CTO

CORONARY CTO
RECANALIZATION-
Current understanding of
wire and Hardware.
DR. DEVINDER KUMAR M.D.
SKIMS SOURA

CTO-DEFINITION
100% luminaldiameter obstruction without flow in that segment of 3 or more months duration
Presence of TIMI 0 flow within an occluded segment with an estimated occlusion duration of >/= to 3months
Eurointerven 2007 :30:43Heart 2012;98:822-828
A lesion with TIMI 0 flow within the occluded segment
that is judged to be at least 3 months in duration

Etiopathogenesis of CTO
1. The late organization and development after an acute occlusion.
2. The progressive occlusion of a long term and high-degree stenosis .

Mix of luminal plaque, thrombin,
fibrin, inflammatory cells,
neovascular channels, dense
collagen and calcium deposits.
Core composition correlates with
the CTO age.
Older occlusions- higher
fibrocalcific material (defined as
“hard plaques”)
CTOs -less than one year-less
fibrous materials (defined as “soft
plaque”)

No prospective randomized trial.
- In a meta-analysis of 13 observational trials encompassing 7288 pts over a 6 year
follow up ( Joyal D. et al 2010, Am Heart J ), successful recanalization was associated
with significant reduction in residual or recurrent angina. P<0.01).
- Improvement in all three health status domains of Seattle angina Questionarre.
( angina freq., physical limitation, and quality of life) – FACTOR TRIAL 2010.
- A considerable body of evidence suggests that ischemia is associated with adverse
CV events and the reduction of ischemic burden is associated with reduction in
mortality.
WHY TO OPEN UP A CTO ?

- In a large study of 10,627 pts undergoing adenosine SPECT, revascularization
compared with medical treatment had greater survival benefit ( absolute
and relative) in patients with inducible ischemia involving more than 10%
of ischemic myocardium (Hachamovitch et al . Circulation 2003)
- In COURAGE nuclear substudy, pts who achieved more than 5% reduction in
ischemic burden with PCI and OMT vs OMT alone had a lower unadjusted risk
of death or MI, particularly if they displayed moderate or severe ischemia
before treatment.
- 2011 ACCF/ AHA / SCAI , PCI of a CTO in patients with appropriate clinical
indications and suitable anatomy is reasonable when performed by operator
with appropriate expertise ( CLASS IIa, LOE B ).

Anatomic Descriptors of Procedural Success
In the current
ERA;
Severe
calcification

J Am Coll Cardiol Intv. 2011;4(2):213-221. doi:10.1016/j.jcin.2010.09.024
J-CTO REGISTRY- (2006-2007),
498 PTS / 528 CTOs
Success rate – 88.6%
Retrograde used in 25.7% with 74.5%
success rate.
Coronary artery perforation- 13.6% in
collateral & 7.2% in CTO artery.

PROBABILITY OF ANTEROGRADE GUIDEWIRE
SUCCESS ( J-CTO REG.)
CTO SCORE
0
1
2
3
SUCCESS IN <30 MIN (%)
92.3
58.3
34.8
22.2

KEYS FOR SUCCESSFUL CTO RECANALIZATION
1. Proper preprocedure planning and angiographic detail.
2. Appropriate guide selection, ( EBU –LAD , AL 1 – LCX)
3. Appropriate wire selection
4. Judicious use of microcatheters
5. Proper selection of balloons,and other hardware(rotablation if required)
6. Most important is expertise of operator.
7. In japan registry(2002-2008), after introduction of new hardware and techniques, CTO-
PCI success rate is increased upto 90%. (compared to 50-70% in contemporary practice)

Preprocedure planning
Paramount importance
Spend time examining diagnostic films & decide on
Approach ,vascular access, guide shape & size
dedicated equipment availability
Occluded & contralateral vessel reviewed in multiple projection frame by frame to
understand complete anatomy
identify proximal & distal cap
vessel course & side branch
calcification
details of collateral circulation
Out of alignment of proximal & distal portion of occlusion with each beat is a sign
of tortuosity inside CTO
EURO CTO club;2012 consensus

Guide catheter selection
Percutaneous. Recanalization of Chronic Total Occlusion (CTO) Coronary Arteries: Looking Back and
Moving Forward
Simona Giubilato, Salvatore Davide Tomasello and Alfredo Ruggero Galassi
http://dx.doi.org/10.5772/54079

