antegrade CTO Didier Tchtch, Clinique Pasteur, Toulouse, France. - PowerPoint PPT Presentation

10 10 Commandments for antegrade CTO Didier Tchétché, Clinique Pasteur, Toulouse, France.

Potential conflicts of f interest • None

1- Prepared your patient and yourself must be -Appropriate hydration -Information about predicted procedure length -Adequate timeslot in your planning -Empty bladders

2- A bilateral injection will get -Features of the CTO -J CTO score -Choice of the initial strategy -Evaluate distal location of the gw

3- An adequate guiding-catheter you will select Amplatz -Support Left 2 or 3 for LCx -Coaxiality EBU or XB -Enable multiple options 3.5 LAD 4.0 LCx -6F- 7F -8F Judkins right/Amplatz for RCA

4- Microcatheters you will systematically use -Support for guide-wires -Guide-wires exchange -CTO crossing -Distal tip injection (contralatreal) -Prohibit antegrade tip injection

5- Adequated selected and shaped your wire will be Non CTO lesion single angulation 2 mm at 45 ° -Know the tip load CTO: distal 1 mm angulation 45 ° + second bend 15 -Double curve Microcatheter: double angulation

6- Antegrade wiring techniques you will learn “Controlled drilling technique” Guide wire advancement with gentle forward movements “Penetrating technique” small movements pushing the wire through the occlusion aiming at the distal lumen.

Paralell Wire technique • Parallel wire (contact wire) technique involves 2 antegrade wires in which the first wire ends up in the false lumen. • 2 nd wire with same tip load or stronger • The shaft of second wire remains in contact with the first wire and the tip is deflected to gain entry into the true lumen.

See Saw technique -Two full sets of microcatheters -and their respective wires are used From Mitsudo

STAR technique (subintimal tracking and reentry) • Create a sub-intimal dissection plane • with hydrophilic wire (Pilot, Fielder XT or whisper) • Re-enter distally with wire, usually at bifurcation • Similar technique to peripheral CTO Colombo A,. Catheter Cardiovasc Interv 2005;64:407-411.

Antegrade dissection-reentry Stingray ™ Crossboss™

IVUS guided wiring • Localize the entry point • Find the true lumen if guidewire into false lumen.

7- How to exchange wires/devices you will learn -Trapping balloon ++ -Wire extension -Flushing technique (Nanto) - GC≥ 7F

8- How to improve guide catheter support you must know -Anchoring techniques -wire -balloon -Centercross -Guide catheter extension

9- What to do if balloon does not cross you must learn -Small OPN balloons -Open mouth technique -Rotablator -Dedicated microcatheters: -Tornus -Turnpike Gold

10- Flexible you must remain -No dogma -Switch techniques -Master retrograde techniques -Continuous learning