How to Control the Wire to Cross the CTO Lesion ? Yuejin Yang MD, PhD, FACC Cardiovascular Institute...
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Transcript of How to Control the Wire to Cross the CTO Lesion ? Yuejin Yang MD, PhD, FACC Cardiovascular Institute...
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How to Control the Wire to Cross the CTO Lesion ?
Yuejin Yang MD, PhD, FACC
Cardiovascular Institute and Fu-
Wai Hopital, CAMS & PUMC
CIT 2010, Mar.31-April.3,2010, Beijing, China
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PCI: Primary Steps
• Punctuating & canulating to get entrance into peripheral artery (femoral or radial)
• Guiding catheter to bridge a tunnel from outside body into diseased CA
• Guidewiring to establish a rail into the CA beyond the blockage lesion
• Balloon dilating the blockage lesion over the wire rail
• Stenting the stenotic lesion over the rail to keep CA open
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PCI: Key Steps for CTO Lesion
• Strong guiding catheter backup support
– No Judkin’s guiding
– Special guiding catheter usually needed
• Different guidewire to get through CTO lesion into distal true lumen (the most important and difficult step)
• Lower profile balloon cross the CTO blockage lesion to dilate
• Stent deployment at the lesion site
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Pathology of CTO Lesions
• Hard plaque
• Soft plaque
• Proximal & distal fibrous caps and central organizing thrombus
• Other Features: Inflammation
Neovascularization
• More soft plaque in DM ( 36% ) than Non-DM ( 11% )
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CTO angiogram
• TIMI flow -0 with
- an ante-grade channel
- a bridge collateral (not 99% stenosis)
- a mid-island
without AMI / RMI
• Tapered type
• Abrupt type (the most tough)
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Ante-grade channel
Flow competition
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Bridge collateral
Some micochannelsFlow competition
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Tapered type CTO
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Abrupt type CTO
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Ante-grade channel or Bridge collateral ?
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A “breakthrough” in A “breakthrough” in CTO TherapyCTO Therapy
• New CTO guidewires
• Advanced techniques
• DES on restenosis
• Improve outmodes after therapy
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CTO: Three Key Elements
• Guiding catheter: strong back-up
support
(Essential) • Wire: Get pass through lesion
(Pivotal role)• Balloon: Cross the lesion
Also important
Sometimes be problematic ?
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PCI: Strategy for CTO
• Antegrade approach
the majority
routine use in daily practice
• Retrograde approach
the minority
the alterative
for special CTO lesion morphology
essential prerequisite needed
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Drilling Technique and Wire• Technique Short tip curve (-2mm) with a proximal secondary bend
Rapid rotational tip motion with gentle forward probing Start with moderate stiffness tips and stepwise↑• Wires Guidant CROSS-IT (100. 200. 300) Asahi-Abbott MIRACLE (3, 4.5, 6, &12) Medtronic PERSUADER (3,6,9) “Workhorse” technique with discrete entry point
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Microcatheter
Support to wire manipulationCancel a secondary curve
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Penetration Technique and Wires• Technique
Minimal tip rotation with aggressive
forward Probing
Tip stiffness should penetrate even
heavily calcified entry cap (9-12gs)• Wires
Asahi –Abbott CONFIENZA
(Regular & Pro)
Miracle ( 6-12gs)
Guidant CROSS-IT 400
Blunt entry point, heavily calcified or
resistant lesions
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Sliding Technique and Wires • Technique Longer and shallower tip shapes No secondary bend Simultaneous tip rotation and probing Hydrophilic wire prefered• Wires Guidant PILOT (50,150,200) BSC PT (LS, MS, choice) For the lesions with microchannels or subtotal, ISR total occlusions, calcified and angulated even STAR technique (subintimal reentry)
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Three Keys for Successful Wiring
• The shaping of the wire tip
double-bend
• The manipulation of the wire
from feather touch to strenuous pushing
• The penetration power of the wire
The second wire tip must stiffer than the
Ca++ in CTO when the softer one enter the
sub-intimal space
Warning against the medium stiff wires
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“Zen Philosophy” in PCI for CTO
• We should overcome the temptation
to rotate actively or
to advance rapidly the dedicated
stiff wires for CTO
• Zen philosophy:
To maintain the directional
control when wire advanced
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CTO: Key Techniques
• Specialized wires ( above )• Dual ( contralateral ) injection
• Parallel wire and see-saw technique
• Lumen reentry ( STAR, CART )• IVUS guidance
• Tornus catheter
• Retrograde ( collateral ) approach
• Novel devices: Safe Cross, Frontrunner
Crosser
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Parallel wire technique
Cross a lesion by using two wires
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Parallel wire technique
Stretching the vessel
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Parallel wire technique
Sharper curve than the first wire
Crossing the first wire
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Retro-grade dilatation of false lumen and Retro-grade puncture (CART)
Penetrate to the proximal from the distal vessel
orAs a landmark for ante-grade penetration
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How to Deal with Dissection
of CTO• Re-steer
• Parallel wire: a standard routine technique
• STAR: wire from false to true lumen,
Stenting false lumen
Last resort, primarily reserved for the RCA
CART: Controlled Antegrade and Retrograde
subintimal Tracking
From true via false to true lumen & stenting
Similar to STAR
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Wire Manipulation Tricks for CTO
• Hydrophilic wire + microcatheter leading to
