Chronic Total Occlusion PCI – Strategies Dr Arun

1. Chronic Total Occlusion PCI – Strategies Dr Arun

2. CTO-DEFINITION 100% luminal diameter obstruction without flow in that segment of 3 or more months duration Presence of TIMI 0 flow within an occluded segment with an estimated occlusion duration of >/= to 3months A lesion with TIMI 0 flow within the occluded segment that is judged to be at least 3 months in duration Eurointerven 2007 :30:43 Heart 2012;98:822-828

3. WHY TO OPEN UP A CTO ? Significant clinical problem (JACC intvn 2009;2:489 –97) Similar risk to non CTO PCI (JACC intvn2009;2:489 –97) Angina relief (FACTOR TRIAL-2010) Improved L V function JACC 2006;47:721–5 Improved tolerance of a future ACS JACC intvn2009;2:1128 –34 Potentially better survival with successful PCI AmHeartJ 2010;160:179-87 Avoidance of CABG AmHeartJ 2010;160:179-87

4. Indication Aim – To improve symptoms and/or prognosis Currently reopening of a CTO Presence of symptoms OR Objective evidence of viability/ischaemia in territory of occluded artery of more than 10% is fully sanctioned by the current guidelines on myocardial revascularisation IMPROVED REGIONAL & GLOBAL LV FUNCTION - ESV EF Limited or no late enhancement on Gd MRI is an excellent predictor of late left ventricular recovery after CTO recanalisation EuroIntervention 2012;8:139-145

5. Histopathologicalinsights Healing total occlussion Fibrin-red, proteoglycan-bluishgreen Vascular channels- asterisks Asterisks- vascular channels Yellow- collagen rich matrix EuroInterv.2006;2:382-388

6. Histopathological progression – not clearly understood Belief –once occlusion occurs thrombus formation uptosidebranch Important components of occlusion Proximal cap, Calcificationmicrovessels ,loose tissue, distal cap Microchannels Often extend to smallside branch & to adventitia Extravascular microchannels in early phase of occlusion More mature CTO –intravascular channels increase Matured CTO - both fewer Longitudnal continuity – 85% of entire lenghth of CTO EuroInterv.2006;2:382-388 J Am CollCardiolIntv 2011;4:941–51

7. Continuous loose tissue segments frequently in tapered entry CTO Majority of CTO autopsy specimen were not totally occluded Non occluded lesions were not related to the age Histopathologicalsubintimal space after failed procedure Sumitsujiet al JACC intvn sep 2 0 1 1 : 9 4 1 – 5 1

8. Preprocedure planning Paramount importance – planning mistakes difficult to circumvent half way through the procedure Discourage routine adhoc CTO PCI Spend time examining diagnostic films & decide on Approach ,vascular access, guide shape & size dedicated equipment availability Occluded & contralateral vessel reviewed in multiple projection frame by frame to understand complete anatomy identify proximal & distal cap vessel course & sidebranch calcification details of collateral circulation Contrast volume defined prior to procedure - 4xGFR(ml) EURO CTO club;2012 consensus

9. Role of dual injection Critical for performing CTO PCI–in all case of contralateral collateral Allows for optimal visualization of CTO vessel Crucial for determining lesion length, size & location of distal target vessel To asses any bifurcation at distal cap Assess presence, size & tortuosity of collateral vessel Best performed At low magnification ,prolonged imaging exposure No table panning - allows for optimal delineation of CTO segment collateral vessel location & course JACC intrvn2012;5:367-79

10. First inject donor – then occluded vessel – minimize radiation Septal collaterals best visualized –RAO cranial OR straight RAO Epicardial collaterals need tailored view more often from diagonal ,LCX or PLV LAO & RAO cranial – Best to image distal lateral wall collaterals (OM-PLV, diagonal to diagonal/OM connections) RAO & AP caudal- proximal OM collaterals and those in AV groove JACC intrvn2012;5:367-79

11. Repeat procedures – when to stop Repeat procedures – More common with CTO failure of a specific recanalization strategy staging of otherwise progressing procedure Parameters to consider before repeat procedure First attempt complete ? contemporary technique & materials properly employed reason for failure recognized ? clear alternative strategy for reattempt ? General rule- two attempts at a CTO Know when to stop key issue in CTO PCI dissection of distal lumen – Better to abandon procedure

12. Anticoagulation UFH – ease of use & available antidote Avoid bivaluridin &gp 2b 3a inhibitor Access route Depend on individual patient situations Operator preference & experience Femoral artery - usual and preferred access in most labs(90% - Europe) Trans radial PCI for CTO - increased Korean Circ J 2010;40:209-215 Brilakis et al,2012

13. Bifemoral approach - characteristic of CTO PCI Side hole guide catheters >/= 7F - both antegrade & retrograde Long femoral sheaths (>/=30cms) - further support (tortuous arteries) Back up support & sidehole - essential in guide selection IVUS guided PCI - 8 F guide catheter to accommodate 2 catheters (IVUS catheter and microcatheter) Simultaneous double contrast injection is mandatory Yamane M. Rev EspCardiol. 2012.

