10:05 Gershlick - The kit

Department Academic Cardiology

Tony GershlickProfessor of Interventional Cardiology

University Hospitals of Leicester UK

Madrid 2014

Chronic Total Occlusions : The kit

National Institute for Health Research, Leicester Cardiovascular Biomedical

Research Unit

Methods

• Analysis of the UK Central Cardiac Audit Database

• Procedures between Jan 1st 2005 – Dec 31st 2009• 326 398 PCI procedures• 15 492 elective CTO procedures on 13 443

patients• Mortality data from the Medical Research

Information Service (MRIS)

Successful revascularisation is associated with reduced mortality

Pandora's box is an artifact in Greek mythology, taken from the myth of Pandora's creation in Hesiod's Works and Days.

The "box" contained all the evils of the world.

Impelled by her curiosity (given to her by the gods ), Pandora opened it and all evil contained therein escaped and spread over the earth. She hastened to close the container, but the whole contents had escaped;

THE CTO PCI TIME LINE

Techniques for chronic total occlusion (CTO) recanalisation.

Smith E J et al. Heart doi:10.1136/heartjnl-2013-304521

Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Date of download: 11/10/2013

Copyright © The American College of Cardiology. All rights reserved.

From: A Novel Modification of the Retrograde Approach for the Recanalization of Chronic Total Occlusion of the Coronary Arteries: Intravascular Ultrasound-Guided Reverse Controlled Antegrade and Retrograde Tracking

J Am Coll Cardiol Intv. 2010;3(2):155-164. doi:10.1016/j.jcin.2009.10.030

Schematic Diagram Showing Use of Snare Wire(A to D) Showing the use of snare wire to keep the subintimal space open after antegrade balloon dilation and intravascular ultrasound (IVUS) confirmation; (E) retrograde wire crossed to the antegrade true lumen. Right arrowhead ( ) indicates distal ▶lumen and left arrowhead ( ) indicates proximal lumen.◀

Figure Legend:

The Kit to get you by

ACT every 30 mins

>> 250 secs

No ReoPro till end

300

The hybrid algorithm for chronic total occlusion percutaneous coronary intervention (CTO PCI).

Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Wires

Wires

Fielder FC

Fielder SION SION blue

XT XT-R ULTIMATEblos3

1mm

Shaping of the Wire Tip

My next 30 slides on wires

- Beyond Fielder XT -• Anti kinking structure• Higher torque performance with W core

Tip loadXT-A = 1.0g XT-R = 0.6g

PTFE Coat

・ Length over all ; 1900・ Coil length ; 160・ Radio paque ; 160

Unit ; (mm)

straight

taper3010

0.014Inch

Urethan + Hydrophilic Polymer Coat

0.009Inch

Fielder XT 　

• Uni-body core with long, smooth taper from support region to tip

• Hydrophilic-coated, polymer sleeve and tip• Intermediate wire with slightly stiffer tip• Crossing performance of polymer tip with visibility of

spring tip

PT Graphix™ Guide Wire

0.014InchHydrophilic Polymer Coat

PTFE Coat

Rope

Unit ; (mm)

・ Length over all ; 1800・ Coil length ; 280・ Radio paque ; 30

Actone

Sion

Abbott –Progress Wires 40-80-120-140-200

0.014“

Hydrophilic Coating

17cm Radiopaque Spring Coil

0.008“

Stainless Steel Core PTFE Coating

0.014“

Confianza Pro 8-20

Tip Load: 20GRadiopacity length: 17cmOutside Diameter:

0.014inchTip outside Diameter: 0.008inch

*Product not available in Europe

Micro cone. enables easy creation of an entry route into hard fibrous cap. almost needle like. The tip loads are low, 1.7 on the first, 3.5 on the second and 4.5 on the third but have the penetrative power of the higher tip miracles.Gaia also is part of the new Sion Tecc range so has 1 - 1 torqueThe shaft thickness are different from 1 st through to 3 rd and the tapers and tip diameter differ on each wire. The Gaia allows you to steer your way through a CTO using rotational deflection, you can change your direction if you get stuck and try a different path, the wire is designed to stay in the true lumen.

Micro-catheter

Finecross ®

TEIS

Improve wire pushabilityConcentrate rotating forcefor better wire control

Superior device passage for the next option

1. 2.

Clinical benefits of Finecross® MG

3.

Micro-catheter for wire support & exchange

Trapping balloon

Wire supported by micro-catheter Need to exchange for a balloon

20 atmos

Specialty Catheter designed for guide wire support and exchange

The Tornus specialty catheter, with its braided stainless steel construction, is designed to enable guide wire exchange and support.Braided Stainless Steel Catheterfor outstanding support and pushability 1mm Distal Radiopaque Markerfor easy visualization of the distal tip Tapered Tipdesigned to facilitate access to challenging lesions

Asahi Tornus ®

The hybrid algorithm for chronic total occlusion percutaneous coronary intervention (CTO PCI).

Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

IVUS to identify entry point

IVUS Findings: Perforation

Optimizing Circular Ring Arrays for Forward-Looking IVUS Imaging : Tekes 2011

C7 Dragonfly™ Intravascular Imaging Catheter

•Non-occlusive flush action eliminates the need for occlusion balloon •Extreme Resolution imaging based on OCT technology •Low-profile minirail tip for fast placement •Hydrophilic coating reduces drag •Dual marker bands for precise positioning •Compatible with standard 0.014” steerable guidewires •Imaging speed up to 25 mm

The hybrid algorithm for chronic total occlusion percutaneous coronary intervention (CTO PCI).

Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Tracks via FAST SPIN technique •Spin should reduce push required •Highly torqueable shaft

0.014" guidewirecompatible (OTW)

Atraumatic 3Frounded distal tip

2.3F shaft profile

The CrossBoss™ CTO Catheter

Balloons: Falcon CTO Balloon RX/OTW 1.00mm

Falcon CTO is a small diameter 1.00mm designed for Chronic Total Occlusions.

Technological Innovations Low entry profile (0.016”) facilitates lesion

access Tapered 4.5mm tip crosses the lesion first Up to 15 atm RBP and a variety of lengths offer

many treatment optionsProprietary Shaft Shaft maintains efficient transmission of push Tack-welded inner tube enhances trackability

and pushability4.5-mm Elongated Tip Tapered tip navigates tortuous anatomy Flexible design enhances steerability

Low-entry profile tip (0.016”) provides excellent tip-to-wire transition

4.5-mm tip crosses the lesion prior to balloon

1.35 mm at 15 atm provides access for a wide range of treatment options

No accordion effects while crossing and recrossing arteries

Test data on file at Medtronic Inc. Bench test results may not be indicative of clinical results

Crossing Semi-Compliant

Falcon CTO is a small diameter 1.00mm designed for Chronic Total Occlusions.

Product SpecificationsCatheter design: RX OTWBalloon material: Flexitec PFBalloon coating: LFC hydrophilic coatingBalloon marker: 1 or 2 swaged (zero profile)

platinum iridiumShaft diameter: OTW: distal 2.2 F; proximal 3.3 F

RX: distal 2.2 F; proximal 2.0 FUsable shaft length: 145 cm and 160 cmMaximum recommended guidewire: 0.014” (0.36 mm)

Low-entry profile tip (0.016”) provides excellent tip-to-wire transition

4.5-mm tip crosses the lesion prior to balloon

1.35 mm at 15 atm provides access for a wide range of treatment options

DCRthisslide

Balloons: Falcon CTO Balloon RX/OTW 1.00mmCrossing

The hybrid algorithm for chronic total occlusion percutaneous coronary intervention (CTO PCI).

Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Getting the retro-grade wire into the antegrade Guide catheter

Odds and Ends

CPS Venture® Wire Control Catheter

Can knowing (and being expert with ) the available kit make a difference ?

• Observational study• 483 participants with CTO• Selection of patients based on symptomatic angina, evidence

of viability and ischaemia in CTO territory (CMR, MPS, exercise stress echo)

• Classification of lesion complexity using J-CTO score• Success determined within 2 time periods: - Period 1: April 2003 – October 2008 - Period 2: October 2008 – May 2012

Sysreloudis D et al. Heart 2013; 99: 474-479

Technique Period 1 Period 2Corsair microcatheter for antegrade/retrograde support

No Yes

7F guiding cathtetrs allowing trapping balloon use No YesReverse CART and wire escalation, retrograde knuckled wire for controlled subintimal dissection

No Yes

7-8Fr Antegrade catheters Rare RoutineAnchoring balloon Rare RoutineLong femoral sheath Rare FrequentContralateral injection Routine Routine

Parallel wire technique Frequent FrequentStingray Catheter for distal re-entry No Rare (bail-out if

no retrograde option present)

Wire “sliding “ with tapered soft wire Rare Routine as start of an antegrade approach

Sysreloudis D et al. Heart 2013; 99: 474-479

Lesion complexity characteristics

Sysreloudis D et al. Heart 2013; 99: 474-479

Success rates by procedural complexity

Sysreloudis D et al. Heart 2013; 99: 474-479

Keep it simple if possible

Become familiar with particular kit and use frequently

Be aware of device options

Don’t get carried away

A series of escalating wires

IVUS

Micro-catheter /Corsaire

Guideliner/Guidezilla