Advanced Crossing and Wiring Technique for BTK Vessels · Strategies of BTK crossing 1. Antegrade...
Transcript of Advanced Crossing and Wiring Technique for BTK Vessels · Strategies of BTK crossing 1. Antegrade...
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Advanced Crossing and Wiring
Technique for BTK Vessels
Hiroyoshi Yokoi MD. Tatsuya Nakama MD.
Fukuoka Sannou Hospital
Fukuoka, Japan
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Disclosure
Speaker name:
..................Hiroyoshi Yokoi....M.D............................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s) Cook, Terumo, BSJ, Medotoronic, BIRD
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Two point of BTK crossing
1. Strategy
2. Guidewire selection
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Strategies of BTK crossing1. Antegrade approach
1-1: Intraluminal approach
・Japanese art: 0.014-inch GW
1-2: Subintimal approach (loop technique)
・Hydro-dynamic boost (SUICA)
・Micro-knuckle
2. Retrograde approach
2-1: Distal puncture
2-2: Trans-collateral or pedal
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Appropriate GW for BTK
0.014 or 0.018 or 0.035
State of art
Japanese technique with 0.014 GW
Japan Euro Not suitable
for BTK
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Strategies of BTK crossing1. Antegrade approach
1-1: Intraluminal approach
・Japanese art: 0.014-inch GW
1-2: Subintimal approach (loop technique)
・Hydro-dynamic boost (SUICA)
・Micro-knuckle
2. Retrograde approach
2-1: Distal puncture
2-2: Trans-collateral or pedal
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First choice & main guidewire
Polymer-jacketed GW
・ Regalia XS 1.0・ Chevalier・ Command・ Jupiter FC
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Differences in each PJ-GWs
・ Regalia XS 1.0Basic GW (best for TCA or TPA), Safe, Poor durability
・ Chevalier floppyControllable GW; Good Trackability & Pushability
・ HT-CommandStrong durability but slightly stiff (Tip weight; 3g)
・ Jupiter FC/ FC3Balanced (Trackability, pushability & Durability)
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First choice guidewire(Polymer jacketed guidewire)
Penetration GW Astato XS 9-12/9-40
Chevalier tapered 15/30gJupiter 45g
Drilling GWRuby (IM, Hard)Treasure XS 12
Halberd
YES NO
Not pass the lesion
Possibility of Ca2+ guided wiring
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Calcium tell us the way to go
Easy to use penetration GW
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How I shape the tip of guidewires?
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Stiffer GW have risk of GW perforation
Ca guided wiring is impossible
→ Subintimal approach may be safe
Penetration GW
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Strong point of Subintimal approach
⚪︎relative safe(Do not to outside of the vessel)
×uncontrollable (By chance procedure)
(bi-directional approach often required)
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Strategies of BTK crossing1. Antegrade approach
1-1: Intraluminal approach
・Japanese art: 0.014-inch GW
1-2: Subintimal approach (loop technique)
・Hydro-dynamic boost (SUICA)
・Micro-knuckle
2. Retrograde approach
2-1: Distal puncture
2-2: Trans-collateral or pedal
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Regalia XS 1.0 (Asahi Intecc)
Shaft of the Regalia XS 1.0 is not so strong:
Easy to make smaller loop than other PJ-GW
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Definition of micro-knuckle
A technique in which a microcatheter
advance into the CTO
without any preceding GW leading
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CLI: 70s female on dialysis
Representative case
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Micro-knuckle for occluded PTA
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Final angiogram
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Antegrade approach sometimes fails
Advancing into CTO lumen Successful penetrationWiring in CTO body
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Retrograde access is
key to success
Antegrade approach
Antegrade fails
Retrograde approach
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Various retrograde access technique
Distal site puncture Trans-collateral
Trans-pedal
(Pedal plantar loop)
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Strategies of BTK crossing1. Antegrade approach
1-1: Intraluminal approach
・Japanese art: 0.014-inch GW
1-2: Subintimal approach
・Hydro-dynamic boost (SUICA)
・Micro-knuckle
2. Retrograde approach
2-1: Distal puncture
2-2: Trans-collateral or pedal
![Page 24: Advanced Crossing and Wiring Technique for BTK Vessels · Strategies of BTK crossing 1. Antegrade approach 1-1: Intraluminal approach ・Japanese art: 0.014-inch GW 1-2: Subintimal](https://reader036.fdocuments.in/reader036/viewer/2022062602/5f01d9b57e708231d401576a/html5/thumbnails/24.jpg)
Lateral view is appropriate for…
Distal PTA and plantar artery
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Frontal view is appropriate for…
ATA, dorsal, metatarsal and peroneal artery
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Extreme retro-access
Metatarsal artery puncture technique
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GW for Distal puncture
Regalia XS 1.0
Do not make injury to punctured artery
Command, Jupiter PC, Chevalier
Shaft is strong = provide strong back-up force
but contains a possibility of vessel injury.
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Strategies of BTK crossing1. Antegrade approach
1-1: Intraluminal approach
・Japanese art: 0.014-inch GW
1-2: Subintimal approach
・Hydro-dynamic boost (SUICA)
・Micro-knuckle
2. Retrograde approach
2-1: Distal puncture
2-2: Trans-collateral or pedal
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1. How to cross
Collateral channels?
2. How to cross
The target lesions?
Two challenges for TCA
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Tortuosity
Bending angle
Channel length
Problem of the channel tracking
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Not tortuous
Not bended
Not long
Select the channel, candidate for wiring
Channel selection is important
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Small, right angled Regalia XS is the best
Type 1
Type 2
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1. How to cross
Collateral channels?
2. How to cross
The target lesions?
Two challenges for TCA
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GW selection for retrograde wiring
Polymer jacketed GW with strong shaft
Situation is slightly severer than antegrade wiring
Maintain the GW Trackablity and pushability
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・Retro wiring with DP
・Retro wiring with TCA/TPA
Polymer jacketed GW with Stainless steal core・Regalia XS 1.0(Asahi), Chevalier floppy, PLX (Cordis)
Polymer jacketed GW with Nitinol Core・ Jupiter FC/FC3 (Boston), Hi-torque Command (Abbot)
Maintain Trackablily & Pushability
Relatively tough situation to DP
Pushability, Durability and Tip memory
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After the retro-set upReverse
CART
CART
Double
balloon
Wire
rendezvous
Several technique for reconstitution
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Take home message
There are many specific techniques for BTK interventions.
We should learn about strength and weakness of each techniques.
Accumulation of evidence , development of dedicated devices and novel techniques were required for standardization of BTK interventions.
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Advanced Crossing and Wiring
Technique for BTK Vessels
Hiroyoshi Yokoi MD. Tatsuya Nakama MD.
Fukuoka Sannou Hospital
Fukuoka, Japan