8th Experts Live CTO Workshop 2016, September, 30th - October 1st, 20116 in Krakow, Poland

1. Guidewires and microcatheters: how to use
Daniel Weilenmann, MD FESC FSCAI
Head Interventional Cardiology
Department of Cardiology
Kantonsspital St. Gallen
Switzerland

2. CTO guidewires
Wire categories

3. CTO wires

4. Polymeric wires

5. Polymer covered wires
FIELDER XT, XT-A or XT-R: Frontline wire for ante- or retrograde channel tracking
FIELDER FC: collateral channel crossing
PILOT 200: antegrad crossing, knuckle wire

6. Stiff Non-Tapered Jacketed
Pilot 200
• Combination of penetration power and push
• Will advance across the path of least resistance
• Follow micro-channels if available
• Will cross over into the subintimal space in fibro-
calcific CTOs without microchannels
• Manages tortuosity, long lesions well
• Can serve as “knuckle wire”

7. Non polymeric wires

11. Externalization wires
Pilot 200 bigger knuckles
Fielder XT smaller knuckles
Knuckle wires (blunt dissection)
RG3
R350
Viper

12. Knuckle wires (blunt dissection)

13. Guidewires : how to use
The task-specific approach

14. Coronary guide-wires: classification
Buller, MLCTO Nice 2016
Conventional
workhorse-wires
Support-wires
CTO-wires
Conventional
workhorse-wires
Support-wires
CTO-wires

15. Coronary guide-wires: classification
Buller, MLCTO Nice 2016
Conventional
workhorse-wires
Support-wires
CTO-wires
Conventional
workhorse-wires
Support-wires
CTO-wires
Task-Specific
access
directed penetration
microchannel
collateral crossing
fenestration re-entry
knuckling
externalization
Task-Specific
access
directed penetration
microchannel
collateral crossing
fenestration re-entry
knuckling
externalization

16. Guidewires and microcatheters: how to use
A task-specific approach
CTO anatomy

17. J-CTO score
• Proximal cap
• Intra CTO Calcium
• In-CTO tortuosity
• Lesion length
• Previous procedural failure
J-CTO score: Morino et al. JACC Interv 2011; 4: 213 - 21

18. Hybrid Algorithm:
task specific wire approach
Wilson et al. Heart 10th May 2016

19. Hybrid Algorithm:
task specific wire approach
Wilson et al. Heart 10th May 2016

20. Predictors of success for A/RWE
• Short lesion length
• cap tapered (or blunt)
• No or low tortuosity

21. Wire based strategies
Microchannels:
taperd polymeric wires
Fielder XT
Fielder XT-A or XT-R
Penetration:
Stiffer tapered wires
Conquest PRO 9/12
Hornet
GAIA 2 or 3
Progress 140/200
Stiffer non tapered wires
Pilot 200
Tortuosity:
Soft polymeric wires Stiffer tapered wires
Tend to bend Risk of perforation
Microchannel No microchannel Tortuosity – long occluded segment

22. Antegrade wire strategies
Microchannels:
taperd polymeric wires
Fielder XT
Fielder XT-A or XT-R
Penetration:
Stiffer tapered wires
Conquest PRO 9/12
Hornet 14
GAIA 2 or 3
Progress 140/200
Stiffer non tapered wires
Pilot 200
Knuckling wires:
Fielder XT (smaller) Pilot 200 (bigger)
Microchannel No microchannel Tortuosity – long occluded segment

23. Retrograde wire strategies
Retrograde Passage/Externialisation
Retrograde knuckle
Extension of the dissection
“LANDMARK WIRE”
Retrograde wire
Antegrade wire
Reverse CART
CART

24. Guidewires : how to use
The wire manipulation

25. CTO wire manipulation: CTO bend

26. CTO wire manipulation

27. CTO wire manipulation
Sartoru Sumitsuij JACC Interv 2011

28. Drilling

29. CONFIANZA PRO 12: punture

30. CONFIANZA PRO 12: punture

31. CTO wire manipulation

32. GAIA: deflection and rotation

33. GAIA: deflection and rotation

34. CTO crossing: wire based approach
Fielder XT
Pilot 200 or GAIA
Confianza PRO 12
Hornet 15
Progress 200

35. Collateral channel crossing
Septal
Septal-Septal
Epicardial- Dg
Epicardial-Apical
Conus-Septal
Epi (OM to Dg or Dg to Dg)
Etc.

