Which lesion to start with which material?

Which lesion to start with which material

Thomas Schmitz, MD

Contilia Heart and Vascular Center Elisabeth Krankenhaus Essen, Germany

Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany

Morino Y et al. JACC Interv, 2011; 4: 213

J-CTO- Score


Morino Y et al. JACC Interv, 2011; 4: 213

J-Score


General Considerations

• Careful planning of the procedure


• Bilateral access to visualize the wire position

and wire progress

• Maximum back-up by guide catheter

• Microcatheter over the wire approach essential


• Better steerability & less friction

• Advance in tortuous proximal vessel with soft tipped wire shaped

• Exchange at proximal cap for CTO wire

• Reshape CTO wire if necessary ( will lose tip curve )

• Exchange CTO wire if necessary

• After exit of distal cap change to atraumatic wire again

Microcatheter


Wahl des Führungsdrahtes

1

Remember always: tip shape is lost rapidly

So reshape, whenever you get stuck

2


Current step-up GW strategy for Antegrade CTO-PCI

PENETRATION DRILLING

(controlled)

SLIDING

Suitable GideWires selection


Sliding technique

Sliding technique

Wiring along microchannel

Incidence of microchannel

Pathology : 80%

Angiography: 30%

9

single wire technique - soft tissue tracking

polymersleeve, tapered tip, low tipload

ASAHI Fielder XT, XT-A, XT-R

• Anti kinking structure

• Higher torque performance with W coil

ASAHI Sion, Abbott Pilot 50 / 150


Morino Y et al, AHA Scientific Sessions Chicago Nov. 2010

Japanese J-CTO registry: Score for difficulty grading

Score points (derived from 494 CTO lesions)

• Calcification 1

• Bending 1

• Blunt stump 1

• Occlusion length >20mm 1

• Previously failed lesion 1


„drilling“ technique

Asahi Miracle / Ultimate Bros 3-12g

Abbott Progress 40/ 80

MIRACLE familyMIRACLE familyMIRACLE familyMIRACLE family

Tip load : 3g, 6g, 12g

110 (Pt Coil length)

・Applying the structure with further improves torque performance for

CTO useCTO use.

・This tip part has the structure which is difficult to be trapped by the

lesions.

„ Never advance it fast and rotate it

rough „


Deflection

Rotation

Intentional control through deflection to stay true lumen

Drilling (controlled)

Gaia wire concept: Deflection & Rotational control


Gaia wires

GAIA Basic structure ASAHI intecc; Japan

Total Length 1900mm

Slip Coat Coating Length 400mm

Coil Length 150mm 0.36mm

(0.014inch) PTFE coat

Various lineups for the different situation or lesion

Diameter ：0.26mm (0.010”) - 0.36mm (0.014”)

Tip load ：1.7gf

Diameter ：0.28mm (0.011”) - 0.36mm (0.014”)

Tip load ：3.5gf

Diameter ：0.30mm (0.012”) - 0.36mm (0.014”)

Tip load ：4.5gf

ASAHI Gaia First

ASAHI Gaia Second

ASAHI Gaia Third

Long hydrophilic coating that enhance the smooth controllability in micro catheter.

First: 0.26mm (0.010inch)

Second: 0.28mm (0.011inch)

Third: 0.30mm (0.012inch)

Gaia wires


Penetration Technique

13

single wire technique - wire escalation - penetration

steel coil, tapered, high tipload

ASAHI Confianza Pro, Confianza Pro 12


UB3

18

Hard plaque Severe calcification

Stiffer tip

XT-A

ASAHI Gaia First

ASAHI Gaia Second

Miracle6

ASAHI Gaia Third

Miracle12

Confianza Pro12

Confianza Pro

XT-R

Asahi & CTOs:

Which wire to use when?

UB3

18


Stiffer tip

XT-A

ASAHI Gaia First

ASAHI Gaia Second

Miracle6

ASAHI Gaia Third

Miracle12

Confianza Pro12

Confianza Pro

XT-R

Asahi & CTOs:


UB3

18


Stiffer tip

XT-A

ASAHI Gaia First

ASAHI Gaia Second

Miracle6

ASAHI Gaia Third

Miracle12

Confianza Pro12

Confianza Pro

XT-R

Asahi & CTOs:


UB3

18


Stiffer tip

XT-A

ASAHI Gaia First

ASAHI Gaia Second

Miracle6

ASAHI Gaia Third

Miracle12

Confianza Pro12

Confianza Pro

XT-R

Asahi & CTOs:


Which wire to use when

Fielder XT


Ideal Case to get started antegrade

• Good indication , informed consent

• J – CTO score < 3

• Good distal target

• Hardware Preparation ( XT, XT, Gaia Series, Pilot 50/200, Miracle,

Confianza , Microcatheter, IVUS, Rota )

• Proctoring

• Radiation protection

• Informed staff

• No CTO before closing time

• No adhoc procedures

• ......


Do not start with:

• Severe calcification

• Severe tortuosity

• Significant sidebranch at the entry point

• Long CTO length

• MVD

• Ostial location

28

• All operators perform cto`s

• No consistent structure

• Different materials were used

• No contralateral injection

• No standardized pre-diagnostic

Avoid the following mistakes:


Thank you!

Which lesion to start with which material?

Health & Medicine

Transcript of Which lesion to start with which material?