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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…
Καλά ΧριστούγενναΚαλά Χριστούγεννα