Chronic total occlusion-PTCA

Chronic total occlusion-PTCA

1. Chronic total occlusion-Management strategies and Wiring Techniques Dr V S R Bhupal Nizam’s Institute of Medical Sciences, India

2. DEFINITION >99% stenosed Duration >3 months TIMI 0-1 CTO-MANAGEMENT AND WIRING TECHNIQUES

3. Histopathology Organized thrombus. Fibrotic plaque Calcified lesions. Proximal/ distal fibrous cap Micro channel in the occlusion segment CTO-MANAGEMENT AND WIRING TECHNIQUES

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7. Micro channels inside the occlusion Often extend to small side branch & to adventitia Extravascular micro channels in early phase of occlusion More mature CTO –intravascular channels increase Matured CTO - both fewer Longitudinal continuity – 85% of entire length of CTO CTO-MANAGEMENT AND WIRING TECHNIQUES

8. Why Bother to do PCI? Chronic Total Occlusion (CTO) Because successful CTO recanalization may result in Angina/Ischemia relief Freedom from subsequent CABG Improved LV function Improvement in event-free survival Presence of CTO in CAD Imparts Adverse Prognosis

9. Series Name/Year Successful PCI (N) FU (months) Asymptomatic (%) Olivari, 2003 248 12 89 Berger, 1996 139 6 87 Ivanhoe, 1992 264 36 69 Ruocco, 1992 160 24 69 Bell, 1992 234 32 76 TOTAL >1000 >24 mo >80% CTO Recanalization and Angina Relief Chronic Total Occlusion (CTO)

10. Symptom relief TOAT-GISE (Total Occlusion An- gioplasty Study– Società Italiana di Cardiologia Invasiva ) trial, CTO-PCI success - 86%, 70% angina-free survival (p=0.008) Cheng et al. Demonstrated that 76% of patients with CTO who were treated with PCI experienced an improved angina classification, whereas 17% of patients who were not treated with PCI improved (p<0.05). CTO-MANAGEMENT AND WIRING TECHNIQUES

11. Meta-Analysis of CTO Outcomes Joyal et al., Am Heart J 2010;160:179. 13 Observational Studies, 7288 patients weighted averaged follow-up 6 years OR for Success vs. Failure 95% Cl p Value Mortality 0.56 0.43-0.72 <0.001 MI 0.74 0.44-1.25 0.26 Subsequent CABG 0.22 0.17-0.27 <0.001 Residual Angina 0.45 0.30-0.67 0.001

12. Evaluation of LV Function 3-Yrs after Percutaneous Recanalization of CTO Kirschbaum S et al, Am J Cardiol 2008;101:179 Changes in LV Volume Indexes and EF between Baseline and 3-Yr FU Measured Using Magnetic Resonance Imaging (N=21) Mean ejection fraction improved slightly, but end-systolic and end-diastolic volume indexes decreased significantly. 35 30 86 63 60 78

13. A 3.8% to 8.4% absolute reduction in mortality was associated with successful versus failed CTO-PCI. Survival advantage CTO-MANAGEMENT AND WIRING TECHNIQUES

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15. 2011 ACCF/AHA/SCAI PCI Guidelines What We Can Do Class IIa Recommendation PCI of a CTO in pts with appropriate clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise (Level of Evidence: B) Levine GN, et al. JACC doi:10.1016/j.jacc.2011.08.007 PCI of CTO CTO-MANAGEMENT AND WIRING TECHNIQUES

16. Symptoms A CTO with well developed collaterals is hemodynamically similar to 90% coronary stenosis without collaterals – significant recovery of ventricular function is expected Viable myocardium Recovery of LV function depends on the presence of hibernating viable myocardium Success If the likelihood of success is moderate to high (>60%) and the likelihood of complications less, PCI is encouraging. Patient selection CTO-MANAGEMENT AND WIRING TECHNIQUES