14. Successful CTO PCI require attention to subtle techniques Guide wire crossing of CTO –most difficult & important Guidewire selection & manipulation tactics – key issues Successful guidewire manipulation requires adequate preparation, guide selection & angiographic techniques

15. DEVICES

16. Guide catheter selection First key to success For effective guide wire manipulation : coaxial orientation of guide catheter important stability& back up force RCA - AL1/0.75 with sideholes Shepared crook RCA - AL1or2 Prox RCA lesion - JR ( avoid ostial damage) LCA - Extraback up (XB,EBU,BL) LCX (short leftmain) - AL1 or2 (better support & co-axial) Guide catheter stability insufficient or unable to achieve May use Anchor technique for guide catheter stabilization Korean Circ J 2010;40:209-215

17. AL from different companies Anchoring technique for guide stabilization OTW baloon inserted in a small sidebranch inflated at low pressure (2mm @ 8atm here) EuroInterv.2006;2:375-381

18. Guide wires Crossing the lesion with GW – very important step in CTO PCI Most common reason for failed CTO PCI- failure of GW to cross Floppy wire- initial choice Exchange to a stiffer dedicated guide wire Polymer coated wires – poor tactile feedback, lack of resistance more chance of subintimal passage Majority favour – step up approach – moderately increased stiffness(miracle-3) – switch to greater stiffness &penetration ability, taperd (conquest pro wires) Some believe –use of stiffer wires initially to cross hard occlusion cap Rationale: risk of initial dissection minimized, procedure shortened & simplified with this approach Kcj 2010

19. Four wire strategy Hydrophillic &/or polymerjacketAntegrademicrochannel/ 0.014 inch,low gram force with soft tissue probing tapered tip knuckle technique Eg : Fielder XT wire (Asahi Intecc) tip-0.009 Runthroughtaper wire (Terumo – 0.008 Nontapered ,polymer jacket collatrel channel crossing Hydrophillic,0.014 inch GW in retrograde procedures Eg: Fielder FC wire(Asahi Intecc) Pilot 50 wire (Abbott Vascular) JACC intrvn2012;5:367-79

20. Moderately high gram force(4-6) complex lesion crossing Polymer jacket,nontapered long lesion,knuckle technique 0.014 inch GW Dissection /rentry tortuous lesion with ambigous course Eg: Pilot-200 GW(Abbott Vascular) High gram force ,0.014GW Penetration techniques tapered,0.009 Cap puncture Nonjacketed tip Complex lesion crossing Lumen reentry techniques Eg: Confianza Pro 12 wire (Asahi Intecc) JACC intrvn2012;5:367-79

21. Guidewires for micro channel tracking CTO LIVE 2007

22. JACC intrvn2012;5:367-79

23. JACC intrvn2012;5:367-79

24. Guide wire strategies for approaching total occlusions Indian heart journal:2009;61:178-85

25. Guide wire selection & Microcatheter based on PCI strategy KEY ELEMENTS TO RECOGNIZE a) Tapered (0.009 in) or not b) Polymer jacket or not c) Stiffness d) Trackability Initial microchannel tracking - soft tapered polymer jacket wire IVUS guided reentry from subintimal space to true lumen Tapered High gram stiff wire Soft polymer jacket wire + microcatheter has improved chance of antegrade recanalization in first attempt

26. Microcatheters Low profile,trackable OTW microcath - indispensable tool for CTO PCI Allow ease of wire exchange ,floppy for dedicated stiffer wire Facilitates transmission of torque to tip & improve feedback Allows primary & secondary curve adjustment Modulates tip stiffness of guide wire Dedicated microcatheters – better tip flexibility > OTW balloons Useful for CTO immediately distal to a bend Larger inner lumen – reduces friction during wire manipulation Disadvantage : rarely able to cross occlusion to be exchanged with OTW baloons

27. Tips for use For wire exchange – inject saline to lumen- avoids introducing air Trapping technique

28. Finecrossmicrocath terumois.com

29. Tornus Rotate anticlockwise to advance Clockwise to remove Screw pitch Tornus-1.1mm Tornus 88Flex - 1.7mm Require exchange length wire for removal

30. Corsair Tapered soft tip Negotiate tortuous channels Platinum marker Distal 60 cm- hydrophilic coating Corsair Features Tungsten braiding +10 elliptical stainless steel braids SHINKA-Shaft Excellent pushability and flexibility due to unique construction Enables contrast injection and wire exchange Superb manoeuvrability due to excellent hydrophilic coating Kink resistant soft radiopaque tapered tip 135cm (antegrade) or 150cm (retrograde) lengths available

32. OTW Balloons

33. STRATEGIES FOR PCI OF CTO DUAL WIRE SINGLE WIRE Soft tapered polymer jacket wire Parallel wire technique Middle weight spring coil wire Bilateral retrograde approach High gram tapered wire IVUS guided approach Yamane M Rev EspCardiol. 2012.