36. Collateral channel crossing
SUOH ?

37. Collateral crossing: septals
Possible sequence
“Collateral Crossing”
SION
SION Black (FFC)
XTR (FXT)

38. Collateral crossing: epicardial
Possible sequence for
“Epicardial
Collateral Crossing”
SION
SUOH ?

40. Collateral crossing: which wire?
Tsuchikane, Euro CTO Club 2015 in Istanbul

42. Microcatheters: how to use

43. Guidewire and microcatheter

44. Microcatheters : what is on the market ?
ASAHI INTECC: Corsair
Caravel
Terumo: Finecross
Vascular solution: Turnpike family
Turnpike LP
Acrostak: Mcath

45. CORSAIR

46. CORSAIR

47. CORSAIR

48. Caravel

49. CARAVEL

50. Microcatheters - FineCross

51. Soft Tip
• Spiral
– Outer coil on the distal shaft for added
rotational advancement
– Increased stability during knuckling in
resistant lesions
– Vessels with > 1.0 mm DS
Turnpike
catheter

52. Soft Tip
• LP
– Lower profile and increased flexibility
compared with turnpike
– Ideal for crossing epicardials
Turnpike
catheter

53. • CenterCross
– Self-expanding anchor
– Coaxial alignment
– Central 3F lumen
Amplified Support – Anchoring and Centering
Simplified Luminal Crossing
Scaffold
MicrocatheterInner Shaft
Outer Sheath
Guidewire
Technical specs:
Up to 4+mm native vessels
OTW guidewire lumen
3F microcatheter compatible
o Corsair, TruePath, Viance
0.035” GW compatible for peripheral
7Fr guide compatible (5F sheath)
130 cm working length

54. Guidewire Access Selectively Deliver
Support Side Branch Contrast/Drug
Twin Pass: Dual access catheter

57. Advance and retrieve the microcath
Distal RCA
Septal CC

58. Ambiguous proximal cap?
Interventional collateral
channel or graft?
Start retrograde
Lesion length > 20 mm?
Retrograde
Dissection
Re-entry
(RDR)
True-to-true
(TTT)
a) Antegrade balloon-assisted
RDR (reverse CART)
b) Mother-and-Child and balloon-
assisted RDR
c) Retrograde balloon-assisted RDR
(or CART)
d) Wire-based RDR (with wires
only)
Expanded Hybrid CTO Crossing Algorithm
Sequential
wires (or WE)
YesNo
Major side branch at distal
cap or disease at distal
target?
Start antegrade
Lesion length > 20 mm?
Antegrade
Dissection
Re-entry (ADR)
a) Sequential wires (or
WE)
b) Device-based
(CrossBoss® for in-
stent restenosis or
native CTO TTT
crossing)
a) Device-based
CrossBoss® and
Stingray® system
Alternatively
b) Wire-based (STAR,
contrast-guided
STAR, mini-STAR,
LAST)
No
Start antegrade
Good segment for re-entry?
BASE (Balloon-
Assisted
Subintimal
Entry)
or
‘Scratch and
go’ technique
IVUS-guided
puncture for
TTT crossing
or
MDCT-guided
puncture for
TTT crossing
Yes
No
True-to-true
(TTT)
Yes
Yes
Yes
Yes
No
No
No
Clear proximal cap?
Yes No
Rinfret S. Percutaneous Intervention for Coronary Chronic Total Occlusion: the Hybrid approach
1st ed. Springer International Publishing, 2016

59. Hybrid algorithm: strategies
50%

60. Thank you