Karl ISAAZ - CTO withHeavy Calcifications

CTO with Heavy

Calcifications

Karl ISAAZ

University of Saint Etienne

France

Euro CTO Club The expert Live Workshop 2016

Presenter: Karl Isaaz

No conflict of interest

Predictive Factors of Success

From the EuroCTO Club EuroInterv 2007; 3: 30-43

Predictive Factors of Success

EuroCTO Club EuroInterv 2007; 3: 30-43

Simple CTO > 90% success rate

Complex CTO 60-70% success rate

Angiographic Predictors

From the EuroCTO Club EuroInterv 2011; 7: 472-79

Angiographic Predictors of PCI failurefrom Tsuchikane et al. CTO In Nguyen Editor, Practical handbook of

advanced interventional cardiology tips and tricks, 3rd Edition 2008

• Severe calcifications

• Very long CTO

length

• Marked tortuosity

• Long occlusion duration

• Antegrade bridging

collaterals

• Blunt stump occlusion

• side branch at occlusion

site

• Absence of antegrade

flow and no or poor

distal vessel visibility

Most important predictors

Other predictors for

less-experienced operators

J-CTO SCORE from the Multicenter CTO Registry of Japan

Morino Y et al. JACC Interv 2011; 4: 213-21

J-CTO SCORE

Morino Y et al. JACC Interv 2011; 4: 213-21

CTO with heavy calcifications

1. Difficulties to penetrate the proximal

or distal cap with the wire

2. Difficulties to advance and

manipulate the wire inside the CTO

3. Difficulties to advance the

microcatheter

4. Difficulties to cross the lesion with the

balloon

5. Difficulties to well expand the stent

Impact on the procedure


Tools Strategies

Success or failure

1. Long sheath (45 cm)

2. Large size guiding catheter (7f/8f)

3. Stiff wires (Confianza pro 12/Progress 200T)

4. Guideliner/Guidezilla

5. Small balloons

6. Tornus microcatheter

7. New microcatheter (turnpike) and anchoring

catheters (centercross and multicross)

8. Rotablator

9. Laser

Tools



1. Crossing the lesion from true to true

2 basic strategies

2. Dissection Reentry

Retrograde approachReverse CART

Antegrade approachModification of the CAP

1. BASE: balloon assisted subintimal dissection

2. Scratch and go

3. Hydraulic dissection

Modification of the CAP



2. Scratch and go




BASE1. Adequate proximal vessel length

1. Balloon diameter slightly larger than

reference diameter of proximal vessel

1. End result is intimal dissection of proximal

cap Knuckle wire

Dissection-reentry technique

Crossboss + stingray



2. Scratch and go




Scratch and Go

1. Stiff wire to create subintimal space

1. Corsair to subintimal space Knuckle wire

Dissection-reentry technique

Crossboss + stingray



2. Scratch and go




Break the CAP: Hydraulic dissection

1. Corsair into subintimal space

2. 3 ml seringe with 1-2 cc injection of contrast

3. Knuckle wire or crossboss for DR


Techniques of anchoring balloon

1. Antegrade guiding catheter anchoring

balloon

1. Antegrade or retrograde GW trapping

balloon

2. Subintimal distal anchoring balloon


CTO with heavy calcificationsTechniques of anchoring balloon

1. Antegrade guiding catheter anchoring

balloon

1. Antegrade or retrograde GW trapping

balloon

2. Subintimal distal anchoring balloon

Trapping of the

Antegrade guidewire

EBU 4.0 7f for the left system

with guideliner to augment supportAR2 7f for the saphenous graftWhisper + CORSAIR in the saphenous graft

Planned Recanalization of LCX CTO

Mr Str. G.

Unstable support: Guideliner

in the AR2 7f to augment the support

Retrograde FIELDER XT in the CORSAIR

to cross the CTO: failure

Retrograde partial crossing of the CTO with a MIRACLE 3 but despite AR2 + Guideliner:

failure to crosse retrogradely the CTO with the CORSAIR due to heavy calcifications

