Teaching CTO

as a Modular System

Achim Büttner

EUROCTOCLUB Krakow, 30. September / 1. October 2016

Germany

No disclosures to declare

Why is CTO PCI fun?

• Technically challenging

• Contemporary recanalisation techniques allow for success

rates >90%

• Choice of different modules / techniques / materials

at certain points of the intervention

• Room for individualisation and technical refinement

Why is CTO PCI difficult to learn?

• Largely standardised recanalisation techniques are developed

from „consolidated knowledge“

• There is limited detailled information on appropriate techniques

from the literature

• During CTO conferences beginners are confronted with:

- a hughe CTO glossary

- complex interventions with many technical components

- application of tools beyond any reimbursement

Teaching that concentrates on CTO modules

would improve learning and getting familiar with

techniques

Hypothesis

Module = one of a set of parts

that can be connected or combined

to build or complete something

www.merriam-webster.com/dictionary

Collateral

passage

Subintimal

technique

Parallel

wires

Wire

escalation

Antegrade RetrogradeConnection

Retrograde

CTO wiringSide-branch

technique

Subintimal

technique

Tip-in

Marker

wires

Reverse

CART

Externalisation

Reverse CART: Balloon dilatation from antegrade

Modified from M. Ochiai

Retrograde wire enters

after balloon deflation

Module: Reverse CART

• Localisation: - Relatively straight CTO segment mid vessel

- also possible more proximal or distal

- may be repeated at different levels

- not at ostium or bifurcation

• Close proximity of antegrade and retrograde wires in

estimated vessel course

• Sufficient wire overlap (> 1cm)

• Balloon from antegrade: 2.0 – 2.5mm / 15 – 20mm

(eventually pre-dilatation with smaller balloon)

Reverse CART: Retrograde wires

Wire from retrograde has to penetrate tissue..

Steerability

through microcatheter

Penetration

force

Intermediate non-tapered (Ulimate 3g) +++ +

Intermediate tapered (Gaia 2nd, 3rd) +++ ++

Hard tapered (ConfianzaPro12/Progress200T) + +++

Hard polymeric (Pilot 200)* ++ ++(+)

*useful in subintimal position

Reverse CART

From antegrade:

2.5mm balloon

Retrograde wire subintimal:

Pilot 200

Reverse CART: Retrograde passage towards antegrade guide

Modified from M. Ochiai

1. Retrograde wire has entered

lumen after balloon deflation

2. Then microcatheter follows

3. Additional proximal balloon

dilatations to facilitate wire

passage from retrograde

Reverse CART: Retrograde wire entry into antegrade guide

• If wire entry into antegrade guide is difficult:

- exchange to standard wire with bigger tip curve

- manipulate guide to coaxial position or different heights at ostium

• Follow with retrograde microcatheter (if microcatheter gets stuck →

wire trapping manoeuver or rendez-vous in antegrade guide)

Reverse CART: Additional devices

• IVUS for unclear antegrade / retrograde wire course (€/$)

• Retrograde wire enters at ostium into ascending aorta:

→ snaring manoeuver (€/$) after exchange of retrograde

wire to RG3

• Guiding catheter extension (e.g. Guideliner) to facilitate

retrograde wire entry into antegrade guide (€/$)

Eventually necessary or helpful…

Collateral

passage

Subintimal

technique

Parallel

wires

Wire

escalation

Antegrade RetrogradeConnection

Retrograde

CTO wiringSide-branch

technique

Subintimal

technique

Tip-in

Marker

wires

Reverse

CART

Externalisation

Exchange to long wire (RG3 330cm)

and externalisation

Collateral

passage

Subintimal

technique

Parallel

wires

Wire

escalation

Antegrade RetrogradeConnection

Retrograde

CTO wiringSide-branch

technique

Subintimal

technique

Tip-in

Marker

wires

Reverse

CART

Externalisation

„Tip-in“ manoeuvre in guiding catheter

Retrograde microcatheter

in antegrade guide

Antegrade wire

Meeting point in outer guide curve

Limitations

• Definition of modules

• Agreement on recommendations in an expert panel

• Continous improvements in material and techniques

• Price versus advantage of tools difficult to define;

dependent on situations and alternatives

• Practical training of a certain module that is only part of a

CTO intervention (simulator training?)

Conclusions

• Teaching CTO as a modular system might faciltate learning

of CTO techniques

• A break down on CTO modules during CTO conferences

(e.g. ten minutes for „Reverse CART“) could parallel the

typical presentation of „crazy“ cases

• CTO modules are appropriate for internet based learning

(e.g. on homepage of the EuroCTO Club)