Practical Approach to ChronicTotal Occlusions Step-by-Step

Techniques – The Antegrade andRetrograde ApproachRetrograde Approach

Scripps 2019

Ashish Pershad MD FACC FSCAI

Banner University Medical Center Phoenix

Which patient with a CTO should we betreating in 2019?-

• Stable CAD patients with anginaand on optimal medical therapy

• Randomized control trial(highest level of evidence)(highest level of evidence)

• Risk of PCI is not higher (deathand MI occurring with equalfrequency in both groups)

Other scenarios for CTO PCI-where there may bebenefit -Pending results of the ISCHEMIA trial

• For Complete Revascularizationin MVD group of patients withSTEMI- RCT LOE 1

• Complete Revascularization inStable CAD patients Syntax 1 vs2- Observational Comparison

How to Approach CTO’s Practically?

4 questions about the Cap

Proximal cap

Ambiguous or unambiguous?

Blunt or tapered?

Side-branch at pCap?

Distal cap

Ambiguous or unambiguous?

Blunt or tapered?

dCap at bifurcation? Side-branch at pCap?

Calcified?

dCap at bifurcation?

Size of distal vessel/diseasebeyond dCap?

Tools for the Trade- Wires andTools for the Trade- Wires andMC’s

WIRE TASKS:

WiringCollaterals

Wiring CTOwith Tapered

Cap

Wiring CTO withBlunt Proximal

Cap

Wiring CTO +Navigating

Calcium

Tapered Proximal CapWire tip tofind loosetissue track

Required Wire Properties

LowTip load

LubricityTapered 0.010” Tip+ Polymer Jacket

Flexibilityin shaft

Wire to tracksoft tissue todistal vessel

Blunt Proximal CapPunctureproximalcap

Wire CTO if short +gooddistal visibility

Required Wire Properties

HeavyTip Load

Tapered WirePenetrative

Wire topenetrateCTO body

Hightorquecontrol

Visible CTO Navigation

Flexibilityin the shaft

Required Wire PropertiesLow-MedTip load

1:1 TorqueResponse

TactileFeedback

Flexibilityin shaft

Flexibilityin the shaft

Collateral Wiring

Required Wire PropertiesHightorquecontrol

Spring CoilHydrophilic Wire

1:1 TorqueResponse

Low TipLoad

Flexibilityin shaft

Atraumatic tip

General Use Ca+ Antegrade

Microcatheters

Channel DilatorsGeneral Use

FinecrossSuperCrossMicro-14

Nhancer Pro

Ca+ Antegrade

Turnpike Spiral

Retro & AntegradeCorsair Pro

TurnpikeTeleport

RetrogradeCorsair XS

CaravelTurnpike LPMamba Flex

Channel Dilators

Principles of ADR- with the Stingray andCross Boss System

• Site of re-entry controllable (to <1 mm)

• Aims to revascularize all distal branches

• Should lead to good run-off

• 1 year outcomes do not appear to bedifferent from other strategies of CTOrevascularization

• CTO proximal RCA

• Non ambiguous proximal cap

• Lesion length about 20mm

• Very good distal target with no

bifurcation at the distal cap

Classic ADR case

bifurcation at the distal cap

• Distal vessel fills via bridging

collaterals and collaterals from Cx to

PLV

1st Limitation of the CrossBoss Catheter-Stiffwith bias to the outer curvature of vessel

2nd Limitation of CrossBoss Catheter-sidebranch seeking

Knuckle Boss Technique Illustration-Sidebranch avoidance & finishing with the Boss

Hematoma Management-101

Following Knuckle wireFollowing CrossBoss

Orientation & Re-entry with StingRaycatheter

Final Angiograms

The Fundamentals of Retrograde CTOTechnique

Gain access in vessel distal to CTOConduits• Septal collaterals• Epicardial collaterals• Bypass grafts

Cross CTO and gain true lumen controlCross CTO and gain true lumen controlproximal and distal Techniques

• Retrograde Wire Crossing (RWE)• Reverse CART (XCART)• Classic CART

PCI • Externalized Wire• Conversion to antegrade system• Safe removal of equipment

Case Example Retrograde Baseline

Retrograde Wire –Septal crossing

Retrograde Wire Escalation

Final Angiograms

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