Antegrade Finecross + FIELDER XT

for kissing wire technique with

Retrograde MIRACLE 3: failure

Antegrade Finecross + PROGRESS 200T

for kissing wire technique with retrograde

MIRACLE 3: success

Antegrade Finecross + PROGRESS 200 with kissing wire technique with a retrograde

MIRACLE 3: success with antegrade crossing of the CTO by the PROGRESS 200 which

is positionned in the saphenous graft

Guideliner saphenous graft

Guideliner left main

Antegrade PROGRESS 200

FINECROSS

CORSAIR + MIRACLE 3

Then, failure to cross the CTO over the PROGRESS 200 with a TAZUNA

1.25 balloon then an ACROSTAK 1.1 balloon and TORNUS 2.1/2.6

Anchoring of the antegrade PROGRESS 200T by a 2.0 20mm balloon advanced

retrogradely in the saphenous graft; crossing of the CTO with an ACROSTAK 1.1

Anchoring balloon

Antegrade ACROSTAK balloon

Antegrade Ballooning

FINAL RESULT

Trapping of the

Retrograde guidewire

Septal connection crossed by a SION +

Finecross

Mr Bur. M.

Advancement with difficulties (frictions) of a Pilot

200 after failure of Fielder XT/Gaia2/Miracle 12

Use of a Guideliner. Pilot 200 advanced into the

Guideliner

Pilot 200 advanced in the antero guiding but

Failure to advance a Finecross, Corsair

and Turnpike

Trapping of the retro Pilot 200 by an

antegrade Maverick balloon in the Guideliner

Anchoring

balloon in the

Guideliner

Advancement of the Finecross into the

Guideliner and externalization

CTO with heavy calcificationsTechniques of distal anchoring balloon

Subintimal distal anchoring balloon

1. Long sheath (45 cm)

2. Large size guiding catheter (7f/8f)

3. Wire escalation (Confianza 12/Progress 200)

4. Anchoring balloon (antero and retro)

5. Guideliner/Guidezilla

6. Small balloons

7. Tornus microcatheter

8. New microcatheter (turnpike)

9. Rotablator

10. Laser

Tools


Mr CON. J

Coronary Angiogram on

April 21, 2016Transradial Approach

Heavily calcified RCA lesion

PCI ProcedureTransradial Approach

Attempt of RCA ad hoc angioplasty using a 6Fr

AR2 guiding catheter through the transradial

access.

Easy crossing of the lesion by a BMW guidewire

but failure of crossing the lesion by a 1.5 mm

diameter Maverick ballon and then by a Minitrek

1.20mm diameter balloon.

PCI ProcedureRe-attempt on April 25, 2016

Right trans-femoral approach with a

long 45 cm 7fr Cook introducer

AR2 7Fr guiding catheter

Easy crossing of the lesion by a BMW

guidewire

Use of a Guideliner

PCI on April 25, 2016Failure of crossing the

lesion with

successively:

a Minitrek 1.20 ballon

a Finecross

a Corsair

a Tornus catheter

and despite the use of a

Guideliner advanced at

the contact of the lesion Guideliner

Tornus 2.1

PCI on April 25, 2016

Successful crossing with a Turnpike catheter


After Turnpike passage, a Maverick 1.5

diameter balloon is easily advanced and

inflated at 18 Atm

Successive inflations with 3.0 mm and 3.5

mm non compliant QUANTUM balloons at

20 atm

Stenting with a RESOLUTE 3.5 15mm drug-

eluting stent deployed at 28 atm


Post–DES implantation at 28 atm. Insufficient result

due to lack of radial force of the stent (arrow)


Final result (arrow) after instent implantaiton of a BMS

Driver 3.5 12mm deployed at 28 atm and post-dilatation

with a Quantum 4.0 8 balloon at 25 atm

Total failure!

Mr Str. G.

Heavy calcifications

Mr Str. G Mr Str. G.

Heavy calcifications

Mr Str. G Mr Str. G.Two 7f GCRetrograde approach

Successful antegrade crossing wi

with a Miracle 12 using kissing GWThen, failure to cross:

Finecross

Corsair

Acrostak 1.1 balloon

TORNUS 2.1/2.6

Guideliner 6f/7f

Despite anchoring antegrade GW by

a retrograde balloon

RotaW failed to cross

Anchoring of the antegrade GW by

a retrograde balloon

Watch the distality of your wire

while trying to cross the lesion


CONCLUSION

Heavy Calcifications in CTOs

1. Persevere, don’t get discouraged

2. Use of many techniques and tools to augment the

backup support

1. Use of dissection-reentry technique to circumvent

the calcified zone when you can’t get from true to

true but you need a good landing zone

1. Watch the tip of your guidewire during efforts for

crossing the CTO with the balloons or other devices

Health & Medicine

Karl ISAAZ - CTO withHeavy Calcifications