Case: Crossing CTOs Mohammad M Ansari, MD Assistant Professor of - - PowerPoint PPT Presentation

Mohammad M Ansari, MD

Assistant Professor of Medicine Director; Cardiac Cath Lab, Structural Heart Prog.& Interventional Cardiology Research Texas Tech University Health Science Center

Access And Crossing Techniques Case: Crossing CTOs

Disclosures:

• Bard Peripheral Vascular – Research, Consultant, Speaker
• Abbott – Research, Consultant
• Medtronic – Consultant
• Cordis – Consultant, Speaker
• Philips– Steering Committee, Consultant
• Boston Scientific – Advisory Board, Consultant, Research
• Ra Medical – Consultant
• Asahi – Consultant
• Edwards- Speaker
• Gore- Consultant, Speaker

• Stating the problem
• CTOP Classification
• CTOP Findings
• Practical Applications

Outline: Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: CTOP

Stating the Problem

• Chronic Total Occlusion rates range any where from 50-60% (PRME

Registry)

• Failure rates in crossing CTOs have ranged from 20% to 40%
• Most operators do not attempt retrograde tibiopedal access unless a

traditional attempt to cross the CTO in antegrade fashion has already been pursued.

• This “traditional” approach provides a false sense of security and could

arguably be harmful in some instances given that after a failed antegrade attempt most physicians tend to stop and reschedule the patient for another procedure.

• This predisposes the patient to another hospitalization, puncture, potential

exposure to anesthesia, and other inherent complications.

PRIME Registry

• The Peripheral Registry of Endovascular Clinical Outcomes (PRIME

Registry)

• Multi-center observational registry with 3-year follow up
• Inclusion: Rutherford Class III-VI subjects undergoing PVI
• First subject enrolled Jan 2013
• Currently > 900 subjects enrolled at 5 centers

Chronic Total Occlusion Crossing Approach based on the Plaque Cap Appearance. The C-TOP Trial

• Retrospective analysis evaluating CTO CAP morphology.
• Analysis of 114 patients enrolled in the PRIME registry with 142 CTO’s
• Prevalence of different CTO caps
• Access selection, technique and success rate of crossing

Plan a CTO Crossing

Revascularization Strategy

Atherectomy DCB Stent

Crossing

Antegrade Crossing Retrograde Crossing Advanced Techniques

Access Selection

Antegrade Dual Retrograde

Define CTO ,Length

Proximal Cap Distal Cap

C-TOP classification

Saab et al

20% 36.6% 14% 29.4%

CTO Distribution:

CTOP Type vs Vessel Location

• Total

n= 142

Type I

n=28

Type II

n=52

Type III

n=20

Type IV

n=42

• SFA
• 50.7%

(72/142)

• 11.1%

(8/72)

• 43.1%

(31/72)

• 12.5%

(9/72)

• 33.3%

(24/72)

• Pop
• 18.3%

(26/142)

• 42.3%

(11/26)

• 19.2

% (5/26)

• 23.1%

(6/26)

• 15.4%

(4/26)

• AT/PT
• 31%

(44/142)

• 20.4%

(9/44)

• 36.4%

(16/44)

• 11.4%

(5/44)

• 31.8%

(14/44)

Access Data

• Type

I

n=28

Type II

n=52

Type III

n=20

Type IV

n=42

• Access
• Pedal

17.6% (25/142) 0% (0/25)

• 16.0%

(4/25) 8.0% (2/25) 76.0% (19/25)

Antegrade

36.6% (52/142) 40.4% (21/52) 36.5% (19/52) 5.8% (3/52) 17.3% (9/52)

Dual

29.6% (42/142) 0% (0/42) 42.9% (18/42) 33.3% (14/42) 23.8% (10/42)

Retrograde CFA

16.2% (23/142)

• 30.4%

(7/23)

• 47.8%

(11/23)

• 4.3%

(1/23)

• 17.4%

(4/23)

Access Conversion

24.6% (35/142) 0% (0/35) 42.9% (15/35) 20% (7/35) 37.1% (13/35)

Lesion Characteristics

• Type

I

n=28

Type II

n=52

Type III

n=20

Type IV

n=42

• Calcium

Density

Non Severe

49.3% (70/142)

• 34.3%

(24/70)

• 35.7%

(25/70)

• 4.3%

(3/70)

• 25.7%

(18/70)

Severe

50.7% (72/142)

• 5.6%

(4/72)

• 37.5%

(27/72)

• 23.6%

(17/72)

• 33.3%

(24/72)

Avg Lesion Length(mm)

• 236.5
• 127.9
• 277.7
• 259.5
• 246.8

Advanced Techniques/Re-Back Technique

• Re-entry using ante grade outback device
• The Outback needle is used to puncture a retrograde balloon
• Utilized if antegrade and retrograde wires/catheters are in two

different sub-intimal planes

Superior control with antegrade access

• Type III CTO
• Longer than 10 cm
• High likelihood of subintimal

crossing

• Re-entry may occur beyond re-

constitution

• Retrograde access will preserve

relatively normal segments

• Wire advanced into the

balloon Balloon pulled distally Wire advanced from one sub- intimal space to another Deliver treatment from true lumen to true lumen

Predictors of Crossing Direction

Type I ------Antegrade Type IV ------Retrograde

Type II & III Lesion Length >10 cm Severe Calcification

CTO Short(<10 cm), Non severe Calcification Antegrade Crossing CTO (long >10cm), Severe Ca CTOP Type Type I traditional CFA access Type II Dual Access Type III Dual Access Type IV Pedal Access

Does it work?????

• 73 year old female with CLI, RF

class V

• ADT to the R AT distribution
• CFA endarterectomy (3 weeks

prior)

• Referred by VS for final tibial

therapy

Type II

Technical Evaluation….???

• What vessel should we access, L

CFA???

• Is it possible perform antegrade

access???

• CTO device ???
• What size sheath???
• CTO wire VS. Work horse Wire???
• Start with Antegrade Crossing????
• If failed…Bring back?
• Start with Pedal Access???

Prepare For Pedal Access??

Lets See What Happens……!!!!!

Did we Cross???

• Advance the wire further????
• Advance a Supporting catheter???
• Inject Contrast

Distal Deflection

Wire meeting distal CTO Saab et al

Saab et al

Confirmation…..!!!!

Sub Intimal Wire

Foot Prepared….!!!!

Tunneling!!!!

Access to Tunneling : 3 min 45 sec Access to Subintimal : 6 min 36 sec VS.

Conclusion:

• CTOP is the first trial to categorize CTO’s in a simple,

easy to apply process

• Lesion length, Calcium content and CTO types II & III

are the major predictors of access conversion

• The implications for technical success are significant

exceeding 98% of cases.

• There are potentially time savings and increase in

safety profile

• Starting with pedal access may be potentially the

standard of care as experience is gained among

• perators