17. Appropriate Use Criteria 2012 Stress test results, Medications Asx CCS 1-2 CCS 3-4 Low risk, No / min meds I (1) I (2) I (3) Low risk, Max meds I (1) U (4) U (6) Intermed risk, No / min meds I (3) U (4) U (6) Intermed risk, Max meds U (4) U (5) A (7) High risk, No / min meds U (4) U (5) A (7) High risk, Max meds U (5) A (7) A (8) CTO (no other CAD) CTO-MANAGEMENT AND WIRING TECHNIQUES

18. Barriers Complications Failure rates Economic burden CIN CTO-MANAGEMENT AND WIRING TECHNIQUES

19. Economic burden Repeat procedures Fluoroscopy Hardware more CTO-MANAGEMENT AND WIRING TECHNIQUES

20. Complications Impairment of collateral flow spasm, shearing off side-branches and collateral by dissection, distal embolization Dissection with branch occlusion & Perforation intra-wall balloon expansion, side-branch dilatation, damage of neochannels connecting vasa vasorum Guidewire entrapment Subacute vessel reocclusion 8% of total occlusion within 24hr Vs. 1.8% of non total occlusion CIN Radiation CTO-MANAGEMENT AND WIRING TECHNIQUES

21. Reasons Not able to cross guidewire – 63% Long intimal dissection – 24% Dye extravasation – 11% Balloon did not cross or dilate – 2% Thrombus – 1.2% Kinoshita I, et al. JACC 1995;26:409-411 CTO-MANAGEMENT AND WIRING TECHNIQUES

22. Predictors of failure Clinical- Duration - >3-6 monthS CRF Angiographic Calcification(at entry point/at distal cap) Blunt stump >45 angulation of target vessel Length of occlusion >15-20mm Vessel <3mm Multiple lesions in target artery Lack of distal vessel filling Bridging collaterals and side branch CTO-MANAGEMENT AND WIRING TECHNIQUES

23. Predictors of success or failure in PCI of CTO Predictors of success Duration < 3 months Antegrade flow + Tapered morphology + Bridging collaterals – Side branch – lesion length < 15 mm Single vessel disease Predictors of failure Duration > 3 months Antegrade flow – Tapered morphology – Bridging collaterals + Side branch +, ostial lesion lesion length > 15 mm Multi vessel disease Vessel & lesion tortuosity & calcification Bridging collaterals are more common in lesions > 3 months old. Extensive bridging collaterals that form caput medusae around the occluded vessel are generally not suitable for PCI CTO-MANAGEMENT AND WIRING TECHNIQUES

24. Predictors of Procedural Success TOAT - GISE CTO-MANAGEMENT AND WIRING TECHNIQUES

25. PROCEDURAL SUCCESS CTO-MANAGEMENT AND WIRING TECHNIQUES

26. 4 angiographic parameters Length Side branches Target vessel at the distal cap Collaterals for retrograde techniques. CTO-MANAGEMENT AND WIRING TECHNIQUES

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28. Two injection same time Collaterals to the distal target vessel. Lesion length and the size and location of the distal target vessel, evaluating whether there is a significant bifurcation at the distal cap, and for deciding on the optimal CTO PCI strategy CTO-MANAGEMENT AND WIRING TECHNIQUES

29. Collaterals Assessment CAG Visible collaterals of 0.3-0.5mm <100 micro m are not visualized Selective using micro catheters CTO-MANAGEMENT AND WIRING TECHNIQUES

30. Collaterals grade[Rentrop] 1 2 3 Visible filling of any collateral channel Filling of the side branches of the occluded artery, with no dye reaching the epicardial segment Partial filling of the epicardial vessel Complete filling of the epicardial vessel by collaterals CTO-MANAGEMENT AND WIRING TECHNIQUES

31. Collaterals -Levine etal Septal Intra arterial (bridging) Epicardial Proximal take off Distal takeoff CTO-MANAGEMENT AND WIRING TECHNIQUES

32. Collaterals CTO-MANAGEMENT AND WIRING TECHNIQUES

33. Werner et al 3 grades CC0-no continues connection CC1 - continuous , threadlike CC2 – continuous , small side branch like CTO-MANAGEMENT AND WIRING TECHNIQUES