HOW TO INCREASE GUIDE SUPPORT
BEST OPTION FOR STRENGTHENING A GUIDE
1. FIRST best maneuver- put the guide in power position or
deep seat the guide.
2. SECOND best maneuver – Add a second stiffer wire
3. THIRD best maneuver – change to a stronger guide
4. use the balloon anchoring technique
5. insert a smaller straight inside the current guide(mother &
child)
6. remove everything- change the short sheath to a longer one
Advanced interventional cardiology TIPS AND TRICKS-
NGUYEN et al

Guide wires
Polymer coated wires – poor tactile feedback, lack of resistance
more chance of subintimal passage
Majority favor – step up approach – moderately increased stiffness(miracle-3)
– switch to greater stiffness &penetration ability, tapered (conquest pro wires)
Some believe –use of stiffer wires initially to cross hard occlusion cap
Rationale: risk of initial dissection minimized, procedure shortened &
simplified with this approach
Kcj 2010
Most common reason for failed CTO PCI- failure of GW to cross
Initial microchannel tracking - soft tapered polymer jacket wire
IVUS guided reentry from subintimal space to true lumen
Tapered High gram stiff wire
Soft polymer jacket wire(FIELDER XT) + microcatheter has improved chance of
antegrade recanalization in first attempt( EURO CTO REGISTRY)

Guidewires for micro channel tracking
CTO LIVE 2007

Four wire strategy
1. Hydrophillic &/or polymer-jacket Antegrade microchannel/
0.014 inch, low gram force with soft tissue probing
tapered tip knuckle technique
Eg : Fielder XT wire (Asahi Intecc) tip-0.009
Runthrough taper wire (Terumo – 0.008
2. Non-tapered ,polymer jacket collateral channel crossing
Hydrophillic, 0.014 inch GW in retrograde procedures
Eg: Fielder FC wire(Asahi Intecc)
Pilot 50 wire (Abbott Vascular)
JACC intrvn2012;5:367-79

3. Moderately high gram force(4-6) complex lesion, crossing
Polymer jacket, non-tapered long lesion, knuckle technique
0.014 inch GW Dissection /reentry
tortuous lesion with ambiguous course
Eg: Pilot-200 GW (Abbott Vascular)
4. High gram force, 0.014GW Penetration techniques
tapered, 0.009 Cap puncture
Non-jacketed tip Complex lesion crossing
Lumen reentry techniques
Eg: Confianza Pro 12 wire (Asahi Intecc)
JACC intrvn2012;5:367-79

ANTEROGRADE WIRING
1. A workhorse, spring coiled wire with a standard working bend is
loaded in an OTW or Micro-catheter.
2. The next wire to use is soft tipped, polymer jacketed, tapered wire
such as Fielder XT. This should be shaped with a 30- 45 degree bend at
1mm.
3. This wire should be manippulated in an attempt to dissect through
occlusion or cross a microchannel.
4. Next wire depends on anatomy :- If occlusion is short and straight-
heavy weight, high puncture force, CTO specific- Confianza pro/
Miracle series. If anatomy unclear or tortuous- Jacketed stiff tipped
such as PILOT 200.
5. Still not, dottering devices- Corsair , Tornus devices.

Low profile , trackable, OTW microcatheters - indispensable tool for CTO PCI
Allow ease of wire exchange
It ease torque in the tip response, preventing flexion, kinking, prolapse of
the guide wire, and improving penetration ability
Allows primary & secondary curve adjustment
Dedicated microcatheters – better tip flexibility > OTW balloons
Useful for CTO immediately distal to a bend
Larger inner lumen – reduces friction during wire manipulation

Available in 130cm and 150cm lengths, for the antegrade and retrograde approaches
respectively

Corsair – HYBRID (support & dilator)
Septal dilator catheter used for the
retrogradeapproach.
Dedicated for selective
engagement of the collateral
channel.
It consists of a tapered tip and
screw head structure, which
reinforces torque transmission for
the guide wire and creates better
back-up support for CTO
penetration.
The Corsair provides superior tip
flexibility which enables smooth
approaches to narrow tortuous
vessels, such as septal channels.
Corsair registry- 93 cto, retrograde, successful channel crossing 96.8%. Successful pci- 84%.

