Hybrid Approach in CTO - PCI Dr V Surya Prakasa Rao Head of Department Cardiology Division Apollo Hospitals, Hyderguda, Hyderabad. WCC & IVUS 2015
HYBRID APPROACH Focuses opening occluded vessels using all feasible techniques. Antegrade, Retrograde ; true- true or Rentry. Safe, effective and efficient way. WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
Base Operations • Antegrade : At or Near near the distal Cap. • Retrogarde : At or Near the proximal Cap • Can be Shifted to different positions in the vessel. Eg. Cart or reverse Cart WCC & IVUS 2015
Concept of “ base of operations ” Antegrade Goal • – Move gear safely and quickly to distal cap to focus on true lumen entry or… – Move gear beyond distal cap to focus on reentry Retrograde Goal • – Move gear safely and quickly to proximal cap for true lumen entry or reverse CART (dissection connection) Mobile, not fixed, base • – Move up and down vessel as circumstances dictate WCC & IVUS 2015
DUAL INJECTIONS • Low magnitude • No Panning • Prolonged Imaging • Donor Vessel first WCC & IVUS 2015
Dual Injection WCC & IVUS 2015
• Proximal Cap • Distal Target vessel and branching • Length of the lesion • Collaterals • Anatomic Strategy WCC & IVUS 2015
HARWARE Short guide (90 cms) : For Donor Long sheaths 7F or 8F Dual Artery access WCC & IVUS 2015
Primary Retrograde • Ambiguous Proximal Cap • Poor Target for antegrade wiring • Good Collaterals • Long length lesions WCC & IVUS 2015
Best views for Collaterals • LAD to PDA Septal collaterals : RAO cr, RAO • OM to PDA : RAO Cau and AP Cau WCC & IVUS 2015
Collaterals WCC & IVUS 2015
Escalation of Wires • Initial strategy of choice : If anatomy suitable Low Gm polymer jacket wire Tapered tip High Gm Non tapered Polymer jacket wire Stiff Tapered confianza WCC & IVUS 2015
Parallel wire WCC & IVUS 2015
New GAIA WCC & IVUS 2015
Dissection Reentry • Wire Based : Knuckle Wire – Safer technique than stiff wire and doesn’t perforate small branches LaST method : Knuckle is replaced with stiff wire. STAR technique. WCC & IVUS 2015
Knukkle wire WCC & IVUS 2015
Star Technique WCC & IVUS 2015
LaST WCC & IVUS 2015
Device Based • CrossBoss and StingRay WCC & IVUS 2015
The CrossBoss ™ CTO Catheter Design Cross Boss is designed to quickly and safely deliver a guidewire via true lumen or subintimal pathways • Multi-wire coiled shaft • Tracks via FAST Spin Technique FAST Spin reduces push required – to cross CTO Bidirectional high speed rotation – of ratcheted torque device • Atraumatic 3 Fr distal tip advanced across a CTO ahead of the guidewire • OTW 0.014” guidewire compatible WCC & IVUS 2015
Cross Boss Technique- Fast Spin WCC & IVUS 2015
Primary Boss Illustration WCC & IVUS 2015
WCC & IVUS 2015
Primary Boss Technique • True lumen to true lumen passage of the CrossBoss Catheter – Occurs approximately 30% of time – More frequent in non-calcified vessels – A tapered “stump” proximal cap makes this even more likely – A large lumen diameter of the distal target is another predictor of true-true passage • Type IV ISR – Scaffold of the stent favors the blunt tip of the Crossboss catheter to remain within true lumen 26 WCC & IVUS 2015
Knuckle Boss Technique 1. Proximal cap ambiguity- • Knuckle technique with a Fielder XT (Tapered tip jacketed wire) allows for safe entry into the sub-intimal space. • The Cross Boss catheter then follows the wire and allows for rapid passage through the CTO to the distal cap “moving the base of operations”. 2. Side branch at proximal cap/Calcium at proximal cap • Penetration with a non jacketed wire for <1cm followed by confirmation of location within vessel “architecture” allows for advancement of CrossBoss catheter into the subintimal space • May need dilatation with 1.25 mm or 1.5mm balloon or even a Tornus catheter to prevent stalling of the case 27 WCC & IVUS 2015
Knuckle Boss Illustration WCC & IVUS 2015
WCC & IVUS 2015
The Stingray™ CTO Re -Entry System Design Stingray System (catheter and guidewire) is designed to accurately target and re-enter the true lumen from a subintimal position Compatibility: 6Fr. Guide/0.014” Wire 2.9Fr. shaft profile Re-entry probe at Stingray Unique self-orienting balloon has a flat 180 ° opposed and offset exit Guidewire tip shape for true lumen targeting ports for selective guidewire re-entry WCC & IVUS 2015
StingRay Technique-Delivery • Profile of the StingRay balloon is roughly that of a 1.5 mm balloon • Most times if the CrossBoss catheter has been delivered to the distal cap, the StingRay balloon can also be delivered • Reentry location is most frequently just beyond the distal cap • Location of proximal branches that may be compromised must be considered when selecting site of reentry WCC & IVUS 2015
Orthogonal Views for Sting Ray Balloon • The width of this balloon is 2.5 times its length • The proximal and distal markers are distal to respective exit ports for the wire • Sometimes, orthogonal views are hard to align in the vertical segment of the RCA/ or proximal segment of the OM’s and you may need to bring the balloon to the distal RCA proximal to the crux or a little distal in the horizontal segment of the OM • Aligning the balloon to understand the orientation of the balloon ports is critical to successful re-entry 32 WCC & IVUS 2015
StingRay Balloon Port Cannulation • The ports are offset at 180 degrees from each other • The angle of entry into the ports is 28 degrees • Balloon inflation is done with contrast after proper balloon preparation • This centers the balloon in the subintimal space • Fenestration is done with the Stingray wire (NOT meant to Torque-Just for puncture of subintimal space and connect back into the true lumen) WCC & IVUS 2015
Re-entry Puncture Technique • After desired reentry location and port has been identified- the Stingray wire is advanced and used to penetrate the true lumen • After advancement of a few mm-STOP and redirect • Use retrograde angiography to confirm true lumen position of the wire WCC & IVUS 2015
Stingray Reentry Illustration WCC & IVUS 2015
StingRay Reentry Illustration WCC & IVUS 2015
Demonstration of stingray wire fenestration WCC & IVUS 2015
Wire Swap • Stingray Wire lacks tactile feedback • Once the fenestration has been completed-<swapping> for a polymer jacketed wire like a Pilot 50 or Pilot 200 allows for completion of the procedure • If site of re-entry needs to be changed, then advancement of the balloon can be done after the wire has been pulled back (“Bob Sled”) WCC & IVUS 2015
Retrograde Reentry • True- True • Just Marker • CART • Reverse CART WCC & IVUS 2015
Case #1 : Reverse CART WCC & IVUS 2015
Case #2 : Reverse CART WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
WCC & IVUS 2015
Weaknesses of Hybrid CTO PCI • Costs of devices may prohibit adoption • Availability of devices limits development • Lack of long term follow up about using subintimal space • Steep learning leave WCC & IVUS 2015
Weaknesses of Hybrid CTO PCI • Still needs high end wiring skills • Requires careful management of antegrade hematoma • Still needs retrograde skill set (30% of cases are done retrograde) WCC & IVUS 2015
Conclusion The More the lesion is complex better are chances of success with hybrid approach. Multistep Strategy with always make progress approach. Stent in subintimal space anyway. Less Radiation and Less Contrast. Needs Additional Cost and Skills. WCC & IVUS 2015
THANK YOU WCC & IVUS 2015
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