Experts "Live" CTO Workshop 2014 26th Septemper 2014 in Madrid, Spain

1. Optimizing Collateral Crossing
The Experts „Live“ Workshop 2014
Session 3
AN INITIATION TO RETROGRADE TECHNIQUES
25 Sept 2014, 15:05 - 15:20
Prof Georgios Sianos, MD, PhD, FESC
Department of Interventional Cardiology, AHEPA University Hospital,
Thessaloniki , Greece

2. Collaterals in RCA occlusion
Pathways and Functional Significance of the Coronary Collateral Circulation
David C Levin, Circ 1974;50:831-837
Collaterals in LAD occlusion
Pathways and Functional Significance of the Coronary Collateral Circulation
David C Levin, Circ 1974;50:831-837

3. Collateral Connections
RAO Caudal Projection
Septal
Septal-Septal
Epicardial- Dg
Epicardial-Apical
Conus-Septal
Epi (OM to Dg or Dg to Dg)
Yamane TCT 2014

4. Collateral Connection Grades in Septal Channels
CC 0 : no visible connection
CC 1: thread-like, but visible connection, mild torturosity and
mild cork-screw morphology
CC 2: clearly defined visible channel, mild torturosity and mild
cork-screw morphology
(Werner G. Circ 2003)

5. ”Collateral Connection Size“ (CC)
Septal pathways in 44%, epicardial in 32%
CC0 14% CC1 51% CC2 35%
B
D E
A C
F
AB C
Werner et al. Circulation 2003;107:1972-7

6. Corkscrew-like
Inextensible/
Stenosis
Length Applicability Distensibility
Epicardial Significant Potential Long Modest(>35%) Undilatable
Atrial Moderate Occasional Long Low(<10%)
Undilatable
Septal Moderate∽Mild Rare Short High(>60%) Dilatable
Modified from O. Katoh: CCT 2008: Retrograde for CTO Course
Characteristics of specific channels-not
all the same

7. Predictors of Retrograde failure
Rathore S, Katoh O, et al, Circ Cardiovasc Intervent. 2009;2:124-132

8. View angle in Septal Channels
 RAO cranial view: good for checking the origin of the septal
channel
 Pitfalls continuing channel crossing with this view
 Notice non-orthogonal view for the junction point
 RA0 caudal view: mandatory to check the anatomy of the body
and the junction point
 Single view is inadequate to check the anatomy
 Rotational angiography

9. View Angle and Issues in Other Channels
optimal view angles issues
epicardial
(RV channel)
•RAO (cranial)
•APcranial for connection to LAD
•most tortuous channel
•many side branches
•invisibility of channel during wiring
•shape-changeable channel by heart
beating
•step by step approach
PL channel
• RAO/ AP cranial (LCx-RCA, Dx-DX/LCx)
• LAO(cranial/ caudal) for PL channels
located in anterolateral wall
tortuous feeding artery
atrial
•LAD (cranial)
•RAO cranial
•RAO/AP caudal for checking origin of
feeding artery
•difficult to access feeding artery
•most fragile channel

10. CC crossing-Tip Injection

11. Tip injection – Epicardial Collateral

12. Tip injection – Epicardial Collateral

13. CC crossing-”septal surfing”

14. Septal Surfing

15. CC crossing-unexpected passage

16. Septal Surfing
• Septal surfing is useful for saving time
• Try to slide the wire through gently, avoid buckling, avoid loops,
follow with the micro-catheter
• Do not persist on a specific pathway
• The wire must move quickly with changing directions towards the
orientation of the target vessel
• The wire tip shaping is less acute bending compared to the targeted
collateral crossing after tip injection
• Tapered wires should not be used for SS
• Invisible channels are sometimes crossed with septal surfing.

17. Tip Injection
 Tip injection (with rotational angiogram) is useful to
maximize chance of channel crossing.
 isolating channel
 revealing channel anatomy
 estimating possibility of crossing
 Check of blood back-flow is mandatory to avoid channel
injury and confirm connection with recipient artery prior to
tip injection.
 As long as channel anatomy is revealed with tip injection,
double/triple wire technique is helpful.

18. Epicardial vs Septal Crossing
Epicardial
Directed
Higher need for
MC support to
negotiate
tortuosity
Higher need for
“tip injections”
Septal
Often more
random (septal
surfing)
Tortuosity
responds less well
to MC support
Tip injection if
failure of septal
surfing

19.  Collateral Connection size and continuity (CC class)
 Tortuosity/branching of the channel
 Angle of take-off from the donor artery
 Collateral take-on from the distal cup
 Donor artery proximal from the take-off of the CC
 Diseased/Tortous
 Relation of the CC insertion site to the distal cup
Parameters to be considered for CC selection

20.  Collateral Connection size and continuity (CC class)
 Tortuosity/branching of the channel
 Angle of take-off from the donor artery
 Collateral take-on from the distal cup
 Donor artery proximal from the take-off of the CC
 Diseased/Tortous
 Relation of the CC insertion site to the distal cup
Parameters to be considered for CC selection

21. Corkscrew appearance: scientific approach
O. Katoh: CCT 2008: Retrograde for CTO Course

22. CC Tortuosity/branching
What is visible is not necessary crossable and visa versa
Failure to cross this branch

23. CC Tortuosity
Septal surfing crossing of a more proximal septal channel

24. CC tortuosity-ischemia at the territory of
the occluded artery

25.  Collateral Connection size and continuity (CC class)
 Tortuosity/branching of the channel
 Angle of take-off from the donor artery
 Collateral take-on from the distal cup
 Donor artery proximal from the take-off of the CC
 Diseased/Tortous
 Relation of the CC insertion site to the distal cup
Parameters to be considered for CC selection