TORNUS
Developed to penetrate severe and
hard lesions with greater flexibility
and torquability with a rotational
burrowing advancement manually
manoeuvred by controlled counter-
clockwise rotation. (SCREWING
EFFECT). Platinum marker at the tip.
Useful in situation when wire
crossed the lesion but balloon could
not negotiate the lesion

Venture™ Catheter (Velocimed, Minneapolis, Minnesota, USA)- Tip
deflecting catheter, designed to help direct the wire where there are
difficult angles, at bends and in steering the wire away from dissection
planes.
Twin pass (Vascular Solutions, Inc Minneapolis, Minnesota, USA)- dual
access lumen rapid exchange micro-catheter (rapid exchange and over
the wire) which helps the guide wire placement and exchange after
reopening the occlusion and gaining access to different main branches.
Crusade (Kaneka Corporation, Japan- similar design and application of
the Twin pass

STRATEGIES FOR PCI OF CTO
DUAL WIRESINGLE WIRE
Soft tapered polymer
jacket wire
Middle weight spring coil
wire
High gram tapered wire
Parallel wire technique
Bilateral retrograde approach
IVUS guided approach
Yamane M Rev Esp Cardiol. 2012.

Procedural Steps of Current CTO-PCI
J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 4 ,
N O . 9 , 2 0 1 1
S E P T E M B E R 2 0 1 1 : 9 4 1 – 5 1

Wire tip shaped as short as possible <45º
Second milder curve - improve maneuverability of wire
Exception - a sharp (>60º) angle with 1 to 2 mm bend based on lumen size, to
navigate the wire from subintimal space back to true lumen( Parallel wire
technique or IVUS guided wiring)
Confianza Pro or Pilot 200 - best suited to this purpose
EuroInterv.2006;2:375-381
How short tip can be bent – depends on length of soldering of spring coil at tip
Usually -1mm, fielder XT -<1mm
Korean Circ J 2010;40:209-215

Shaping the wire
1ºbend of 30-45º
1-2mm from tip
Find softest part
2ºbend-10-15º
@3-6mm
Work as a navigator
to orient tip

Tip curve should be just larger than lumen diameter
CTO, the lumen diameter = 0 mm
For CTO lesion - Guidewire-tip curve should be very small
Larger curve may hurt the vessel wall during direction control
Hermiller ,SCAI Fellows Course 2009

Different methods
Sliding AT proximal cap
Drilling inside CTO
Penetration Distal cap
Short, focal, straight noncalcified lesion – any method
Long tortuous calcified occlusion – wiring tailored to lesion
characteristics
Hard fibrocalcific plaque and tortuosity in CTO- major obstacle
watching the wire tip in relation to lumen in at least 2 orthogonal views
Yamane M Rev Esp Cardiol. 2012
HOW TO AVOID ENTERING THE INTIMA? When trying to cross a curved
segment, avoid positioning the wire at the outer curve of the bend.
3 fundamental elements of wire handling are ROTATING, PUSHING AND
PULLING the wire.

ideally there should not be side branches at the site of occlusion and point of entry
should be concave in shape
Simultaneous rotation & probing of lesion
High chance of entering to subintimal space ( tactile response - nil )
SLIDING
Relatively recent occlusion with predominance of microchannels
Extremly low friction wires for picking microchannels used
Recent total, subtotal occlusion ,ISR attempted with this strategy
Long duration – Microchannels replaced by fibrotic tissue
Indian Heart J. 2009; 61:275-280

BEWARE bridging collaterals masquerading as microchannel
Polymer sleeved wires NOT forced against resistance, small tip bend, probing with
mild rotation
Soft wires with polymer sleeve – Fielder series/ Whisper/ PT II

Drilling Strategy
If discrete entry point present
Technique
short curve(2mm) @45-60º to distal tip
sometimes a secondary curve given proximally
wire advanced with rapid rotational tip and gentle probing
start with MOD stiffness – progressive increase in stiffness(miracle)
Entry to false lumen judged by tactile feel on pulling stiff wire
Reserved for the most skilled and experienced operator
Ineffective with Blunt entry ,heavily calcific & resistant lesions
Indian Heart J. 2009; 61:275-280

