The language of CTO
interventions – what it
all means
Dr Angela Hoye
Senior Lecturer in Cardiology
Hull & East Yorkshire Hospitals
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..............
Why do we open CTOs?
Improved symptoms
Improved exercise capacity
Improved LV function
Reduced need for CABG
(Improved survival (?))
• Explosion of interest!
CTO`s!
• Try to explain/simplify some of the
language used during CTO angioplasty
1.Discuss the design and use of some of the
specialised devices
2.Focus on the techniques
• antegrade
• retrograde
• 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
Tip load: Weight needed to be applied to
bend / buckle the tip of the guide wire
<1g
Stiff:
≥4.5g
3g
4.5g
Flexibility
Intermediate: ~3g
More
Floppy:
6g
12g
Less
Less
Support
More
Stiff wires especially when combined with a
tapered tip increase penetration power but also
increase the risk of perforation
• Examples:
Wire
Tip load (g)
Size of tip
Fielder FC
1.6
0.014”
Fielder XT
1.2
0.009
Miracle 6
≈6
0.014”
Confianza 9
8.6
0.009
Confianza Pro 9
9.3
0.009
Confianza Pro 12
12.4
0.009
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
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
Wiring techniques (antegrade approach)
→ Parallel wires / seesaw
Mitsudo et al J Inv Cardiol 2008
• Eg. Balloon support, parallel wire technique, use of
simultaneous coronary injection
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)
Fujita et al Catheterization and Cardiovascular Interventions 59:482–488 (2003)
STAR: “subintimal tracking and re-entry”
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
Case example
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)
• What about “backwards”?
–
–
–
–
–
Kissing wires
CART
Reverse CART
Knuckle wire technique
“rendezvous”
etc etc.................
• Principle of the retrograde technique
Antegrade
wire
Retrograde wire
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
• Kissing wires
• What about the CART technique?
“controlled antegrade
and retrograde
subintimal tracking”
Surmely et al J Invasive Cardiology 2006
• 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
• 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
CART
“localised”
dissection
STAR
“long”
dissection
Reverse CART:
Surmely et al J Invasive Cardiology 2006
Rathore et al J Am Coll Cardiol Intv 2010;3:155– 64
• Knuckle wire:
Galassi et al Clin Res Cardiol (2010) 99:587–590
“Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010
“Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010
“Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010
“Rendezvous in coronary” technique
Muramatsu et al J Invas Cardiol 2010
• “Reverse anchoring technique”
Matsumi et al Catheterization and Cardiovascular Interventions 71:810–814 (2008)
IVUS
• All these techniques can be facilitated with
adjunctive IVUS
– Help identify the entry point into the occlusion
– Help direct a stiff wire to penetrate from the
sub-intima back into the true lumen
– Guide and optimise the result of stenting
Summary & Conclusions
• Recent advances in CTO angioplasty have
increased the rate of successful recanalization
• In contemporary practice CTO PCI involves a
range of specialised devices
• Specialist techniques may involve both an
antegrade and retrograde approach with the
aim of passing the wire from the proximal to the
distal true vessel lumen
• In “expert” hands, these techniques have a
good success rate (and low complication rate)
Thankyou!