34. CTO MANGEMENT CTO-MANAGEMENT AND WIRING TECHNIQUES

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

36. Precautions Covered stents Embolization coils Pericardiocentesis trays Thrombectomy devices CTO-MANAGEMENT AND WIRING TECHNIQUES

37. Role of dual injection Critical for performing CTO PCI–in all cases with good contralateral collaterals Allows for optimal visualization of CTO vessel Crucial for determining lesion length, size & location of distal target vessel To assess 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 CTO-MANAGEMENT AND WIRING TECHNIQUES

38. 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 CTO-MANAGEMENT AND WIRING TECHNIQUES

39. Guide catheter First key to success For effective guide wire manipulation : coaxial orientation of guide catheter important stability& back up force RCA - AL1/0.75 with side holes Sheperd crook RCA - AL1or2 Prox RCA lesion - JR ( avoid ostial damage) LCA - Extra back up(XBU,EBU,) LCX (short left main) - AL1 or2 (better support, co-axial) CTO-MANAGEMENT AND WIRING TECHNIQUES

40. Guide catheter 7F or 8F guide catheter Superior backup support (needed in CTO) Inter twining is less common while using parallel wires Switching over to devices like rotablator is easy Permit better contrast injection. R adial approach,usually is not preferred for CTO. Side hole guide catheter is useful for RCA Maintains perfusion to the sinus node artery & conus branch CTO-MANAGEMENT AND WIRING TECHNIQUES

41. CTO WIRES CTO-MANAGEMENT AND WIRING TECHNIQUES

42. CTO-MANAGEMENT AND WIRING TECHNIQUES

43. CLASSIFICATION OF CTO WIRES CTO-MANAGEMENT AND WIRING TECHNIQUES

44. CTO guide wire techniques CTO-MANAGEMENT AND WIRING TECHNIQUES

45. Lesion specific CTO approaches SLIDING Micro-channels present CTO’s < 6 months ISR total occlusions STAR technique Hydrophilic wires Fielder,CrosswireNT , HT Pilot, Whisper, Choice PT CTO-MANAGEMENT AND WIRING TECHNIQUES

46. Lesion specific CTO approaches DRILLING (controlled) “ Workhorse technique ” Most CTOs with discrete entry point after initial attempt with soft (intermediate wires) Stiff , hydrophobic non-tapered wires MiracleBros (3 g, 4.5 g and 6 g), Persuader (3 g and 6 g) and Cross-IT XT (100/200/300) CTO-MANAGEMENT AND WIRING TECHNIQUES

47. Lesion specific CTO approaches Penetration Blunt entry point Heavily calcific or resistant lesions Alternative to “drilling” as the “work horse technique” after initial soft wire failure Super stiff tapered wires Conquest Pro (9 g, 12 g), Cross-IT XT 400, MiracleBros 12 CTO-MANAGEMENT AND WIRING TECHNIQUES

48. GUIDEWIRES FOR RETROGRADE TECHNIQUES Fielder/ FielderFC    X - treme    Whisper    ChoICE PT2   Runthrough / Runthrough Hypercoat CTO-MANAGEMENT AND WIRING TECHNIQUES

49. COMMONLY USED CTO WIRES CTO-MANAGEMENT AND WIRING TECHNIQUES

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52. Fielder™ / Fielder FC™ (Asahi Intec Co.) Special guidewire - distal coil coated with polymer sleeve & further coated with a hydrophilic coating Provides advanced slip performance & trackability for highly stenosed lesion & tortuous vessels Very good torque performance Combines both slide and torque performance Primary wire used in the retrograde technique of recanalization of CTO CTO-MANAGEMENT AND WIRING TECHNIQUES

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55. Whisper Durasteel ™ Core-to-tip designed to improve steering, durable shape retention and tactile feedback Full Polymer cover with Hydrophilic coating intended for deliverability and smooth lesion access Responsease ™ “ transitionless ” core grind designed to provide improved tracking and better torque response Tip coils designed to provide softer, shapeable tip and also improve tactile feedback CTO-MANAGEMENT AND WIRING TECHNIQUES

