gerald werner - antegradeapproach step by step

Antegrade Approach Step by Step

Gerald S. Werner, MD, FESC, FACC, FSCAI

Medizinische Klinik I

Klinikum Darmstadt GmbH

Darmstadt, Germany

Conflict of interest

• I, Gerald S. Werner, MD, have no conflict of interest to declare with regard to the following presentation

The goal of CTO-PCI

• Ideally: Restore the original anatomy of an occluded artery

• Open an occluded artery

– with the least damage to the coronary anatomy

– with the least investment of time and material, reducing procedural risks

• There is no retrograde vs antegrade approach, there is only the choice of the best strategy for the specific lesion and patient

Strategic options for CTOs in Europe

Bilateral

Maximal Guide backup

AntegradeFielder XT -> Ultimate

or -> Progress 200T/Conf.Pro 9

Penetration, then step down

Distal good target Parallel with stiff

wire

ReentrysystemBridgePoint

Antegradeno Stump

IVUS for guided Penetration ?

Retrograde

With feasible collateral pathways

Ostial CTO

Long CTO

Re-Attempt

Ideal access

Strategic options for CTOs in EuropeThe antegrade spectrum of technical options

Bilateral






wire


Antegradeno Stump


Retrograde


J-CTO Score Sheet: Predicting complexity

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

Examples not likely to work antegrade

Likely targets for the antegrade approach

Antegrade: Step by Step

• Lesion specific analysis

– Identify the proximal cap

– How long is the lesion

– What is the presumed course of the occluded segment

– Identify the distal target

• Patient specific considerations

– Previous attempts (which wires, why failed)

– Renal function (limits on contrast use)

Basic Setup

• Two catheters (radial and/or femoral route)

• Guide backup: 7F provides all options, in ostial locations and with IVUS guidance 8F preferred

• Microcatheter selection:

– Finecross: sleek profile, passes deep into lesions

– Corsair: provides additional support for the guide

– Caravelle: sleek profile with tapered tip

– Others to mention: Nhancer, Vascular Solutions

UB3UB3

Hard plaque

Severe calcification

Stiffer tip

XT-(A)XT-(A)

ASAHI Gaia FirstASAHI Gaia First

ASAHI Gaia SecondASAHI Gaia Second

ASAHI Gaia ThirdASAHI Gaia Third

Miracle12Miracle12

Confianza Pro 12

Hornet 14;

Progress 200T

Confianza Pro 12

Hornet 14;

Progress 200T

XT-RXT-R

2016: Which wire to use when?

The wire selection

• Explore the lesion– Fielder XT, atraumatic, provides feedback on lesion

rigidity, tracks loose tissue and may even penetrate noncalcified caps; “you follow the wire”

• Pass the lesion– Gaia 1-3 to penetrate the cap and steer through the

occluded segment; “the wire follows you”

• Conquer the calcified lesions – Confianza Pro 12 for penetration

– Others: Hornet 14, Progress 200T

– Pilot 200 to find the soft spots within severe calcium

Advance with in the vessel: work horse

Penetrate the cap

Wire tip shape: adapt to the purpose

Remember always: tip shape is lost rapidly

So reshape, whenever you get stuck

Remember always: tip shape is lost rapidly

So reshape, whenever you get stuck

Pass within the occlusion

Pass a collateral

Which wire to start with ?Examples from the Live Cases

Case #4Tapered lesion

My approach:

Fielder XT(-A) on microcatheterIf stuck -> Gaia 1

If distal target missed ->Proceed to parallel wire

Gaia 1st controlled wire passage


Case #8Faint notch at side branch

My approach:Fielder XT(-A) to deliver the microcatheter to the proximal cap, exploring, but penetration unlikelyGaia 2 as starter

If distal target missed ->Proceed to parallel wire

The parrallel wiretechnique is classic

Crossit

200-400 or

Conquest

3g-6g

N.Reifart/O.Katoh 1996

Why parallel wiring works well in the RCA:the wire straightens the vessel architecture

When and why parallel wire works

• If the 1st wire is close to the target, the 1st wire straightens the vessel course, and allows passage of the 2nd (stiffer) wire

• If the 1st wire is far from the target, the 2nd

wire needs to find a new course, especially in bent segments

• Often the entry point into the proximal cap needs to be changed

• Parallel wire is not a reentry technique

When and why parallel wire may fail

• The distal target is diffusely diseased and narrow

• The distal target is severely calcified and prevents entry even with a stiff wire tip

• Failure of the operator to check orthogonal views frequently: biplane systems are helpful


Case #5Blunt occlusion at side branch

Possible approach:Pass wire in side branch, dilate proximal and advance IVUS

IVUS guided penetration with Gaia 2

Bailout: retrograde

RCA CTO: Strategic options

Torino. 16.4.15

Retrograde approach in mind as

most likely strategy

Chair of session: “antegrade

approach nonsense”

Agreed, but still we need an

antegrade wire for a successful

retrograde approach

The further the antegrade wire

reaches, the shorter the

retrograde wire needs to

travel….

RCA CTO: Strategic options

Torino. 16.4.15

Puncture of the cap with Gaia 2

Torino. 16.4.15

Then via Finecross wire downgraded to Sion Black

Torino. 16.4.15

Complex long RCA CTO

Torino. 16.4.15

20 years Post CABG: Ostial RCA CTOAdditional information from MSCT

Retrograde options are challenging

Moderate calcification -> medium-strength wire

If parallel wiring fails: StingRay reentry device

H.B. 30.1.15

Parallel fails, then StingRay

H.B. 30.1.15

Strategic options for CTOs in Europe

Bilateral






wire


Antegradeno Stump


Retrograde


Ostial CTO

Long CTO

Re-Attempt

Ideal access

Parallel fails, then StingRay

H.B. 30.1.15

StingRay wire passed before the stent

H.B. 30.1.15

Antegrade: Step by Step

• Lesion specific approach

– Start with the softest possible wire

– Step up if necessary

– Use parallel wire as an early and easy bailout

– If retrograde is difficult, early decision for guided reentry technique (StingRay)

• Patient specific approach

– Select the most likely strategy to solve the lesion

– Do not attempt complex lesions without the option for retrograde conversion

gerald werner - antegradeapproach step by step

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