Penetration
Technique
Pushing stiff wire slowly& gradually – minimum rotation to target direction
Tapered tip wires (confianza pro 9/12)
Softer tip intially progressively stiffer wires
Route determined – various angio or CT findings (not by tactile feel ).
Useful for blunt ,heavily calcific or resistant lesions
Not for CTO with tortuous angulated or bridging collaterals because of
higher chance of perforation
Drilling & penetration – guide support & tip load important
Tip load - success - chance of perforation

Penetration power = tip load/tip area

In the antegrade wire procedure,plaque tracking
should be described as either
1. intimal (loose tissue tarcking)
2. subintimal.

“Sigmoid Curve Sign” - to detect subintimal tracking .If the wire is running in a sigmoid
shaped curve with the same width as the vessel diameter, subintimal tracking should
be suspected

SENSATION FROM THE FINGERTIPS
.BODY
.GRASPED – false lumen tracking or high
resistance lesion
.SENSATION OF GETTING STUCK WHEN PULLING
BACK - in the intima
.RESISTANCE AT THE TIP OR MOVEMENT DECREASE
– in the false lumen
.EXIT
.FREE MOVEMENT – in the true lumen or in the
extravascular space.
Advanced interventional cardiology- NGUYEN et al

Parallel wire technique or Seesaw wiring

1st wire in false channel
left in situ
2nd stiffer wire advanced parallel to first wire in same path
redirected to enter distal true lumen
main pitfall is wire twisting each other
Support catheter use, appropriate wire selection& handling –essential to avoid wire
twisting
Main purpose : - redirecting a wire inside body of a CTO & puncturing distal fibrous
cap
Important prerequisite – distal vessel visualization
Korean Circ J 2010;40:209-215

Visualization of 1st GW & its relative position to 2nd GW using orthogonal view is
essential for success of technique
Adopt the technique before a large subintimal dissection
Chance of successful recanalization by 2nd wire decreases proportionally to the
extent of sub-intimal dissection induced by the first guide-wire.
2nd wire –stiffer with superior torquability
Eg:Miracle12 or Conquest Pro 9/12

Check in multiple angiographic views
Advantages
a)Decreased fluro time
b) Reduced contrast

See-saw wiring technique
Modification of parallel wire technique
Uses 2 microcatheters or OTW baloons
When first wire fails , 2nd wire with microcatheter or OTW baloon is inserted
Risk – false lumen may enlarge – procedure failure
Japanese operators demonstrated ability to improve wire crossing over
time with this technique(Nakamura& Bae 2008)

IVUS Navigated Wiring
IVUS – Depict cross sectional view of coronary tree
IVUS focus on plaque distribution, calcification, reference vessel size & side
branch anatomy
Applicability of IVUS in CTO PCI
1)Side branch method to navigate CTO wire into true lumen from proximal cap .
helps in identify the ambiguous proximal cap.
2)Subintimal rentry from the proximal true lumen
IVUS guided sub intimal rentry – Last resort for getting a subintimal wire into
distal true lumen
Applicable even after losing site of distal vascular bed on angio

Importance of wire crossing from true lumen to true lumen
If Subintimal wire crosses without many side branch compromise
Subintimal stenting practical
CTO PCI should be planned to minimize subintimal wiring
Subintimal wiring & stenting – unavoidable in some
Eg: severe fibrocalcific occlusion over a negatively remodelled segment
Larger distal vascular bed – higher chance of TIMI-3 flow

WHEN BALLOON NOT
CROSSING CTO
- Deep seat the guide.
- Introduction of second wire into branch proximal to
occlusion to increase support of guide.
- Introduction of wire into true lumen adjacent to first wire
as buddy wire or to increase the dimensions of the channel.
- Larger and more supportive guides.
- Inflation of an angioplasty balloon either in MB or SB to
stabilize the guide.
- Debulking devices.

