Antegrade dissection re-entry step

by step

EuroCTO Club

September 30, 2016

Emmanouil S. Brilakis, MD, PhD

Minneapolis Heart Institute

Adj. Professor of Medicine, UT Southwestern

14.00-14.30

ES Brilakis: Disclosures

Consulting/speaker honoraria: Abbott

Vascular, Asahi, Cardinal Health, CTI,

Elsevier, GE Healthcare, St Jude

Medical

Employment (spouse): Medtronic

Grants: InfraRedx, Boston Scientific

VA - I01-CX000787-01

VA CSP#571 – DIVA

CTO dissection/re-entry

strategies

Antegrade Retrograde

Dissection

Re-entry

Dissection

Re-entry

Knuckle wire

CrossBoss

•STAR

•Contrast-guided STAR

•mini-STAR

•LAST

•Stingray

Knuckle wire

CART

Reverse CART

Michael et al

Circ Intv 2012

1 2

34

Extensive dissection/re-entry long-term outcomes

Brilakis, Grantham, Rinfret, Wyman, Burke, Karmpaliotis, Lembo, Pershad,

Kandzari, Buller, De Martini, Lombardi, Thompson. JACC Intv 2012

Antegrade dissection/re-entry: WHEN?

Nagoya Heart Center

Asian-Pacific CTO Club Algorithm

www.crossbossfirst.org

Ratchet Handle for FAST-Spin Technique

Atraumatic 1 mm Distal Tip

CrossBoss Knuckle wire

Polymer-jacketed

guidewire

Dissection

How to form a knuckle

Wire: Fielder XT – Fighter -Pilot 200

Tip: umbrella handle or no shaping

Movement: PUSH (hard!)

Do NOT turn

Step 1: get to proximal cap

Step 2: torquer positioning

2 fingerbreadths

Step 3: SPIN (fast!)

CrossBoss does not advance: ↑ guide catheter support,

Guideliner, knuckle wire, use stiff wire

Any direction is fine

Step 4: Assess!

A

B

C

BridgePoint Procedure

Step 5A: wire + stent

A

Case 1

RCA

CTO due

to ISR

ASSESSMENT

Target vessel: RCA

Proximal cap: clear

Length: ~50 mm

Distal vessel: good landing zone before

the bifurcation

Collaterals: Septal, epicardial

PLAN

1. ADR (Crossboss)

2. Retrograde

CrossBoss

with Sion

Blue

Wire inside

CrossBoss

Crossing

with

CrossBoss

CrossBoss

confirmed

in true

lumen

Confirmed

in RAO

Cranial

Final result

Procedure time: 65 min

Fluoroscopy time: 14.6 min

AK dose: 0.348 Gray

Contrast: 200 mL

N=31 CTOs - Procedural success: 90%

N=6

Procedural success: 83%

Step 5B: Re-enter

B

1) Use Stingray LP

2) Aspirate first

3) “stick and swap” (especially in

diffusely diseased vessels)

4) Orthogonal view for re-entry (good

balloon preparation)

5) Minimize area of dissection (using

CrossBoss)

6) select optimal re-entry location

(horizontal part of RCA)

Facilitating Stingray Re-entry

Stick and Swap – 1

Stingray wire –

or Gaia 2nd/3rd

Stiff wire cannot track into diffusely diseased vessel

Stingray

wire

removed

Stick and Swap – 2

Polymer

jacketed wire –

Pilot 200 -

Gladius

Polymer-jacketed wire tracks distal vessel

Stick and Swap – 3

Stingray Re-entry

Orthogonal view

railroad tracks

1) Aspirate through Stingray balloon

2) STRAW

3) Double blind stick and swap

4) Bobsled

5) Retrograde

What to do for subintimal hematoma

STRAW: Subintimal TRAnscatheter Withdrawal

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

LCX CTO

ASSESSMENT

Target vessel: LCX

Stump: Tapered

Length: ~20 mm

Distal vessel: Bifurcation

Collaterals: Ipsilateral

J-CTO score: 2

Stump: 0

Length: 0

Calcification: 1

Tortuosity: 1

Previous attempt: 0

CrossBoss

Some

progress

Crossed

Confirmed

Corsair

with a Sion

Blue

Stingray to

open OM

1st

Re-entry

with “stick

and swap”

Stingray

with Pilot

200

Predilation

Kissing

balloons

3.0x38 mm

DES

Postdilation

Final result

Procedure time: 73 min

Fluoroscopy time: 29.7 min

AK dose: 1.608 Gray

Contrast: 100 mL

Step 5C: Redirect

C

RCA

CTO

Case 2

RCA

CTO

Case 2

CrossBoss

into side

branches

Knuckle

for

advancing

Case 2

In distal

cap now

Case 2

Stingray

Case 2

Are we in?

Case 2

Case 2

Restick

Case 2

IVUS 2

Case 2

RCA CTO

Retrograde

failed

Proximal

cap??

Lateral

Confianza

Pro 12

“scratch

and go”

Aka

“move the

cap”

Proximal

dissection

1.5x8 mm

anchor

Knuckle

started

Distal RCA

ISR

Wire is out!

CrossBoss

Pilot 200

Some

progress..

Getting

closer..

