What to do if antegradeballoon cannot pass?

Imre UNGIUniversity of Szeged

Szeged, Hungary

2

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Antegrade wiring of LAD CTO Final result

Magnitude of the problemPatient population:

▪ 718 CTO PCI2012-2016;

▪ 9.0% in thePROGRESS registry;

Predisposing factors:

▪ Calcification(82 vs. 52%);

▪ Tortuosity(61 vs. 35%);

▪ Higher J-CTO score(2.95 vs. 2.43)

What can we do?

▪ Force ↑

▪ Resistance ↓

▪ By-pass ●

Mechanisms of uncrossability?

What can we do?

▪ Force of crossing:o Passive and active guiding support;o Anchoring (SB, distal, retrograde distal);o Guide extension catheters;

▪ Break the power of resistance:o Change of microcatheters;o Progressive balloon tracking;o BAM (grenadoplasty) technique;o Excimer laser;o Rotational atherectomy;

▪ By-pass the obstruction:o Subintimal plaque modification;o Retrograde

Balloon Assisted Microdissection

MN Vo, et al. J Invasive Cardiol 2016;28(84):E37-E41

Uncrossable RCA CTO – Patient 1

Uncrossable RCA CTO – Patient 1

Rotational atherec-tomy (1.5 mm burr)

Uncrossable RCA CTO – Patient 2

Uncrossable RCA CTO – Patient 2

ELCA 0.9 mm X-80Vitesse RX catheter

Fluence: 30→60 mJ/mm2

Rate: 25→40 pulse/sec

1st line

2nd line▪ Other Microcatheter

▪ Carlino

▪ Subintimal crossing techniques

(external crush, retrograde subintimal)

▪ Inflate 1.20-1.5 mm balloon in the lesion (special balloon?)

▪ Intentional small balloon rupture (grenadoplasty)

Approach to “balloon uncrossable” CTOFigure adapted from Fig 8.1. in Brilakis ES. Manual of Chronic Total Occlusion Interventions. Elsevier 2018

▪ Guide catheter extensions

▪ Anchor balloon strategies

▪ Laser

▪ Rotational atherectomy 3rd line

4th line

1st line

2nd line▪ Other Microcatheter

▪ Carlino

▪ Subintimal crossing techniques

(external crush, retrograde subintimal)

▪ Inflate 1.20-1.5 mm balloon in the lesion (special balloon?)

▪ Intentional small balloon rupture (grenadoplasty)

Approach to “balloon uncrossable” CTOFigure adapted from Fig 8.1. in Brilakis ES. Manual of Chronic Total Occlusion Interventions. Elsevier 2018

▪ Guide catheter extensions

▪ Anchor balloon strategies

▪ Laser

▪ Rotational atherectomy 3rd line

4th line