26. CC take-off

27. Acute angle at origin/destination
 Acute angle (>90°) at A or B is a negative
factor for channel crossing.
 Dissection/ rupture is rarely caused by
wire/ catheter.
 For negotiating acute curve at origin (A/B),
double lumen microcatheres (Twinpass,
Crusade are useful.
A
B

28.  Collateral Connection size and continuity (CC class)
 Tortuosity/branching of the channel
 Angle of take-off from the donor artery
 Collateral take-on from the distal cup
 Donor artery proximal from the take-off of the CC
 Diseased/Tortous
 Relation of the CC insertion site to the distal cup
Parameters to be considered for CC selection

29. Donor artery and CC selection

30. Donor artery and CC selection

31.  Collateral Connection size and continuity (CC class)
 Tortuosity/branching of the channel
 Angle of take-off from the donor artery
 Collateral take-on from the distal cup
 Donor artery proximal from the take-off of the CC
 Diseased/Tortous
 Relation of the CC insertion site to the distal cup
Parameters to be considered for CC selection

32. Relation of the CC insertion site to
the distal cup

33. Relation of the CC insertion site to
the distal cup
Wire entrapment

34. Channel crossing wire selection
 Polymer wires (Fielder FC / Whisper) were the first to be used
for channel crossing but were related with high incidence of
collateral injuries.
 Metal ball tip hydrophilic wires are more effective and safer.
 Sion is first choice wire for channel crossing instead of polymer jacket
wire (Fielder FC, Whisper, etc).
 Tapered polymer jacket wires (XTR) became the choice for
very thin and very tourtous collaterals during targeted channel
crossing

35. Composite core technology
Addressing the channel tortousity

36. Collateral Crossing Wires
+ Tortuosity/Size -
Modified J. Spratt

37. Potential Sequence for Collateral Crossing
SION
SION Black / FFC
XRT
Hydrophilic ball tip
Polymeric
Tapered

38. Bend used for septal access Bend used to facilitate septal crossing
Tip shaping for Collateral Crossing
In targeted crossing of very tortuous and thing channels a very sharp and short tip
bending might be necessary

39. Retrograde: Collateral approach
48.6%
18.6%
9.9%
9.9%
13.0% SION
XT-R
Fielder FC
SION blue
other
Attempt
94.2%
9.6% 1.5%
0%
50%
100%
Corsair OTW
Catheter
Other
microcatheter
Catheter used for GW support
(multiple selection)
92.2%
7.2% 0.6%
0%
50%
100%
Successfully crossed catheter
Corsair OTW
Catheter
Other
microcatheter
No. of GW: 1.8
60.1%25.1%
7.1%
3.3% 4.4%
Succesful collateral route
Septal
Epicardial
AC
Ipsilateral
Bypass graft
Collateral cross by GW, 77.1% (370/480)
Multicenter Japanese Registry (2012)

40. Japanese Multicenter Registry Evaluating the Retrograde
Approach for Chronic Coronary Total Occlusion
(801 patients treated in 28 Japanese centers between January 2009 and December 2010,
Corsair use increased from 36% to 95.3% from 2009 to 2010)
Tsuchikane et al, Catheterization and Cardiovascular Interventions 82:E654–E661 (2013)
Procedural success rate 84.8 % (retrograde success 71.2%)
Clinical success rate 83.8% (retrograde success70.3%)
All (n:801) 2009 (n:378) 2010 (n:423)
Collateral channel cross by guidewire 82.3% (659) 80.4% (304) 83.9% (355)
Successfully crossed collateral channel
Septal 63.0% (415/659) 68.4% (208/304) 58.3% (207/355)
Epicardial 32.6% (215/659) 27.6% (84/304) 36.9% (131/355)
Bypass graft 4.4% (29/659) 3.9% (12/304) 4.8% (17/355)
Procedure time (min) 195.1±84.5 203.3±84.4 187.9±84.1 (p:0.024)
Multivariate analysis identified age 65 years or more and lesion calcification as unfavorable factors and the use of a
channel dilator as a favorable factor for retrograde procedural success.

41. MALE, 63 Y, SA CLASS III
Radial AL 1.5 6Fr
Femoral EBU 3.5 7 Fr
Gaia First

42. Septal Surfing FC

43. Corsair/ Finecross failed to cross despite anchoring in D1

44. Different S crossing with surfing
also failed to cross
Return to first S and balloon dilatation
Mini Trek 1.25

45. Prox LAD spasm MC crossing

46. LAD compromised

47. Balloon predilatation and stent implantation in prox LAD

48. MC advancement underneath the stent struts

49. Final result

50. Solving MC crossing problems
 Choose Guiding catheters with good backup support
 Change the failing MC (Corsair/Finecross)
 Ballooning by small balloon with low pressure
 Balloon anchoring
 Others (another retro channel, ante approach)

51. Summary
 Good guiding catheter support
 Careful evaluation of the angiogram in multiple projections or rotational
angiography
 Donor artery
 CC for angle of take-off, size, tortouosity, branching, angle of insertion at the
distal vessel, its relation with the distal cup
 In septal channels try surfing first
 Slide the wire through gently, avoid buckling, avoid loops, follow with the
microcatheter
 In case of failure continue with tip injections
 In epicardial channels tip injection is mandatory
 Use composite core SION wire as first choice followed by polymeric/tapered wires
according to the anatomy of the channel
 Reshape the wire tip once you are in the channel if necessary
 Optimize parameters for micro-cather crossing
 Most injuries are un-harmful but be prepared for coil embolization if nessecary
 Remember what is visible is not necessary crossable and visa versa