Α Δ. ΜΑΤΡΟΓΙΑΝΝΗ ΚΑΡΔΙΟΛΟΓΟ · In-hospital outcomes of percutaneous coronary...

Α-Δ. ΜΑΤΡΟΓΙΑΝΝΗ

ΚΑΡΔΙΟΛΟΓΟ

AIMOΔΤΝΑΜΙΚΟ ΕΡΓΑΣΗΡΙΟ

Γ.Ν.Θ. «Γ.ΠΑΠΑΝΙΚΟΛΑΟΤ»

ΘΕΑΛΟΝΙΚΗ

Disclosures

None whatsoever…

Stone GW. Et al.

Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I.

Circulation . 2005 Oct 11;112(15):2364-72.

“…can we fix it? ”

“ Yes we can !!! ”

Bob the Builder

children's animated television hero

Number of Procedures in the European

Registry on CTO (ERCTO)N

o o

f pro

cedure

s

Galassi AR et al.

In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from

the ERCTO (European Registry of Chronic Total Occlusion) registry.

EuroIntervention. 2011 Aug;7(4):472-9.

Δῶς μοι πᾶ στῶ καὶ τὰν γᾶν κινάσωAρχιμήδης ο Συρακούσιος (περ. 287 π.Χ- περ. 212 π.Χ.)

sheaths

catheters

wires

balloons

microcatheters

dedicated devices

IVUS

other…

RevascularizationAdvanced Strategies and Technique

…from scratch: sheaths and catheters

Additional considerations

Long Guides

vs

Short Guides

Long sheaths

vs

Standard

Passive support

vs

Active support

Armoured

vs

Non-armoured sheaths

PRO CONAll TRA Cannot always trap Corsair

Less bleeding All ADR over long wires

Less support

Corsair and trap No Stingray and trap

Stingray and trap

Corsair+branch anchor+trap Usually TFA

Stingray and trap Uncomfortable

Real time IVUS guidance Bleeding

7 FR

6 FR

8 FR

Wired…Guide Wire Clinical Segmentation

During the course of CTO therapy, a variety of diverse

guidewires are needed to manage both CTO crossing and

subsequent lesion treatment

Guidewire Anatomy: the essentials

Tip styles

Core tapers &

materials

Core diameter

Coils & covers Coatings

CTO Guidewires: the hallmarks

Tip styles: core-to-tip/ sometimes tapered

Coils and covers: some favor increased radiopacity;

jointless coils for improved torque response; polymer covers

for selected applications (e.g. ISR, calcified lesions, micro-

channels)

Core tapers and materials: shorter tapers for improved

torque response/ generally stainless steel

Core diameters: larger for increased support and torque

response

Coatings: hydrophilic for tracking (body) and hydrophobic for

torque response (esp. near tip)

Guidewires: Core Taper

Longer taper

Shorter taper

Guidewires: Penetration Power

Area of GW Tip

(Guide Wire Tip)

Tip Stiffness / Area of GW Tip

.004kg/ (3.14*.006”²)

PROGRESS 40

( Area = )

r

Guide Wire ManufacturerTip Stiffness

(load) (g)

Tip

Diameter

Penetration Power

(Kg/in²)

Fielder XT Asahi 1.2 g .009" 19 (polymer cover)

Cross-It 100 XT Abbot 1.7 g .0105" 20

Miracle Bros 3 Asahi 3.9 g .0125" 32

Miracle Bros 4.5 Asahi 4.4 g .0125" 36

PROGRESS 40 Abbot 4.8 g .012" 40

Cross-It 200 XT Abbot 4.7 g .0105" 54

Cross-It 300 XT Abbot 6.2 g .0105" 72

Miracle Bros 6 Asahi 8.8 g .0125" 72

PROGRESS 80 Abbot 9.7 g .012" 80

Cross-It 400 XT Abbot 8.7 g .0105" 101

Miracle Bros 12 Asahi 13 g .0125" 106

PROGRESS 120 Abbot 13.9 g .012" 120

Confianza 9 Asahi 8.6 g .009" 135

PROGRESS 140 Abbot 12.5 g .0105" 140

Confianza Pro Asahi 9.3 g .009" 146

Confianza Pro 12 Asahi 12.4 g .009" 195

PROGRESS 200 Abbot 13 g .009" 200

Guidewire Stiffness: effect of Microcatheters

Tip Stiffness according to the length extending from the tip of a Microcatheter

Guidewires: Covers and Coatings

Tactile feedback

No Coating

Hydrophobic Coating

Hydrophilic Coating

Polymer Cover with

Hydrophilic Coating

Guidewire: Performance Characteristics

Primary

•Torque transmission (steering)

•Tip Stiffness

•Lubricity

•Support

•Visibility / Markers

Secondary

•Penetration vs Safety

•Shaping and Shape Retention

•Durability

•Prolapse / Tracking

•Tactile Feedback

Workhorse Access Support CTO wires

CTO guide wire milestones

1999

GUIDANT HT CROSS-IT XT

Tapered Tip Design

2008

1995

ASAHI Fielder XT

Polymer Covered Tapered

Guide Wire

SCIMEDChoice PT

1st Polymer Covered GW

ASAHI Miracle

1st Dedicated CTO spring

coil GW

TERUMOCrosswire

1st Nitinol

Hydrophilic

CTO Guide

Wire

2009

ABBOTT PROGRESS

Polymer Sleeve CTO GWi

incorporating Penetration

Power

1996

ASAHIConfianza/Pro

Tappered hydrophilic

wires

2010/11

ASAHI SION

Fielder XT-A/R

TipDouble Coil GW

CTO toolbox

wires•4 Wire Platform

•Tapered soft (~1gram) hydrophilic guidewire

•Antegrade microchannel/soft plaque

probing

•Knuckle wire technique

•Non tapered, plastic jacketed low gram force wire •Retrograde collateral workhorse wire

