Advanced CTO Techniques Case Review VI AR Galassi

Advanced CTO Techniques: Case Review VI AR Galassi, MD, FACC, FESC, FSCAI Head of Cardiac Catheterization and Interventional Cardiology Unit, Division of Cardiology, Ferrarotto Hospital Associate Professor of Cardiology University of Catania, ITALY

Disclosure Statement of Financial Interest I, Alfredo R Galassi DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation

CTO CTOWire. Escalation. Techniques Old Trends Recent Trends “Hybrid” Sliding-Drilling/Penetration-Sliding Soft Polymeric-hydrophilic GW Fielder XT or FC Not cross Severe Moderate Stiff GW 0. 014” Miracle 4. 5 -6, 3, Medium, Crossit Miracle Confianza Pro 200 9 -12 Not cross Soft Polymeric-hydrophilic Severe Stiff GW Miracle 4. 5 -6, Fielder. Confianza XT or FC Pro 9 -12

Entering a microchannel with a soft polymeric wire Fielder XT-FC supported by a microcatheter

Entering the lesion by a moderate-stiff wire supported by a microcatheter

Advancing the microcatheter and exchanging the stiff wire by a soft polymeric wire Fielder XT-TC

A) The Fielder XT-FC enters the true lumen The Mini-STAR technique

B) The Fielder XT-FC enters a false lumen The Mini-STAR technique

B) The Fielder XT-FC reenters from the false lumen The Mini-STAR technique

75 yrs, male, CCS class III LAD CTO with ipsilateral collateral circulation Belgrade live

Approach with Fielder XT and Finecross microcatheter but failed Finecross (Terumo) Belgrade live Fielder XT (Asahi-Abbott)

Approach with Fielder FC and Finecross microcatheter but failed Finecross (Terumo) Fielder FC (Asahi-Abbott)

Subsequent approach with Confianza Pro 9 Stiff guidewire penetrated only proximal part of CTO

Subsequent advancement of microcatheter onto Confianza Pro 9

Exchanging Confianza Pro 9 with Fielder FC into microcatheter and its advancement into CTO body

Subsequent advancement of small profile OTW balloon Falcon CTO 1. 0/14 mm (Invatec)

Sequential attempt to dilate the lesion without success

Due to the presence of heavy calcification balloon was not able to cross the CTO body

An attempt was performed with a small RX balloon entry profile without success Sprinter 1. 5/15 mm (Medtronic)

A Tornus 2. 6 was hardly advancing into the CTO body reentering the true lumen Tornus 2. 6 Fr (Asahi)

Finally the Tornus 2. 6 was able to advance into the CTO body

The Fielder FC guidewire was exchanged within Tornus with Prowater Flex (Asahi-Abbott)

Distal Tornus position was checked with ipsilateral collateral flow injection Prowater Flex (Asahi-Abbott)

Final result after 4 DES implantation

67 yrs, male 1994: CABG LIMA on LAD, SVG on OM 1 January 2010: Subocclusion of SVG on OM 1, occlusion of native Cx 7 FR JR 4

January 2010: Subocclusion of SVG on OM 1, Occlusion of native Cx

January 2010: LCX CTO with collateral circulation from suboccluded bypass

February 2010: LCX CTO with ipsilateral collateral circulation

February 2010: LCX CTO with ipsilateral collateral circulation Fielder XT (Asahi-Abbott) Finecross (Terumo)

Failed approach with Fielder XT and subsequent approach with Confianza Pro 9 Stiff guidewire penetrated into subintima

Successfull mini-STAR in OM 1

Successfull mini-STAR in OM 1 The auto J-wire shape configuration

Successful mini-STAR in LCX and OM 2 with Fielder FC wires

Final result after 3 DES implantation on LCX-OM 1 -OM 2 trifurcation

58 yrs, male, CCS class 3 Proximal LAD CTO with ipsilateral and retrograde collateral fillings 77 FR FRXB AL 3. 5 1

Proximal LAD CTO with ipsilateral and retrograde collateral fillings 77 FR FRXB AL 3. 5 1

Antegrade approach by Fielder FC and Corsair (Asahi) Fielder FC (Asahi-Abbott) 1. 35 min

Antegrade approach by Confianza Pro 9 and Corsair (Asahi) Confianza Pro 9 (Asahi-Abbott) 0. 57 min

Reentering into true lumen by Fielder FC Corsair (Asahi) Fielder FC (Asahi-Abbott) 1. 47 min

Advancement of Corsair across CTO onto Fielder FC Corsair (Asahi) Fielder FC (Asahi-Abbott) 0. 30 min

Mini-STAR technique on D 1 Finecross (Terumo) Fielder FC (Asahi-Abbott) 0. 20 min

Mini-STAR technique on D 1 Finecross (Terumo) Fielder FC (Asahi-Abbott) 0. 13 min

Final result after SES implantation Cypher 2. 75/33 2. 25/18 mm mm. LAD D 1 (Cordis)

PCI Success Rate in CTOs, and Percentage Use of Stiff Wires vs Plastic Wires by AR Galassi % 100 79. 3 93. 9 89 82. 4 94. 4 78. 9 80 69 54. 1 60 SUCCESS 45. 9 31 40 21. 1 WIRES PLASTIC 17. 6 20 STIFF WIRES 0 2007 84/109 lesions 2008 123/137 lesions 2009 154/164 lesions 154/163 lesions 2010

Conclusions Ø The mini-STAR technique, using Fielder wires family (Abbott/Asahi), is feasible and safe Ø The mini-STAR technique is generally used when: - a soft polymeric wire pass into a microchannel and stop into the body of the occlusion - a dissection is previously created by a stiff wire with a standard antegrade approach