CTO lesion and change stiff wire to penetrate
the CTO lesion • Routine dual injection as long as no ante grade
lumen seen • Not try passage hydrophilic wire through true
CTO lesion except for recent AMI “false CTO”
due to easy subintimal false lumen passage.• No pushing too much while wire forwarding
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Wire Manipulation Tricks for CTO
• No wire stuck when backward pulling• Protect side branch when wiring• No ballooning without confirming the true
lumen• Stop if severe dissection occurred with wiring• Protamine given against heparin if failed
and routine Echo examination needed • Plaque crack technique works if balloon
uncross
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Determination of True Lumen• Wire going side branches freely• Wire going forward easily • Wire tip rotating freely when manipulation• No resistance in wire forwarding• No tip bending even twisting in wire
forwarding• No resistance in balloon forwarding• Ante grade flow restored after ballooning• (even very low profile balloon i.e. rujin
1.25mm)
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Case 6: RCA CTO with SVG occluded after 3 years of CABG
彭世英 F 61 岁 病案号: 606891
CHD 4 年 CABG 2 年 症状再发 1 年TFI : 5Fr 导管 SVG-LAD 引导TRI : AL1-RCA
CAA : SVG-RCA 100%
SVG-LAD OK
LM OK LAD 100%
LCX 100% RCA 100%
IVUS : Perfect
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CAA: 2008-4-28
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EUROPCR 2008 Life DEMO case (2008-5-16)
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Case 3. LAD ostium CTO with 3 yearsCase 3. LAD ostium CTO with 3 years
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Case 5: Triple-CTO, Refuse to do CABG
王波 M 42 yrs 630746
No chance to retrograde approach
Staged PCI successful
07-7-9 baseline CAA: LM: OK, LAD: 100%,
RCA-mid: 100% RCA-CTO PCI guiding×2
07-7-16: LCX PCI guiding×2
08-2-28 Follow-up CAA: RCA, LCX OK
08-2-22 CIT: No time to do
08-3-24 LAD ostium PCI: successful
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LAD100 % LEX99 % RCA100 %
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Ruijin1.25 、 2.5 球囊扩张
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植入 Excell2.5×28mm 、 3.0×28mm 支架
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Ruijin1.25 、 2.5 球囊扩张,提供 LAD 充分侧支循环
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支架通畅, LEX100% , LAD100%
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钢丝 Pilot150 进真腔,用 1.25 、 2.5 的球囊扩张
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植入 Excell2.5×28mm 、 2.5×14mm 、 2.5×24mm 支架
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08-2-28 Follow-up CAA
Follow-up CAA: baseline, LM: OK, LCX stents: OK, Prox LCX: 80%
LAD: CTO RCA Stents: open No chance to retrograde approach
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Case 5: 08-3-24 LAD Ostium-CTO
TRI-improssible done to occluded RA
TRI: Guiding: 6Fr EBU 3.5
Wire: Conquest×2
Miracle 6×1
Miracle 12×1
Universal×1
Pilot 50×1
Balloon: 1.25mm
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Wiring
Universal wire to LCX Conquest not to ostium of LAD
Refind ostium of LAD Wire to LAD Wire to LAD-Dia
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Contralateral injeetion: seemed to be OK Looked OK
Wire to true lumen of distal LAD Balloon to distal LAD
Wiring true lumen check
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Ballooning
Ballooning Opened
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Reallooning
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Stenting
Stenting: Excel 2.5×28mm, Excel 2.7×28mm,
Excel 3.0×24mm, Excel 2.5×18mm
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Results & LCX stenting
Pro-LCX ballooning LCX stenting: Excel 3.0×15mm
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Final results
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Balloon Uncross?
• Guiding catheter backup support ?
bigger, special one,
and 5 in 6 or 7• Lower profile balloon?
rujin, sprinter 1.25mm• Buddy wire technique?• Anchor balloon technique?• Rotablator ?• Plaque cracking technique?• Tornus?
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How to Deal with Balloon Uncross
• Maximize guiding support
8Fr, A-L1-2, Deep engagement
• Buddy wire technique
• Anchor balloon
• Child-mother catheter system
• Rotational atherectomy
• Tornus crossing catheter ( 2.1Fr 2.6Fr )• Laser
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TRI - CTO ( X12yrs )Anker balloon budy wire Miracle 60gr
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TRI - CTO ( X12yrs )Anker balloon budy wire Miracle 60gr
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TRI - CTO ( X12yrs )Anker balloon budy wire Miracle 60gr
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TRI - CTO ( X12yrs )Anker balloon budy wire Miracle 60gr
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TRI - CTO ( X12yrs )Anker balloon budy wire Miracle 60gr
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TRI - CTO ( X12yrs )Anker balloon budy wire Miracle 60gr
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LCX—OM CTO lesion
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Guiding: 6Fr-AL1 Wire : PT Graphics intermediate Balloon : marverick 1.5-20mm
No pass of the balloon
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Still NO Pass of the balloon
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After changing 7 Fr guiding to get stronger backup support , balloon pass throught the lesion.
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Final result after stenting with 2.5-16mm
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Tornus Crossing Catheter
• Counterclockwise rotation (driving) ( < 20times)
to cross CTO
• Other roles
Guiding backup support↑
Wiring force imcrease and exchange
Remove the barrier between a side and a
main
branch
• Limitations: cannot cross severe Ca++ lesion
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Welcome Attend China Heart Conference (IHF2010) :
2nd international TR Coronary Therapeutics (TRCT)
Chaired byYue-Jin Yang MD. PhD. FACC
Co-Chaired byDr. Saito
Dr. kiemeneijiNCC, 2010/08/13-15, Beijing, China
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Thank you very much !
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