56. CONQUEST SERIES CTO-MANAGEMENT AND WIRING TECHNIQUES

57. Pilot 200 guidewire (Abbott Vascular). Polymer-jacket Moderately high– gram-force (4 to 6 g),, Non tapered 0.014-inch guide wire. For complex lesion crossing, long lesions, knuckle technique, and dissection/re-entry. Performs well in very tortuous segments with an ambiguous course CTO-MANAGEMENT AND WIRING TECHNIQUES

58. GAIA WIRES CTO-MANAGEMENT AND WIRING TECHNIQUES

59. Micro catheters Wire exchange[floppy to dedicated stiffer] Torque to tip & improve feedback Tip stiffness of guide wire CTO-MANAGEMENT AND WIRING TECHNIQUES

60. Corsair micro catheter (Asahi Intecc ) 2.7-F catheter with OTW hybrid catheter Both micro catheter and support Bidirectional wire braiding for torque transmission, and an inner polymer lumen with soft tip for optimal wire control Cross collateral channels and provides the primary basis for conventional retrograde procedures. Super selective injection for collaterals Antegrade direction for wire support. CTO-MANAGEMENT AND WIRING TECHNIQUES

61. The Corsair catheter is advanced by rotation in either direction. The Corsair should not be over-rotated (10 consecutive turns without release) as over-rotation could cause catheter kinking CTO-MANAGEMENT AND WIRING TECHNIQUES

62. Tornus micro catheter (Asahi Intecc ) Braided-wire mesh OTW microcatheter with left-handed thread allowing for channel preparation and lesion crossing in resistant occlusions. Advanced using counterclockwise rotation and removed using clockwise rotation. Guidewire should remain within the Tornus inner lumen during manipulations, and over-rotation should be avoided to minimize the risk of kinking. Contrast injections should not be performed through the Tornus , as the contrast escapes through the wire braid. CTO-MANAGEMENT AND WIRING TECHNIQUES

63. CTO-MANAGEMENT AND WIRING TECHNIQUES

64. Finecross microcath terumois.com CTO-MANAGEMENT AND WIRING TECHNIQUES

65. CTO-MANAGEMENT AND WIRING TECHNIQUES

66. Lesion crossing and lumen re-entry technologies CrossBoss catheter ( BridgePoint Medical, Plymouth, Minnesota) Stingray balloon and Stingray guidewire systems ( BridgePoint Medical). CTO-MANAGEMENT AND WIRING TECHNIQUES

67. STRATEGIES Antegrade approach Retrograde approach SINGLE WIRE DOUBLE WIRE Parallel wiring Seesaw wiring Subintimal tracking and reentry IVUS guided approach Retrograde wire crossing Kissing wire technique Knuckle wire technique CART Reverse CART CTO-MANAGEMENT AND WIRING TECHNIQUES

68. Wire escalation strategy 1. Floppy wire as the 1st wire 2. Intermediate or MIRACLE 3 3. MIRACLE 6 4. MIRACLE 12 or Conquest Family CTO-MANAGEMENT AND WIRING TECHNIQUES

69. Wire shaping 1ºbend of 30-45º 1-2mm from tip Find softest part 2ºbend-10-15º @3-6mm Work as a navigator t o orient tip CTO-MANAGEMENT AND WIRING TECHNIQUES

70. Tip curve should be just larger than lumen diameter CTO, the lumen diameter = mm For CTO lesion – Guide wire-tip curve should be very small Larger curve may hurt the vessel wall during direction control CTO-MANAGEMENT AND WIRING TECHNIQUES

71. Guide wire negotiation Different methods Sliding AT proximal cap Drilling inside CTO Penetration Distal cap CTO-MANAGEMENT AND WIRING TECHNIQUES

72. Simultaneous rotation & probing of lesion High chance of entering to subintimal space ( tactile response - nil ) SLIDING Recent occlusion Predominance of micro channels Extremely low friction wires for picking micro channels used Recent total, subtotal occlusion ,ISR attempted with this strategy Long duration – Micro channels replaced by fibrotic tissue CTO-MANAGEMENT AND WIRING TECHNIQUES

