The language of CTO interventions – what it all means

1. The language of CTO interventions – what it all means Dr Angela Hoye Senior Lecturer in Cardiology Hull & East Yorkshire Hospitals

2. 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..............

3. Improved symptoms Why do we open CTOs? Improved exercise capacity Improved LV function Reduced need for CABG (Improved survival (?)) Quality of life

4. Explosion of interest! CTO`s!

6. Try to explain/simplify some of the language used during CTO angioplasty • Discuss the design and use of some of the specialised devices • Focus on the techniques • antegrade • retrograde

9. 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

10. 3g More 4.5g Flexibility 6g 12g Less Less More Support 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

11. Examples:

12. 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

13. 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

14. Wiring techniques (antegrade approach) → Parallel wires / seesaw

15. Mitsudo et al J Inv Cardiol 2008

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

19. 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)

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

21. STAR:“subintimal tracking and re-entry”

22. 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

24. Case example

25. 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)

26. What about “backwards”? • Kissing wires • CART • Reverse CART • Knuckle wire technique • “rendezvous” etc etc.................

27. Principle of the retrograde technique Antegrade wire Retrograde wire

28. 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

34. Kissing wires

37. What about the CART technique? “controlled antegrade and retrograde subintimal tracking” Surmely et al J Invasive Cardiology 2006

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

39. 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

40. CART “localised” dissection STAR “long” dissection

41. Reverse CART:

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

45. Knuckle wire: Galassi et al Clin Res Cardiol (2010) 99:587–590

46. “Rendezvous in coronary” technique Muramatsu et al J Invas Cardiol 2010

47. “Rendezvous in coronary” technique Muramatsu et al J Invas Cardiol 2010

48. “Rendezvous in coronary” technique Muramatsu et al J Invas Cardiol 2010

49. “Rendezvous in coronary” technique Muramatsu et al J Invas Cardiol 2010

50. “Reverse anchoring technique” Matsumi et al Catheterization and Cardiovascular Interventions 71:810–814 (2008)