STAR Technique - Subintimal tracking and rentry technique
Used when attempts to recanalize true lumen failed.
0.014 hydrophillic wire with J configration used(whisper, pilot).
Hydrophillic wire pushed through subintimal dissection plane.
When pushed distal to occlusion, J tip should be directed to true lumen in an
attempt to reenter.
Successful in those with previous attempt failed.
Most Ideal vessel for STAR is RCA then LCx. And least ideal
is LAD. Not used now in view of frequent side branch compromise.
High chance of perforation.
Catheter Cardiovasc Interv 2005;64:407–411
Dissection reentry techniques

2013- 355 pts(japan)- cardiac death in STAR VS CONVENTIONAL CTO PCI is comparable.

Knuckle wire technique
Polymer jacket wire (fielder XT or pilot-200)manipulated
to create wire loop – advanced subintimally-across CTO –
OTW system advanced to this area- rentry to true lumen
with a stiffer wire or pilot 200

BRIDGEPOINT RE-ENTRY SYSTEM
(FDA APPROVED)
CROSSBOSS CATHETER
FAST CTO- 149 pts, success -77% : 42 pts trial(japan)- 67% successful in previous failed cto-pci

WHEN TO STOP ANTEGRADE
• Creating a large false lumen.
• Disappearance of the distal vessel course(most likely
because collaterals were sheared off by dissection).
•Reaching limit of dye consumption( typically 600 ml in a
non-diabetic patient with normal renal function.)
•After 2 hours of unsuccessful wiring.(60 min of
flouroscopic time) NGUYEN: TIPS AND TRICKS 4th Ed.
•Excessive patient and operator fatigue.

Retrograde Wire Technique of CTO
Recanalization

•Initially used after a failed antegrade approach.
• Now used as initial strategy in challenging cases
1) Ostial occlusion 4) Large side branch at proximal cap
2) Long occlusion (>30mm) 5) Severe tortuosity and calcification
3) Without stump 6) Visible continuous collaterals
• Dual femoral arterial access preferred

Collateral selection
- Preference - Bypass graft > septal > epicardial
- Selective injection of collateral
- Wiring collateral – achieved with OTW system or dedicated
septal dialator(corsair)
- Contrast injection to assess best connection
- Before injection – aspirate to remove air in microcatheter
- Dripping saline over hub during insertion& removal of guidewire

- Hydrophillic polymer jacket wire with <1mm 30-45º tip used
to cross recipient artery
- Fielder FC, Pilot-50, Whisper, Choice PT, Runthrough
- Wiring done in diastole
- Wire should move freely - difficulty to advance – perforation?
- VPC or whipping of wire - RV or LV entry (rarely pericardium)
- Of no consequence if recognized before advancing OTW system
- Collateral dilatation using 1.25-1.5 mm balloon @ 1-2 atm or Corsair
- Epicardial collaterals
size most important factor in wiring success
should never be dilated
-Septal collaterals- tortuosity most imp. factor in wiring success

• Manipulation of both antegrade and retrograde wires in CTO until they meet
• Antegrade wire follow channel made by retrograde wire in true lumen of distal vessel
• Simplest form of retrograde technique
• Retrograde wire advanced to distal cap
Acts as a marker of distal true lumen
Serves as a target for antegrade wire

Most pure form of retrograde technique(only in 40% retro tech)
Hydrophillic wire advanced to the lesion
Advancement of microcatheter or OTW balloon – additional support
CTO crossed retrogradely using hydrophillic wire or stiffer wire
Manuevers to enhace chance of crossing:-
- Inflating retrograde balloon - coaxial anchor
- Stiffer tapered tip or hydrophillic wires
- IVUS facilitation of retrograde wire to proximal true lumen

Controlled antegrade & retrograde subintimal tracking
C A R T
Basic concept –create subintimal dissection with limited extension only at the site of
a CTO
Antegrade wire advanced into CTO then to subintimal space.
Retrograde wire through collateral with microcatheter to distal end of CTO -
into the CTO- then to subintimal space.
Balloon inflation inside CTO using small balloon over the retrograde wire to
subintima.
Balloon inflated inside CTO.
To keep inflated space open, deflated balloon left in subintimal space.
Surmely Jf et alnJ Invasive Cardiol 2006;18:334–338
Limited subintimal tracking (dissection) (LaST) only in CTO segment

