CTO

14. Ante-grade channel or Bridge collateral ?

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

16. 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 ?

17. 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

19. 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

20. Microcatheter Support to wire manipulation Cancel a secondary curve

21. 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

22. 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)

23. 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

24. “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

25. 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

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

27. Parallel wire technique Stretching the vessel

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

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

30. 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

31. 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

32. 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

33. 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)

34. 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

35. CAA: 2008-4-28

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

45. Case 3. LAD ostium CTO with 3 years