Hybrid Approach in CTO - PCI Dr V Surya Prakasa Rao Head of - - PowerPoint PPT Presentation

▶
hybrid approach in cto pci
SMART_READER_LITE
LIVE PREVIEW

Hybrid Approach in CTO - PCI Dr V Surya Prakasa Rao Head of - - PowerPoint PPT Presentation

Jul 22, 2023 281 likes •861 views

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,

slide-1
SLIDE 1

Hybrid Approach in CTO - PCI

Dr V Surya Prakasa Rao Head of Department Cardiology Division Apollo Hospitals, Hyderguda, Hyderabad.

WCC & IVUS 2015

slide-2
SLIDE 2

HYBRID APPROACH

Focuses opening occluded vessels using all feasible techniques. Antegrade, Retrograde ; true- true or

  • Rentry. Safe, effective and efficient

way.

WCC & IVUS 2015

slide-3
SLIDE 3

WCC & IVUS 2015

slide-4
SLIDE 4

WCC & IVUS 2015

slide-5
SLIDE 5

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

slide-6
SLIDE 6

Concept of “base of operations”

  • Antegrade Goal

– Move gear safely and quickly to distal cap to focus on true lumen entry

  • r…

– 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

slide-7
SLIDE 7

DUAL INJECTIONS

  • Low magnitude
  • No Panning
  • Prolonged Imaging
  • Donor Vessel first

WCC & IVUS 2015

slide-8
SLIDE 8

Dual Injection

WCC & IVUS 2015

slide-9
SLIDE 9
  • Proximal Cap
  • Distal Target vessel and branching
  • Length of the lesion
  • Collaterals
  • Anatomic Strategy

WCC & IVUS 2015

slide-10
SLIDE 10

HARWARE

Short guide (90 cms) : For Donor Long sheaths 7F or 8F Dual Artery access

WCC & IVUS 2015

slide-11
SLIDE 11

Primary Retrograde

  • Ambiguous Proximal Cap
  • Poor Target for antegrade wiring
  • Good Collaterals
  • Long length lesions

WCC & IVUS 2015

slide-12
SLIDE 12

Best views for Collaterals

  • LAD to PDA Septal collaterals : RAO cr, RAO
  • OM to PDA : RAO Cau and AP Cau

WCC & IVUS 2015

slide-13
SLIDE 13

Collaterals

WCC & IVUS 2015

slide-14
SLIDE 14

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

slide-15
SLIDE 15

Parallel wire

WCC & IVUS 2015

slide-16
SLIDE 16

New GAIA

WCC & IVUS 2015

slide-17
SLIDE 17

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

slide-18
SLIDE 18

Knukkle wire

WCC & IVUS 2015

slide-19
SLIDE 19

Star Technique

WCC & IVUS 2015

slide-20
SLIDE 20

LaST

WCC & IVUS 2015

slide-21
SLIDE 21

Device Based

  • CrossBoss and StingRay

WCC & IVUS 2015

slide-22
SLIDE 22

The CrossBoss™ CTO Catheter Design

  • Multi-wire coiled shaft
  • Tracks via FAST Spin Technique

–

FAST Spin reduces push required to cross CTO

–

Bidirectional high speed rotation

  • f ratcheted torque device
  • Atraumatic 3 Fr distal tip advanced

across a CTO ahead of the guidewire

  • OTW 0.014” guidewire compatible

Cross Boss is designed to quickly and safely deliver a guidewire via true lumen or subintimal pathways

WCC & IVUS 2015

slide-23
SLIDE 23

Cross Boss Technique- Fast Spin

WCC & IVUS 2015

slide-24
SLIDE 24

Primary Boss Illustration

WCC & IVUS 2015

slide-25
SLIDE 25

WCC & IVUS 2015

slide-26
SLIDE 26

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

slide-27
SLIDE 27

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

  • perations”.
  • 2. Side branch at proximal cap/Calcium at proximal cap
  • Penetration with a non jacketed wire for <1cm followed by confirmation
  • f 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

slide-28
SLIDE 28

Knuckle Boss Illustration

WCC & IVUS 2015

slide-29
SLIDE 29

WCC & IVUS 2015

slide-30
SLIDE 30

The Stingray™ CTO Re-Entry System Design

Unique self-orienting balloon has a flat shape for true lumen targeting 180° opposed and offset exit ports for selective guidewire re-entry Re-entry probe at Stingray Guidewire tip

Compatibility:

  • 6Fr. Guide/0.014” Wire

2.9Fr. shaft profile

Stingray System (catheter and guidewire) is designed to accurately target and re-enter the true lumen from a subintimal position

WCC & IVUS 2015

slide-31
SLIDE 31

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

slide-32
SLIDE 32

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

slide-33
SLIDE 33

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

slide-34
SLIDE 34

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

slide-35
SLIDE 35

Stingray Reentry Illustration

WCC & IVUS 2015

slide-36
SLIDE 36

StingRay Reentry Illustration

WCC & IVUS 2015

slide-37
SLIDE 37

Demonstration of stingray wire fenestration

WCC & IVUS 2015

slide-38
SLIDE 38

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

slide-39
SLIDE 39

Retrograde Reentry

  • True- True
  • Just Marker
  • CART
  • Reverse CART

WCC & IVUS 2015

slide-40
SLIDE 40

Case #1 : Reverse CART

WCC & IVUS 2015

slide-41
SLIDE 41

Case #2 : Reverse CART

WCC & IVUS 2015

slide-42
SLIDE 42

WCC & IVUS 2015

slide-43
SLIDE 43

WCC & IVUS 2015

slide-44
SLIDE 44

WCC & IVUS 2015

slide-45
SLIDE 45

WCC & IVUS 2015

slide-46
SLIDE 46

WCC & IVUS 2015

slide-47
SLIDE 47

WCC & IVUS 2015

slide-48
SLIDE 48

WCC & IVUS 2015

slide-49
SLIDE 49

WCC & IVUS 2015

slide-50
SLIDE 50

WCC & IVUS 2015

slide-51
SLIDE 51

WCC & IVUS 2015

slide-52
SLIDE 52

WCC & IVUS 2015

slide-53
SLIDE 53

WCC & IVUS 2015

slide-54
SLIDE 54

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

slide-55
SLIDE 55

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

slide-56
SLIDE 56

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

slide-57
SLIDE 57

THANK YOU

WCC & IVUS 2015