73. BEWARE bridging collaterals masquerading as microchannel Polymer sleeved wires NOT forced against resistance, small tip bend, probing with mild rotation S oft wires with polymer sleeve – Fielder series/ Whisper/ PT II CTO-MANAGEMENT AND WIRING TECHNIQUES

74. 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 stiffness 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 CTO-MANAGEMENT AND WIRING TECHNIQUES

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76. Penetration Technique Pushing stiff wire slowly& gradually – minimum rotation to target direction Tapered tip wires Softer tip intially progressively stiffer wires Route determined – various angio findings in multiple views, not by tactile feel Useful for blunt ,heavily calcific or resistant lesions 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 CTO-MANAGEMENT AND WIRING TECHNIQUES

77. Penetration power = tipload / tiparea CTO-MANAGEMENT AND WIRING TECHNIQUES

78. Tactile sensations F eeling of the dimple at the entry point, especially in the abrupt type of CTO entry F eeling of strong resistance when pulling back the wire inside the CTO body, —in this situation, the wire tip has most likely migrated into the subintima . F eeling of no resistance the wire tip moves freely—this most likely means that the wire tip is either in the true lumen or in the extravascular space CTO-MANAGEMENT AND WIRING TECHNIQUES

79. Anchoring wire technique Guiding catheter is unstable One wire is positioned in a prox side branch Other wire for crossing of the occlusion CTO-MANAGEMENT AND WIRING TECHNIQUES

80. Anchoring wire Side branch protection Occlusion is long/ distal to side branch Correction of tortuosities Proximal tortuosities Buddy wire technique Facilitate passage of stent in complex lesions Serves as rail support. CTO-MANAGEMENT AND WIRING TECHNIQUES

81. Double wire Parallel wire technique CTO-MANAGEMENT AND WIRING TECHNIQUES

82. 1 st wire in false channel left in situ 2nd stiffer wire advanced parallel to first wire in same path redirected to enter distal true lumen main pitfall is wire twisting each other Support catheter use, appropriate wire selection& handling –essential to avoid wire twisting Main purpose : - redirecting a wire inside body of a cto & puncturing distal fibrous cap Important prerequisite – distal vessel visualization CTO-MANAGEMENT AND WIRING TECHNIQUES

83. See-Saw Wiring CTO-MANAGEMENT AND WIRING TECHNIQUES

84. See-Saw Wiring Modification of parallel wire technique Uses 2 microcatheters or OTW baloons When first wire fails , 2 nd wire with microcatheter or OTW baloon is inserted Risk – false lumen may enlarge – procedure failure CTO-MANAGEMENT AND WIRING TECHNIQUES

85. Side branch technique CTO-MANAGEMENT AND WIRING TECHNIQUES

86. Success (1) Angle between direction in which the wire lies and the bifurcating side branch is less than 90°; (2) No diffuse plaque build-up about the true lumen in the distal portion of the CTO (3)True lumen to the ostium of the side branch, the wire must be just to the side of the true lumen in the distal part of the CTO CTO-MANAGEMENT AND WIRING TECHNIQUES

87. Open sesame technique Hard plaque Failed even with conquest pro 8-20 Side branch just in front of proximal cap Pass stiff guide wire and/ or a balloon into side branch. Distortion of geometry Enables guide wire to advance into true lumen. CTO-MANAGEMENT AND WIRING TECHNIQUES

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90. Dissection reentry techniques STAR -Uncontrolled LAST - Somewhat controlled Dedicated systems -Controlled CTO-MANAGEMENT AND WIRING TECHNIQUES

91. Subintimal tracking and rentry technique Used when attempts to recanalize true lumen failed 0.014 hydrophilic wire with J configration used( whisper,pilot ) Hydrophilic wire pushed through subintimal dissection plane When pushed distal to occlusion J tip directed to truelumen In an attempt to reenter the true lumen Successful in those with previous attempt failed High chance of perforation STAR Technique CTO-MANAGEMENT AND WIRING TECHNIQUES