34. Attempted in this order chance of successful recanalization - 90% Clinical background & situation dictates - onetime or a staged procedure 2nd or 3rd attempt in case if unsuccessful procedure Yamane M Rev EspCardiol. 2012

35. Antegrade approach

36. Guide wire Tip shaping Wire tip shaped as short as possible <45º Second milder curve - improve maneuverability of wire Exception - a sharp (>60º) angle with 1 to 2 mm bend based on lumen size, to navigate the wire from subintimal space back to true lumen( Parallel wire technique or IVUS guided wiring) Confianza Pro or Pilot 200 - best suited to this purpose How short tip can be bent – depends on length of soldering of spring coil at tip Usually -1mm, fielder XT -<1mm Korean CircJ 2010;40:209-215 EuroInterv.2006;2:375-381

37. Shaping the wire 1ºbend of 30-45º 1-2mm from tip Find softest part 2ºbend-10-15º @3-6mm Work as a navigator to orient tip

38. Tip curve should be just larger than lumen diameter CTO, the lumen diameter =0 mm For CTO lesion - Guidewire-tip curve should be very small Larger curve may hurt the vessel wall during direction control Hermiller ,SCAI Fellows Course 2009

39. Guide wire handling Different methods Sliding AT proximal cap Drilling inside CTO Penetration Distal cap Short, focal, straight noncalcified lesion – any method Long tortuous calcified occlusion – wiring tailored to lesion characteristics Hard fibrocalcific plaque and tortuosity in CTO- major obstacle Combination of penetration and sliding over a microcatheter watching the wire tip in relation to lumen in at least 2 orthogonal views Yamane M Rev EspCardiol. 2012

40. SLIDING Relatively recent occlusion with predominance of microchannels Extremly low friction wires for picking microchannels used Simultaneous rotation & probing of lesion High chance of entering to subintimal space ( tactile response - nil ) Recent total, subtotal occlusion ,ISR attempted with this strategy Long duration – Microchannels replaced by fibrotic tissue Indian Heart J. 2009; 61:275-280

41. BEWARE bridging collaterals masquerading as microchannel Polymer sleeved wires NOT forced against resistance, small tip bend, probing with mild rotation Soft wires with polymer sleeve – Fielder series/ Whisper/ PT II

42. Drilling Strategy If discrete entry point present Technique short curve(2mm) @45-60º to distal tip sometimes a secondary curve given proximally wire advanced with rapid rotational tip and gentle probing start with MOD stiffness – progressive increase in stifness Entry to false lumen judged by tactile feel on pulling stiff wire Reserved for the most skilled and experienced operator Ineffective with Blunt entry ,heavily calcific & resistant lesions Indian Heart J. 2009; 61:275-280

44. Penetration Useful for blunt ,heavily calcific or resistant lesions Technique Pushing stiff wire slowly& gradually – minimum rotation to target direction Tapered tip wires Softer tip intially progressively stiffer wires Route determined – various angio or CT findings not by tactile feel Not for CTO with tortuous angulated or bridging collaterals because of higher chance of perforation Drilling & penetration – guide support & tipload important Tip load - success - chance of perforation

45. Penetration power = tipload/tiparea May use to redirect in conjunction with parallel wire technique

46. Parallel wire technique or Seesaw wiring

47. 1st wire in false channel left in situ 2nd stiffer wire advanced parallel to first wire in same path redirected to enter distal true lumen Important prerequisite – distal vessel visualization Main purpose : - redirecting a wire inside body of a cto & puncturing distal fibrous cap main pitfall is wire twisting each other Support catheter use, appropriate wire selection& handling –essential to avoid wire twisting Korean Circ J 2010;40:209-215

48. Visualization of 1st GW & its relative position to 2nd GW using orthogonal view is essential for success of technique Adopt the technique before a large subintimal dissection Chance of successful recanalization by 2nd wire decreases proportionally to the extent of subintimal dissection induced by the first guidewire 2nd wire –stiffer with superior torquability Eg:Miracle12 or Conquest Pro

49. Check in multiple angiographic views Advantages a)Decreased fluro time b) Reduced contrast

50. See-saw wiring technique Modification of parallel wire technique Uses 2 microcatheters or OTW baloons When first wire fails , 2nd wire with microcatheter or OTW baloon is inserted Risk – false lumen may enlarge – procedure failure Japanese operators demonstrated ability to improve wire crossing over time with this technique(Nakamura& Bae 2008)