•Non tapered, high gram force plastic jacketed wire

•Lesion crossing

•Facilitation of wiring in complex and/or

dissection

•High gram force (12g+), tapered penetration wire

•Lesion crossing

Fielder FC/ Fielder XT

Fielder XT: precise tip shaping due to its short

soldering tip

before shaping after shaping

Spinning out of control: Torque Whip

Fielder XT-R: revolution

Spring coil

Rope coil

“Composite core” ~ Rope coil in spring coilSame as SION family

More torque ability

Tip durability

Sion Blue/ Sion

New Guide Wire for Epicardial Channel Tracking

Gaia Wires

Gaia First

Gaia Second

Gaia Third

Coated with a hydrophilic coating that enhances smooth controllability inside

the micro catheter

Wire for circumferential technique

reverse CART technique

tip load 3.00 gr

coil 8cm

diameter .010"

length 330 cm

Fielder XT-R/ A long

Viper

Rota

any wire long enough

Small O.D/ OTW microcatheters: Finnecross stainless steel braid structure

hydrophilic coating

PTFE inner layer

tapered diameter

catheter length 130 cm / 150 cm

optimal guidewire support

Septal Crossing and Support Catheter: Corsair

tapered soft polyurethane tip

20 cm screw head structure

hydrophilic polymer coating

PTFE inner layer

Septal Crossing and Support Catheter: Corsair

The advantage of Corsair

Channel Tracking

excellent cross-ability through collateral channel

no need of channel dilatation (less injury)

better support for tortuous channel tracking

expanded indication for epicardial channel

Retrograde Wiring of CTO

excellent support for wire manipulation

good cross-ability into/through the occlusion

enabled usage of 300cm wire or snare wire

Corsair : Extraordinary trackability

Would you believe that this epicardial channel

can be crossed without perforation?

Standard Retrograde Approach with Corsair

Collateral channel tracking

Advancement of channel dilator

Reverse CART (w/wo IVUS)

Externalization of 300 cm wire

Antegrade balloon/stent through the reversed 300 cm wire

Dedicated devices in the ERCTO trial

Galassi AR et al.

In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from

the ERCTO (European Registry of Chronic Total Occlusion) registry.

EuroIntervention. 2011 Aug;7(4):472-9.

know the limits of your hardware

Just screw it ! : Tornus tip: blunt/ platinum

main shaft: coreless/ 8 SS wires

polymer sleeve: prevents blood leakage

hub connector: saline flushing

The advantage of Tornus

passes through tight lesions

facilitates guidewire exchange

provides guidewire back up support

provides anchor effect

Lesion crossability

Flexibility

TORNUS

TORNUS

PRO

TORNUS

88 FLEX

GW maneuverability

Inner lumen

TORNUS

TORNUS

PRO

TORNUS

88 FLEX

Chimera: the Hybrid Approach

Hybrid Approach: asking the 4 key questions

Is the proximal cap clear or ambiguous?

Quality of the distal vessel

CTO length < or ≥ 20mm ?

Suitability of contralateral collaterals (accesible)

All cases are planned in anticipation

of both antegrade and retrograde approaches

Brilakis ES et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions.

JACC Cardiovasc Interv.2012 Apr;5(4):367-79.

CROSSBOSS multi wire coiled shaft

FAST SPIN technique

atraumatic distal tip advanced

across a CTO ahead of GW

OTW .014” GW compatible

STINGRAY self orienting flat balloon

180° opposed/ off seting exit ports

2 radiopaque marker bands

hydrophillic coated balloon shaft

GW with angled tip/ distal probe

The FAST CTO Trial:CTO characteristics

Whitlow PL et al.

Use of a novel crossing and re-entry system in coronary chronic total occlusions that have failed standard

crossing techniques: results of the FAST-CTOs (Facilitated Antegrade Steering Technique in Chronic Total

Occlusions) trial.

JACC Cardiovasc Interv.2012 Apr;5(4):393-401.

The FAST CTO Trial:compared to other CTO IDE trials

Whitlow PL et al.

Use of a novel crossing and re-entry system in coronary chronic total occlusions that have failed standard

crossing techniques: results of the FAST-CTOs (Facilitated Antegrade Steering Technique in Chronic Total

Occlusions) trial.

JACC Cardiovasc Interv.2012 Apr;5(4):393-401.

CTO Devices – FDA Approved

CTO

DevicesFDA approved

Safe Cross (RF)

Guidewire

Frontrunner

(Mechanical) Catheter

New Devices for Chronic Total Occlusion

PRIMA (Laser)

Wire

Crosser (Vibration)

CatheterBridgePoint CrossBoss & Stingray Devices

FAST-CTOs Study

New Devices for Chronic Total Occlusion Novel Approach to CTO Under Investigation

Thrombolytic therapy

• Therapeutic UltrasoundSonicross SystemUltrasound wire

Collagenase infusion

• Lumen Re-entryPioneer catheter

• Penetration deviceTornus, Corsair

• Vibrational/Acoustic DevicesOmniWave,Resolution

• Magnetic navigationCronus wire

Guided Recanalization of CTOs: IVUS

false lumen

guide wire

true lumen

OCT-assisted orientation: Ocelot

Schwindt A. et al.

Crossing chronic total occlusions with the Ocelot system: the initial European experience.

EuroIntervention.2013 Nov 22;9(7):854-62

CTOs: the final frontier…

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