Going the

wrong

way…

Gaia

redirection

Gaia

redirection

Threader

1st line

2nd line

Brilakis ES. Manual of coronary CTO interventions. Elsevier 2013

Approach to “balloon uncrossable” CTO

“Balloon Uncrossable” CTO

• Inflate 1.20-1.5 mm balloon, Threader, Glider

• Rupture balloon in vessel (grenadoplasty)

• Tornus, Corsair, Finecross

• Wire “cutting”

• Guide catheter extensions

• Anchor balloon strategies

• Laser

• Rotational atherectomy

• Subintimal: external “crush” - retrograde

• Subintimal: distal anchor

combinations

3rd line

4th line

Sticking UP

Sticking

down

Swap

Confirm 1

Confirm 2

IVUS post crossing

Final

IVUS after stenting

RAO

Case 3

Hybrid CTO crossing algorithm

Brilakis, Grantham, Rinfret, Wyman, Burke, Karmpaliotis, Lembo, Pershad, Kandzari, Buller, De Martini,

Lombardi, Thompson J Am Coll Cardiol Intv 2012;5:367-379

Knuckle

started

Fielder XT

Stuck!

Carlino

Next step?

Aggressive

knuckle

Gaia 2nd

Stick down!

Stick up!

Swap

Orthogonal

view

Final

Contrast: 450 mL iodixanol

AK dose: 5.8 Gray

Fluoro time: 56.9 min

Antegrade crossing

Finecross

Pilot 200

Finecross and 1.5 mm balloon: No crossing

Subintimal wiring

2nd wire

“Subintimal” Distal Anchor

Subintimaldistal

anchor

Final result

COMPLICATIONS

STAR

After

balloon

Fielder XT

Stuck…

Parallel

wire

Crossed?

Visconti G, Focaccio A, Donahue M, Briguori C. CCI 2015;85:382–390

Spontaneous echo contrast

Visconti G, Focaccio A, Donahue M, Briguori C. CCI 2015;85:382–390

Spontaneous echo contrast

2.5 x 28 mm EES x 2

2.75 x 28 mm EES x 1

2.75 x 23 mm EES x 1ADR

Baseline

Final

Final

8-month angiographic follow-up

Patient asymptomatic

1/2012 to 6/2016

15 centers, 1,810

lesionsTechnical success: 88%

Major complications: 2.5%

•Appleton Cardiology, WI

•Baylor Heart and Vascular Hospital, TX

•Columbia University, NY

•Central Arkansas VAMC, AR

•Dallas VAMC/UTSW, TX

•Henry Ford Hospital, MI

•Massachusetts General Hospital, MA

•Medical Center of the Rockies, CO

•Minneapolis VAMC, MN

•PeaceHealth St. Joseph MC, WA

•Piedmont Heart Institute, GA

•San Diego VAMC and UCSD, CA

•St Luke’s Mid America Heart Institute, MO

•Torrance Medical Center, CA

•UPMC Medical Center, PA

49%

24%

27%

Antegrade wiring

Antegrade dissection/re-entry

Retrograde75.9%

34.6%39.9%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Techniques Used

Antegrade

Antegrade DR

Retrograde

Successful technique

PROspective Global REgiStry for the Study of CTO interventions

0.6% mortality, 0.9% MI

0.8% pericardiocentesis, 0.2% stroke

0.1% CABG, 0.2% re-PCI

J-CTO score and CTO PCI

approach

PROspective Global REgiStry for the

Study of CTO interventions

J-CTO score validation

Procedural time and J-CTO

score

1/2012 to 7/2014

6 centers, n=650

lesions

Christopoulos, Wyman, Alaswad, Karmpaliotis, Lombardi, Grantham, Yeh, Jaffer, Cipher, Rangan,

Christakopoulos, Kypreos, Lembo, Kandzari, Garcia, Thompson, Banerjee, Brilakis

Circ Cardiovasc Interv 2015;8:e002171

N=1313

11 US centers

ADR=458 (34.9%), ADR after exclusion of retrograde cases=248 (32.3% of 767

antegrade-only cases)

Complications 2.9 vs. 2.2% all cases, 1.5 vs. 0.6% antegrade-onlyDanek, Karatasakis, Karmpaliotis, Alaswad, Yeh, Jaffer, Patel, Bahadorani, Lombardi, Wyman, Grantham, Doing,

Moses, Kirtane, Parikh, Ali, Kalra, Kandzari, Lembo, Garcia, Rangan, Thompson, Banerjee, Brilakis.

Int J Cardiol 2016

Antegrade Dissection Re-entry

PROspective Global REgiStry for the Study of CTO interventions

89.9 87.0

93.2 91.8

70

80

90

100

Technical success Procedural success

%

ADR Non-ADR Δ=3.3%

P<0.01

89.9 87.0 93.2 91.8

70

80

90

100

Technical success Procedural success

%

ADR AWE-only

Antegrade-

only cases

All cases

Δ=5.7%

P<0.01

Δ=2.3%

P=0.23

Δ=1.5%

P=0.43

PROspective Global REgiStry for the

Study of CTO interventionsRetrograde vs. antegrade-only: in-hospital MACE

4.3

2.1

0.4

1.3

0.60.8

1.1

0.3 0.3 0.30.1 0.1

0

Com

plic

atio

n ra

te (%

)

Retrograde

Antegrade-only

p<0.001

p=0.003

p=0.999

p=0.039

P=0.314

p=0.167

UK Hybrid CTO registry

7 centers

2012-2014

1,156 pts

30-day MACE: 1.6%

Martinez-Rumayor et

al. JACC Intv 2012

How CTO

equipment can

help in non-CTO

cases!

ADR gives you (safe) options

Options are good for life and

CTO PCI!

hence…

ADR is good!!!

1.Subintimal dissection/re-entry

techniques have revolutionized CTO

PCI (success + efficiency) – critical

part of the hybrid algorithm

2.ADR safer than retrograde

3.No increased risk for restenosis

Conclusions