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93. Knuckle wire technique Polymer jacket wire (fielder XT or pilot-200)manipulated To create wire loop – advanced subintimally across CTO OTW system advanced to this area- rentry to true lumen with a stiffer wire or pilot 200 CTO-MANAGEMENT AND WIRING TECHNIQUES

94. LAST technique To initiate subintimal angioplasty and to enter CTO body to limit long false lumens CTO-MANAGEMENT AND WIRING TECHNIQUES

95. Cross Boss catheter Metal OTW micro catheter with rounded tip to prevent vessel exit Device rotated rapidly in either direction using fast spin Can advance through the CTO without a wire in the lead Subintimal position- true lumen reentry performed Smaller subadventitial space – less likely to accumulate blood CTO-MANAGEMENT AND WIRING TECHNIQUES

96. CTO-MANAGEMENT AND WIRING TECHNIQUES

97. Sting ray balloon & guide wire system 1mm flat balloon with 3 exit ports connected to the same lumen Distal exit port – for balloon positioning Uses guide wire with extreme tapered tip (0.0025) for reentry Distal true lumen entry confirmed by contralateral injection CTO-MANAGEMENT AND WIRING TECHNIQUES

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100. RETROGRADE APPROACH Initially used after a failed antegrade approach Now used as initial strategy in challenging cases Ostial occlusion Large side branch at proximal cap Long occlusion (>30mm) Severe tortuosity or calcification Without stump Visible continuous collaterals CTO-MANAGEMENT AND WIRING TECHNIQUES

101. Collateral selection Preference - Bypass graft > septal > epicardial Selective injection of collateral Surfing technique for crossing invisible septal collateral Wiring collateral – achieved with OTW system or dedicated septal dilator(corsair) Contrast injection to assess best connection CTO-MANAGEMENT AND WIRING TECHNIQUES

102. Hydrophillic polymer jacket wire with <1mm 30-45º tip used to cross recipient artey Fielder FC,Pilot-50,Whisper, Choicept,Runthrough Wire should move freely - difficulty to advance – perforation? whipping of wire - RV or LV entry (rarely pericardium) Of no consequence if recognized before advancing OTW system Collateral dilatation using 1.5 mm balloon @ 1-2 atm or Corsair Epicardial collaterals size most important factor in wiring success should never be dilated CTO-MANAGEMENT AND WIRING TECHNIQUES

103. Antegrade crossing Simplest form of retrograde technique Retrograde wire advanced to distal cap Acts as a marker of distal true lumen Serves as a target for antegrade wire CTO-MANAGEMENT AND WIRING TECHNIQUES

104. Kissing wire Manipulation of both antegrade and retrograde wires in CTO until they meet Antegrade wire follow channel made by retrograde wire in true lumen of distal vessel CTO-MANAGEMENT AND WIRING TECHNIQUES

105. Retrograde true lumen puncture Most pure form of retrograde technique(only in 40% retro tech) Hydrophilic wire advanced to the lesion Advancement of microcatheter or OTW baloon – additional support CTO crossed retrogradely using hydrophillic wire or stiffer wire Maneuvers to enhance chance of crossing Inflating retrograde baloon - coaxial anchor Stiffer tapered tip or hydrophilic wires IVUS facilitation of retrograde wire to proximal true lumen CTO-MANAGEMENT AND WIRING TECHNIQUES

106. CTO-MANAGEMENT AND WIRING TECHNIQUES

107. Basic concept –create subintimal dissection with limited extension only at the site of a CTO. Antegrade wire advanced into CTO then to subintimal space. Retrograde wire through collateral with microcatheter to distal end of CTO - into the CTO- then to subintimal space. Baloon inflation inside CTO using small balloon over the retrograde wire in subintima Balloon inflated inside CTO To keep inflated space open deflated baloon left in subintimal space C A R T Controlled antegrade & retrograde subintimal tracking CTO-MANAGEMENT AND WIRING TECHNIQUES