Reverse CART technique
- Engage a guidewire retrogradely in the distal cap of the CTO
- Another wire anterogradely in the proximal cap of the CTO
- Retrograde wire advanced in subintimal space into CTO lesion
- Subintimal channel is enlarged by anterograde balloon
- Plaque dissection and modification of the lesion
- Retrograde wire advanced to cross the dissection
- Link up with the anterograde wire in proximal true lumen
- Wire externalized (Exchange length)
- Anterograde PCI done

KNUCKLE WIRE TECHNIQUE
Best suited for long segment of occlusion
Retrograde wire usually a polymer jacket wire manipulated to form a loop at wire
tip advanced in subintimal space across CTO
Eg: Fielder XT or Pilot-200
Rounded wire loop advanced in subintimal space across CTO without causing
perforation
OTW system advanced to this area followed by attempt to reenter
true lumen using a stiffwire with short bend or hydrophillic wire
Eg: Confianza Pro 12 or Pilot 200

Treating lesion after crossing
1 . CTO crossed by antegrade wiring (kissing wire, just marker, CART)
Antegrade CTO PCI can be done
Retrograde balloon can trap antegrade wire to facilitate procedure
2 . Retrograde wire crosses to true lumen
Options : Antegrade wiring
Retrograde wire externalization
ACROSTAK ACROSS CTO BALLOON - smallest lesion entry profile(0.015”), 1.1 mm
DES is preferred in CTO PCI
Viper advance wire preffered for retrograde wire externalisation

Complications
Thrombosis and dissection of donor artery
Collateral perforation & occlusion
treated with coil embolization
injection of autologous subcutaneous fat tissue/thrombus
emergency CABG
Entrapment of pci equipment in septal collaterals
Radiation skin injury/CIN/
Subintimal stenting – late coronary aneurysm & stent fractures

SafeCross RF Guidewire System
The Safe-Cross radiofrequency guidewire
(IntraLuminal Therapeutics, Carlsbad,
California) combines 3 capabilities: (1)
steerability of a conventional 0.014-in
intermediate-stiffness guidewire, (2) optical
coherence reflectometry to warn the operator
when the wire tip approaches within 1 mm of
the vessel wall, and (3) delivery of
radiofrequency energy pulses to the wire tip
to facilitate passage through an occluded
segment.
NOW FDA APPROVED FOR CORONARY CTO

special role in refractory in-stent CTOs wherein the stent serves to
confine the device as it passes through the occlusion
FDA APPROVED for coronary CTO.
Success rate of 56% in series of 107 pts with previous failed cto pci. Perforation rate 0.9-6%

UNDER EVALUATION
- Prolonged infusions of fibrinolytic agents
- Collagenase infusion
- ultrasound device(CROSSER, FlowCardia, Inc)- therapeutic ultrasound in
crossing vascular occlusions
- Vibrational angioplasty (Medical Miracles) is a mechanical device that
generates reciprocal and lateral movements in the distal end of a standard
guidewire with frequencies of 16 to 100 Hz
- Ultrasoundguided Pioneer catheter (Medtronic AVE)- Lumen reentry devices
- An alternative approach to CTOs with the use of the Pioneer system also
undergoing investigation is the creation of connections between a coronary
artery and vein (percutaneous in situ coronary vein arterialization [PICVA])
- novel guidance modalities are under development, including forward-looking
ultrasound69,70 and magnetically enabled 3-dimensional wire guidance

COMPATIBILITY OF DEVICES INSIDE A 6 FR GUIDING CATHETER.
A) COMBINATION OF FINECROSS AND MONORAIL BALLOON;
B) COMBINATION OF TWO FINECROSS MICROCATHETERS; C)
COMBINATION OF VALET AND MONORAIL BALLOON; D)
COMBINATION OF VALET AND FINECROSS.

COMPATIBILITY OF DEVICES INSIDE AN 8 FR GUIDING CATHETER. A)
COMBINATION OF STINGRAY® (BRIDGEPOINT/BOSTON SCIENTIFIC,
NATICK, MA, USA) AND 1.25 MM OTW BALLOON; B) COMBINATION OF
TWO CORSAIRS AND A MONORAIL BALLOON; C) COMBINATION OF TWO
CORSAIRS AND IVUS PROBE; D) COMBINATION OF VENTURE AND
CORSAIR PLUS IVUS PROBE.

CTO

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CTO

Editor's Notes