108. Two subintimal dissection provide reentry space for antegrade wiring Antegrade wire advanced along deflated retrograde balloon into the distal true lumen L imited subintimal tracking (dissection) only in CTO segment Avoids difficulty of reentering distal true lumen Dilatation and stent implantation after successful recanalization CTO-MANAGEMENT AND WIRING TECHNIQUES

109. CTO-MANAGEMENT AND WIRING TECHNIQUES

110. Use smallest sized baloon inside CTO to create sufficient wire reentry space Access to distal CTO mainly via septal collatrels , by polymer jacket wire over microcatheter or otw baloon Septal channel dilatation at 1.25mm baloon at low pressure Major limitations Limited access of collateral channels to target CTO Empiric estimation of retrograde baloon size Overall unpredictable procedure time CTO-MANAGEMENT AND WIRING TECHNIQUES

111. Reverse CART technique Engage a guidewire retrogradely in the distal cap of the CTO Another wire anterogradely in the proximal cap of the CTO Retrograde wire advanced in subintimal space into CTO lesion Subintimal channel is enlarged by anterograde balloon Plaque dissection and modification of the lesion Retrograde wire advanced to cross the dissection Link up with the anterograde wire in proximal true lumen Wire externalized (Exchange length) Anterograde PCI done CTO-MANAGEMENT AND WIRING TECHNIQUES

112. CTO-MANAGEMENT AND WIRING TECHNIQUES

113. KNUCKLE WIRE TECHNIQUE Best suited for long segment of occlusion Retrograde wire usually a polymer jacket wire manipulated to form a loop at wire tip advanced in subintimal space across CTO Eg : Fielder XT or Pilot-200 Rounded wire loop advanced in subintimal space across CTO without causing perforation OTW system advanced to this area followed by attempt to reenter true lumen using a stiff wire with short bend or hydrophillic wire Eg : C onfianza Pro 12 or Pilot 200 CTO-MANAGEMENT AND WIRING TECHNIQUES

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118. Antegrade vs retrograde CTO-MANAGEMENT AND WIRING TECHNIQUES

119. Treating lesion after crossing CTO crossed by antegrade wiring (kissing wire,CART ) Antegrade CTO PCI can be done Retrograde balloon can trap antegrade wire to facilitate procedure Retrograde wire crosses to true lumen Options : Antegrade wiring Retrograde wire externalization Retrograde stent delivery DES is preferred in CTO PCI CTO-MANAGEMENT AND WIRING TECHNIQUES

120. CTO-MANAGEMENT AND WIRING TECHNIQUES

121. BVS IN CTO CTO-MANAGEMENT AND WIRING TECHNIQUES

122. APPROACH CTO-MANAGEMENT AND WIRING TECHNIQUES

123. CTO-MANAGEMENT AND WIRING TECHNIQUES

124. IVUS N avigated Wiring IVUS – Depict cross sectional view of coronary tree IVUS focus on plaque distribution, calcification, reference vessel size & side branch anatomy Applicability of IVUS in CTO PCI 1)Side branch method to navigate CTO wire into true lumen from proximal cap 2) Subintimal rentry from the proximal true lumen IVUS guided subintimal rentry – Last resort for getting a subintimal wire into distal true lumen A pplicable even after losing site of distal vascular bed on angio CTO-MANAGEMENT AND WIRING TECHNIQUES

125. 1.5-2mm baloon dilatation in presumed subintimal space IVUS is advanced into the space monitored to orient 2 nd wire to true lumen Key points Ability to translate cross sectional image into 3D needed 2 nd stiff tapered wire over micro catheter - 8f guide mandatory Reentry point should be closer to proximal cap Contrast injection should be withheld esp after small ballon dilatation CTO-MANAGEMENT AND WIRING TECHNIQUES

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128. Forward looking IVUS CTO-MANAGEMENT AND WIRING TECHNIQUES

129. Forward looking IVUS CTO-MANAGEMENT AND WIRING TECHNIQUES

130. Forward looking IVUS CTO-MANAGEMENT AND WIRING TECHNIQUES

131. Optical coherence reflectometry CTO-MANAGEMENT AND WIRING TECHNIQUES

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135. n CTO-MANAGEMENT AND WIRING TECHNIQUES

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